Elsevier

Public Health

Volume 141, December 2016, Pages 42-51
Public Health

Original Research
Tackling the burden of the hepatitis C virus in the UK: characterizing and assessing the clinical and economic consequences

https://doi.org/10.1016/j.puhe.2016.08.002Get rights and content

Highlights

  • Although HCV prevalence is expected to fall, the financial burden is expected to increase due to increasing ESLD incidence.

  • This study highlights the significant costs of managing ESLD complications without the use of DAAs or treatment prioritisation.

  • Partitioning patients according to certain characteristics equips policy makers for efficient treatment prioritisation.

  • An estimated £1,202,827,444 (discounted) will be attributable to the management of ESLD patients progressing over 2015–2035.

  • The benefits of targeting patients with advanced disease may only be fully realised with the use of therapies with high SVR.

Abstract

Objectives

The hepatitis C virus (HCV) remains a significant public health issue. This study aimed to quantify the clinical and economic burden of chronic hepatitis C in the UK, stratified by disease severity, age and awareness of infection, with concurrent assessment of the impact of implementing a treatment prioritization approach.

Study design and methods

A previously published back projection, natural history and cost-effectiveness HCV model was adapted to a UK setting to estimate the disease burden of chronic hepatitis C and end-stage liver disease (ESLD) between 1980 and 2035. A published meta-regression analysis informed disease progression, and UK-specific data informed other model inputs.

Results

At 2015, prevalence of chronic hepatitis C is estimated to be 241,487 with 22.20%, 33.72%, 17.22%, 16.67% and 10.19% of patients in METAVIR stages F0, F1, F2, F3 and F4, respectively, but is estimated to fall to 193,999 by 2035. ESLD incidence is predicted to peak in 2031. Assuming all patients are diagnosed and treatment is prioritized in F3 and F4 using highly efficacious direct-acting antiviral (DAA) regimens, a 69.85% reduction in ESLD incidence is predicted between 2015 and 2035, and the cumulative discounted medical expenditure associated with the lifetime management of incident ESLD events is estimated to be £1,202,827,444.

Conclusions

The prevalence of chronic hepatitis C is expected to fall in coming decades; however, the ongoing financial burden is expected to be high due to an increase in ESLD incidence. This study highlights the significant costs of managing ESLD that are likely to be incurred without the employment of effective treatment approaches.

Introduction

Patients with chronic hepatitis C are at risk of developing long-term, life-threatening sequelae, including decompensated cirrhosis and hepatocellular carcinoma (HCC), precursors to liver transplant, and death.1, 2, 3 While chronic hepatitis C can be successfully diagnosed and treated, significant numbers of patients are unaware of their infection due to the asymptomatic nature of the condition until the development of end-stage liver disease (ESLD); therefore, the expected financial burden of these undiagnosed cases is not well categorized, but is expected to be substantial.4

In the UK, the two major routes of HCV transmission have historically been the sharing of needles and paraphernalia among people who inject drugs (PWID) and transfusion of infected blood or blood products.5, 6 Screening of blood products and heat inactivation of the virus have virtually eliminated the latter as a source of newly acquired HCV infection, and the HCV epidemic in the UK is now largely driven by injecting drug use.5, 6 Latest estimates from UK public health bodies suggest that up to 90% of current HCV infections have occurred as a direct result of injection drug use,6 it is estimated that between 20% and 68% of PWID in the UK are infected with HCV, depending on geographical location and injection practices.4, 7, 8

Recent advances in the therapeutic landscape have led to the introduction of direct-acting antiviral (DAA) regimens with sustained virologic response (SVR) rates consistently >90%.9, 10, 11, 12 These treatments are associated with improved safety profiles and reduced therapy durations compared to historical interferon-based regimens, which provides the potential for improved adherence.9, 10, 11, 12 In principle, these therapies introduce the possibility of eradicating HCV; however, this depends not only on the effectiveness and acceptability of treatments, but on implementation approaches that are both clinically feasible and economically viable. Related research has suggested that concerns around the affordability of treating a large number of patients with chronic hepatitis C may be alleviated by prioritizing treatment in certain patient groups, such as those most likely to transmit infection to others.13 However, assessment of the impact of targeted implementation at a national level has not been undertaken. With this in mind, the principle aims of this research were to derive estimates of the prevalence of chronic hepatitis C in the UK, stratified by disease severity, age and awareness of infection, predict the onward presentation of ESLD and its economic burden, and assess the impact of implementing a targeted approach to treatment, prioritizing patients with advanced disease, on incidence of ESLD at the population level.

