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Routine rapid HCV testing cost-effective in younger generations
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Routine rapid testing for hepatitis C virus infection among adolescents and young adults was cost-effective when implemented in communities with a high prevalence of the virus and injection drug use, according to results of a recent modeling study.
“In light of high rates of HCV infection among young adults, our findings provide information to inform recommendations for HCV testing among persons between 15 [and] 30 years of age,” Bruce R. Schackman, PhD, professor of health care policy and research at Weill Cornell Medical College, and colleagues wrote in Clinical Infectious Diseases.
In the United States, HCV testing is currently recommended for individuals born between 1945 and 1965 and patients at risk for infection. According to the researchers, nearly all cases of HCV transmission occur among young people who inject drugs (PWID).
Schackman and colleagues developed a decision analytic model to determine the clinical benefit and cost-effectiveness of testing all patients aged 15 to 30 years, regardless of risk status, at urban community health centers in the U.S. They estimated quality-adjusted life years (QALYs), lifetime costs and incremental cost-effectiveness ratios (ICERs) that were associated with targeted vs. routine testing, rapid finger stick testing vs. standard venipuncture, and testing ordered by a physician vs. a counselor. The researchers based current practice scenarios on data from three community health centers with a high number of HCV cases in Boston.
Compared with targeted risk-based testing, which is the current standard of care, routine HCV testing increased lifetime medical costs by $80 and reduced QALYs by 0.0013 per patient. In each scenario, rapid testing provided greater life expectancy and resulted in higher QALYs at a lower cost per QALY gained.
Counselor-initiated routine rapid testing yielded an ICER of $71,000/QALY gained and was the optimal strategy in 90% of 100,000 simulations. This strategy identified more cases of HCV (20% vs. 5%) and was associated with a higher SVR rate (18% vs. 2%) and fewer HCV-related deaths (34% vs. 31%) compared with current practice.
In sensitivity analyses, counselor-initiated routine rapid testing was cost-effective (ICER < $100,000/QALY) unless the prevalence of PWID among patients aged 15 to 30 years was less than 0.59%, the HCV prevalence among PWID was less than 16%, reinfection rates exceeded 26 cases per 100 person-years, or reflex confirmatory testing was performed following all reactive venipuncture diagnostics.
“When standard testing was applied, patients were less likely to come back for that second appointment to get their results, which in turn meant more people weren't getting the treatment they so desperately needed,” study researcher Sabrina Assoumou, MD, MPH, an infectious disease physician at Boston Medical Center and assistant professor of medicine at Boston University School of Medicine, said in a press release. "Our results indicate that we must initiate rapid [testing] strategies so that more people will know their status and get treatment more quickly."
In a related editorial, Jagpreet Chhatwal, PhD, assistant professor of radiology at Harvard Medical School and decision scientist at Massachusetts General Hospital Institute for Technology Assessment, said that additional modeling studies validating the findings may help encourage policymakers to update current HCV testing recommendations.
“Evidence-based updates in HCV screening policies are needed to reduce HCV transmission and diagnose and treat patients who otherwise would remain unaware of their infection,” he wrote. “Decision-analytic modeling is an ideal method to explore and “test” potential strategies for HCV elimination before resources are spent to implement them in practice. Such models can guide planners in establishing evidence-based guidelines that can restrict disease spread.” – by Stephanie Viguers
Disclosures: Chhatwal reports receiving consultancy fees and institutional grant funding through Merck and Gilead Sciences. Schackman and colleagues report no relevant financial disclosures.
Perspective
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This is a valuable study. The identification of HCV is important because then physicians can refer patients to treatment and prevent them from passing the virus on to other people.
Through modeling, the researchers compared a few different strategies for HCV testing in young adults aged 15 to 30 years. The researchers compared rapid point-of-care testing, which produces results in about 20 minutes, vs. venipuncture, the gold standard of testing that produces results anywhere between 3 days and a week and requires a return visit. They found that in all communities, it was much more cost-effective to offer HCV rapid testing. They also found that you can save money and link more people to care if a trained counselor tests people rather than a doctor or a nurse.
The results suggest that, in communities where nonprescription opioid use is common, counselor-initiated testing was more cost-effective than physician-initiated testing. We should not wait until the patient comes in with an abscess or an overdose event; rather, we should test every patient aged 15 to 30 years who comes to our clinic. Early, broader HCV testing is important because the stigma of opioid use disorder prevents patients from disclosing risks that may trigger testing. I think that is a real paradigm shift for a lot of infectious disease physicians because we often wait for signs, symptoms or illnesses that travel with someone who has opioid use disorder. It is a great primary preventive strategy to try to diagnose and link people to care.
This study is very powerful, and we hope that it will lead to state and national shifts in testing algorithms to help address the HCV epidemic. However, the researchers calculated the average lifespan to be 80 years old. Unfortunately, many of these patients may not live that long because of limited treatment options for the underlying opioid use disorder and limited access to these current treatment options. It would be interesting to know how competing causes of death not related directly to HCV or liver disease would impact the findings.
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