HEPATITIS C PREVENTION BY SCREENING AND TREATMENT IN UNITED STATES PRISONS: AN AGENT-BASED APPROACH

Purpose:

The prevalence of hepatitis C virus (HCV) in United Stated prisons is between 16-41%; however, no standard protocols exist for HCV screening. The objective of our study was to evaluate the cost-effectiveness HCV screening in prisons and HCV prevention in society by interventions in prisons.

Method:

We developed an agent-based simulation model that simulated the transmission and progression of HCV disease in United States population in prisons and society. Chronic stages of HCV were modeled as Markov states. We used Bureau of Justice Statistics data to simulate movement of people between prisons and society by incorporating data on arrest, recidivism and duration of sentence. We evaluated three screening scenarios: risk-based screening only (RISK), 1-time screening of all existing inmates followed by screening of any incoming inmate for 2 years (2YR), and 1-time screening of all existing inmates followed by screening of any incoming inmate for 5 years (5YR). Inmates with length of sentence more than 12 months were eligible for treatment with recently approved direct-acting antivirals. We assigned treatment based on patient’s HCV genotype, treatment-history and tolerance to interferon, as recommended by the new clinical guidelines. We projected the total cost, quality-adjusted life years (QALYs), cumulative incidence of cirrhosis, decompensated cirrhosis (DC), hepatocellular carcinoma (HCC), and liver-related deaths (LRD). We also projected the number of new HCV infections in society because of HCV-infected people released from prisons.

Result:

The total cost under RISK, 2YR, and 5YR were $11.08 million, $11.68 million and $11.75 million per 10,000 people, respectively. The corresponding total QALYs were 189 417, 189 439 and 189 440, respectively. The incremental cost-effectiveness ratio of screening for 2YR and 5YR were $28,000 and $60,000 per QALY, respectively. Compared with RISK, 2YR and 5YR could avoid 56,700 and 63,300 new HCV infections in the next 30 years, where 53% of these infections can be attributed to HCV-infected persons released from correctional facilities.

Conclusion:

HCV screening followed by treatment with recently approved therapies in prisons is highly cost-effective. Our study quantifies reduction in HCV transmission and disease burden in society at large as a result of screening in prisons. Resources spent in prisons can substantially reduce the burden of HCV in both prisons and the society at large.