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Sofosbuvir-Based Treatment Regimens for Chronic, Genotype 1 Hepatitis C Virus Infection in U.S. Incarcerated Populations: A Cost-Effectiveness AnalysisSofosbuvir-Based Treatment of Hepatitis C in U.S. Incarcerated Populations

Shan Liu, PhD; Daena Watcha, MD, MS; Mark Holodniy, MD; and Jeremy D. Goldhaber-Fiebert, PhD
[+] Article, Author, and Disclosure Information

From University of Washington, Seattle, Washington; UCSF School of Medicine, San Francisco, California; Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and Stanford University School of Medicine and Stanford University, Stanford, California.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the U.S. Department of Veterans Affairs or the U.S. government.

Acknowledgment: The authors thank Lauren Cipriano, Douglas K. Owens, Paul Barnett, Steve Asch, and other colleagues focused on HCV treatment within the U.S. Department of Veterans Affairs for their helpful conversations.

Financial Support: Dr. Holodniy was supported by intramural funding from the U.S. Department of Veterans Affairs. Dr. Goldhaber-Fiebert was supported in part by a Career Development Award (K01AG037593-01A1) from the National Institute on Aging of the National Institutes of Health.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0602.

Reproducible Research Statement:Study protocol: Not applicable. Statistical code and data set: Available from Dr. Goldhaber-Fiebert (e-mail, jeremygf@stanford.edu).

Requests for Single Reprints: Jeremy D. Goldhaber-Fiebert, PhD, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, 117 Encina Commons, Stanford, CA 94305-6019; e-mail, jeremygf@stanford.edu.

Current Author Addresses: Dr. Liu: Industrial and Systems Engineering, University of Washington, Box 352650, Seattle, WA 98195.

Dr. Watcha: UCSF School of Medicine, 513 Parnassus Avenue, San Francisco, CA 94143.

Dr. Holodniy: Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue (132), Palo Alto, CA 94304.

Dr. Goldhaber-Fiebert: Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, 117 Encina Commons, Stanford, CA 94305-6019.

Author Contributions: Conception and design: S. Liu, J.D. Goldhaber-Fiebert, D. Watcha.

Analysis and interpretation of the data: S. Liu, D. Watcha, M. Holodniy, J.D. Goldhaber-Fiebert.

Drafting of the article: S. Liu, D. Watcha, M. Holodniy, J.D. Goldhaber-Fiebert.

Critical revision of the article for important intellectual content: S. Liu, M. Holodniy, J.D. Goldhaber-Fiebert.

Final approval of the article: S. Liu, D. Watcha, M. Holodniy, J.D. Goldhaber-Fiebert.

Statistical expertise: J.D. Goldhaber-Fiebert.

Obtaining of funding: J.D. Goldhaber-Fiebert.

Collection and assembly of data: S. Liu, D. Watcha, J.D. Goldhaber-Fiebert.

Ann Intern Med. 2014;161(8):546-553. doi:10.7326/M14-0602
Text Size: A A A

Background: Prevalence of chronic hepatitis C virus (HCV) infection is high among incarcerated persons in the United States. New, short-duration, high-efficacy therapies may expand treatment eligibility in this population.

Objective: To assess the cost-effectiveness of sofosbuvir for HCV treatment in incarcerated populations.

Design: Markov model.

Data Sources: Published literature and expert opinion.

Target Population: Treatment-naive men with chronic, genotype 1 HCV monoinfection.

Time Horizon: Lifetime.

Perspective: Societal.

Intervention: No treatment, 2-drug therapy (pegylated interferon and ribavirin), or 3-drug therapy with either boceprevir or sofosbuvir. For inmates with short remaining sentences (<1.5 years), only no treatment or sofosbuvir 3-drug therapy was feasible; for those with long sentences (≥1.5 years; mean, 10 years), all strategies were considered. After release, eligible persons could receive sofosbuvir 3-drug therapy.

Outcome Measures: Discounted costs (in 2013 U.S. dollars), discounted quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.

Results of Base-Case Analysis: The strategies yielded 13.12, 13.57, 14.43, and 15.18 QALYs, respectively, for persons with long sentences. Sofosbuvir produced the largest absolute reductions in decompensated cirrhosis (16%) and hepatocellular carcinoma (9%), resulting in 2.1 additional QALYs at an added cost exceeding $54 000 compared with no treatment. For persons with short sentences, sofosbuvir cost $25 700 per QALY gained compared with no treatment; for those with long sentences, it dominated other treatments, costing $28 800 per QALY gained compared with no treatment.

Results of Sensitivity Analysis: High reinfection rates in prison attenuated cost-effectiveness for persons with long sentences.

Limitations: Data on sofosbuvir's long-term effectiveness and price are limited. The analysis did not consider women, Hispanic persons, or patients co-infected with HIV or hepatitis B virus.

Conclusion: Sofosbuvir-based treatment is cost-effective for incarcerated persons, but affordability is an important consideration.

Primary Funding Source: National Institutes of Health.


Grahic Jump Location

Cost-effectiveness results.

Discounted QALYs (y-axis) and discounted total expected lifetime costs (x-axis) for each treatment strategy for inmates with short remaining sentences (<1.5 y) and those with long remaining sentences (≥1.5 y). The line segments represent the efficient frontier. The squares depict strategies on the frontier, and incremental cost-effectiveness ratios (i.e., the ratio of the additional costs of an intervention and its additional effects compared with the next best alternative) are reported. The diamonds represent strategies not on the efficient frontier, which cost more and provide less benefit than a strategy or combination of strategies on the frontier. QALY = quality-adjusted life-year.

Grahic Jump Location




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