COST-EFFECTIVENESS ANALYSIS OF SOFOSBUVIR-BASED TREATMENT FOR CHRONIC, GENOTYPE 1 HEPATITIS C INFECTIONS IN U.S. INCARCERATED POPULATIONS

Purpose: The prevalence of chronic hepatitis C virus (HCV) infection is estimated at 12-35% among U.S. incarcerated individuals—nearly 10 times the U.S. general population prevalence. The recent availability of highly efficacious therapies may be beneficial for HCV-infected inmates, given that they are less likely to receive treatment upon release. New direct-acting antiviral therapies may also expand treatment eligibility for inmates with short sentences given the newer regimen’s 12 weeks duration. We assessed the cost-effectiveness of sofosbuvir-based therapy for HCV treatment in incarcerated populations.

Method: We developed a decision-analytic Markov model that included the natural history of chronic HCV (genotypes 1) and advanced liver disease; combinations of HCV treatment options both in and out of prisons; and the possibility of reinfection. We assessed the lifetime costs (2013 USD), quality-adjusted life-years (QALYs) gained, and incremental cost-effectiveness ratios (ICERs) of treatment strategies for eligible mono-infected inmates during incarceration: 1) no treatment; 2) two-drug therapy (pegylated interferon and ribavirin, up to 48 weeks); 3) three-drug therapy with boceprevir (up to 48 weeks); 4) three-drug therapy with sofosbuvir (up to 12 weeks). For inmates with short (mean 1.5 years) remaining sentences only strategies 1) and 4) are feasible according to the current prison treatment policy, while for inmates with longer sentences (>1.5 years; mean 10 years), all strategies are considered. Upon release, eligible individuals can be treated with sofosbuvir-based therapy. 

Result: Sofosbuvir-based therapy results in absolute reductions in decompensated cirrhosis and hepatocellular carcinoma of 17% and 9% respectively, and adds 2.6 QALYs at an additional cost of more than $60,000 per individual compared to no treatment. For short sentences, sofosbuvir costs $24,100 per QALY gained compared to no treatment. For longer sentences, sofosbuvir costs $26,600 per QALY gained compared to no treatment. Two-drug and boceprevir-based therapies are dominated by sofosbuvir. Very high prison reinfection rates reduce cost-effectiveness for inmates with longer remaining sentences.

Conclusion: Despite limited data on sofosbuvir’s long-term effectiveness and price, sofosbuvir-based therapy is cost-effective for long and short-term incarcerated individuals. The therapy’s shorter duration enables treatment of inmates with short remaining sentences and reduces risks of treatment discontinuation due to early release. Given sofosbuvir’s high price and the large size of the chronic HCV-infected incarcerated population in the U.S. (>500,000), affordability is an important consideration.