Section snippets

Analysis plan

Using a previously published back projection, natural history and cost-effectiveness HCV model14, 15, 16, 17, 18 adapted to a UK setting, a three-stage approach was taken:

Stage 1: The back-projection component of the model was used to predict the UK prevalence of chronic hepatitis C between 1980 and 2014 with constant infection rates applied to extrapolate to years 2015–2035. These prevalence estimates were then stratified by METAVIR fibrosis stage, age at infection and awareness of infection.

Results

The back projection analysis produced a chronic hepatitis C prevalence estimate of 241,487 in 2015 (Fig. 2). The trend indicated that the most rapid period of growth occurred during the 1980s. At 2015, it was estimated that 53,603 (22.20%), 81,422 (33.72%), 41,588 (17.22%), 40,266 (16.67%), and 24,608 (10.19%) of those chronically infected were in METAVIR fibrosis stages F0, F1, F2, F3 and F4, respectively. However, while the overall prevalence of chronic hepatitis C is predicted to decline to

Discussion

This study utilized a contemporary HCV natural history disease progression model to produce estimates of chronic hepatitis C prevalence that are consistent with previously predicted estimates.6, 20 The predicted prevalence of HCC events at 2012 is supported by observational record-linkage data on liver-related sequelae.6 This study has provided further granularity by partitioning according to METAVIR fibrosis stage, age and knowledge of infection status. This information is valuable as fibrosis

Ethical approval

Not required, as the manuscript describes an economic analysis using publicly available data.

Funding

Writing and research was funded by Bristol-Myers Squibb Pharmaceuticals Ltd; however, the publication of study results is not contingent on the sponsor's approval or censorship of the manuscript.

Competing interests

Thomas Ward, Phil McEwan, Jason Gordon, Hayley Bennett Wilton, Beverley Jones, Daniel Sugrue and Samantha Webster are employees of Health Economics and Outcomes Research Ltd, who received funding from

References (49)

  • D. Goldberg et al.

    Who is at risk and how do we identify them?

    J Viral Hepat

    (2004)
  • Public Health England

    Health Protection Scotland, Public Health Wales, Public Health Agency. Hepatitis C in the UK: 2015 report

    (2015)
  • L. Wiessing et al.

    Hepatitis C virus infection epidemiology among people who inject drugs in Europe: a systematic review of data for scaling up treatment and prevention

    PloS One

    (2014)
  • N.K. Martin et al.

    HCV treatment rates and sustained viral response among people who inject drugs in seven UK sites: real world results and modelling of treatment impact

    J Viral Hepat

    (2014)
  • M.S. Sulkowski et al.

    Daclatasvir plus sofosbuvir for previously treated or untreated chronic HCV infection

    N Engl J Med

    (2014)
  • E. Lawitz et al.

    Sofosbuvir for previously untreated chronic hepatitis C infection

    N Engl J Med

    (2013)
  • H. Innes et al.

    Strategies for the treatment of Hepatitis C in an era of interferon-free therapies: what public health outcomes do we value most?

    Gut

    (2014)
  • P. McEwan et al.

    The impact of timing and prioritization on the cost-effectiveness of birth cohort testing and treatment for hepatitis C virus in the United States

    Hepatology

    (2013)
  • P. McEwan et al.

    Estimating the incidence and prevalence of chronic hepatitis C infection in Taiwan using back projection

    Value Health Regional Issues

    (2013)
  • P. McEwan et al.

    Assessing the cost utility of response-guided therapy in patients with chronic hepatitis C genotype 1 in the UK using the MONARCH model

    Appl Health Econ Health Policy

    (2013)
  • P. McEwan et al.

    Estimating the clinical and economic benefit associated with incremental improvements in sustained virologic response in chronic hepatitis C

    PLoS One

    (2015)
  • P. Bacchetti et al.

    Backcalculation of HIV infection rates

    Stat Sci

    (1993)
  • M.J. Sweeting et al.

    The burden of hepatitis C in England

    J Viral Hepat

    (2007)
  • S. Deuffic et al.

    Modeling the hepatitis C virus epidemic in France

    Hepatology

    (1999)
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