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. Author manuscript; available in PMC: 2023 Apr 5.
Published in final edited form as: Am J Prev Med. 2022 Oct 17;64(1):96–104. doi: 10.1016/j.amepre.2022.08.016

ECONOMIC IMPACT OF UNIVERSAL HCV TESTING FOR MIDDLE AGED ADULTS WHO INJECT DRUGS

Xinyi Jiang 1, Vakaramoko Diaby 1,2, Scott Martin Vouri 1,2, Weihsuan Lo-Ciganic 1,2, Robert Parker 3, Wei Wang 1, Shao-Hsuan Chang 1, Debbie L Wilson 1, Linda Henry 1, Haesuk Park 1,2
PMCID: PMC10074824  NIHMSID: NIHMS1884413  PMID: 36257884

Abstract

Objective:

To estimate the economic impact of providing universal hepatitis C virus (HCV) testing in commercially insured middle aged persons who inject drugs (PWIDs) in the United States.

Methods:

This study developed a dynamic ten-year economic model to project the clinical and economic outcomes associated with HCV testing among middle aged adult PWIDs, from a payer’s perspective. Costs related to HCV testing, direct-acting antiviral (DAA), and liver-related outcomes between the (1) current HCV testing rate (i.e., 8%) and (2) universal HCV testing rate (i.e., 100%) were compared. Among patients testing positive, 21% of those without cirrhosis and 48% with cirrhosis were assumed to initiate DAAs. Sensitivity analyses were performed to identify variables (e.g.: DAA drugs costs, HCV testing costs, DAA treatment rate) influencing this study’s conclusion.

Results:

The model predicts that during the 10-year period, universal HCV testing will cost an additional $242 per PWID to the payers’ health care budgets compared to the current scenario. Sensitivity analyses demonstrated values ranging from $1,656 additional costs to $1,085 cost savings across all varied parameters and scenarios. 80% of the current DAA costs indicated that cost savings will be $383 per PWID.

Conclusion:

Universal HCV testing among PWIDs would not achieve cost savings within 10 years, with the cost of DAAs contributing the most to the spending. To promote the universal HCV testing among PWIDs, decreasing DAA costs and sustainable funding streams for HCV testing should be considered.

Introduction

In the United States (US), more than 40% of all adults with hepatitis C virus (HCV) infection are unaware that they have HCV.1 Concurrent with the US opioid crisis, rates of new HCV infections increased by more than 60% from 2015 to 2019.2 New chronic HCV infections have occurred primarily among young adults aged 20-39 years due to sharing intranasal and intravenous drug use supplies, accounting for as much as 43% of newly reported infected individuals with chronic HCV in 2019.3 Indeed, persons who inject drugs (PWIDs) account for approximately 70% of all HCV cases in 2019.4

While the advent of highly effective all-oral, interferon-free direct acting antivirals (DAA) could stimulate the testing of patients for HCV, current evidence indicates PWIDs have very low HCV testing rates (< 20%).5,6 The most common barriers for some treatment programs to providing on-site HCV testing for PWIDs is declining federal funding and lack of integrated health care payment systems.7–9 Other barriers include human resource limitations and a lack of technical assistance.8

Previous studies concluded that the universal-testing approach among the specific populations (e.g.: PWIDs, baby boomer, and individuals receiving care in federally qualified health centers) was cost-effective compared to the status quo in the US and could eliminate HCV transmission completely with DAA treatment.10–14 However, little is known about the affordability of universal HCV testing among commercially-insured PWIDs in the US and how it may affect long-term healthcare costs.

Thus, this study aimed to estimate clinical and economic outcomes of universal HCV testing for commercially-insured PWIDs. This study constructed an economic model to project ten-year clinical and economic outcomes associated with increasing HCV testing rates for commercially-insured PWIDs, from a third-party payer’s perspective.

Methods

Model Overview

This study developed a dynamic economic model using Microsoft Excel 2016, following the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guideline.15 The economic model was set to predict the clinical and economic impact of HCV testing over 10 years among commercially-insured PWIDs.

Model Inputs

Eligible population and assumptions

This study used a hypothetical nationally representative cohort of 1,000 commercially-insured middle aged adult PWIDs. The mean age was 35 years, and the proportion of males was 50%. Since not all PWIDs have HCV infections, this study assumed 60% of them would be infected with HCV but unaware of their HCV status.4,12. This study also assumed that the sensitivity of HCV antibody and HCV RNA testing and the DAA cure rate were 100%.16–20 This study defined “HCV testing” as HCV antibody testing followed by immediate HCV RNA testing for patients with positive HCV antibody results (Supplement Table 1).13 This study assumed that patients were tested for HCV at year 0 and treated in year 0 only. If patients were not tested for HCV in year 0, they remained untested or untreated in the subsequent ten years in the model. The treatment initiation probabilities are based on cirrhosis status. Among PWIDs with diagnosed HCV in year 0, 21% of those without cirrhosis would initiate all-oral interferon-free DAA treatment, while 48% of those with cirrhosis would initiate all-oral interferon-free DAA treatment.19

PWIDs who are already diagnosed with HCV, HCV reinfection cases, and new HCV infection cases were not included in this model.

Current scenario and Universal-testing Scenario

This study developed the economic model under two scenarios. The first scenario was the current scenario using the current HCV testing rate (i.e., a testing rate of 8%) for all PWIDs in the baseline year (year 0), which was then followed by DAA treatment immediately after HCV diagnosis in year 0 for PWIDs diagnosed with HCV. The second scenario was the universal-testing scenario in which universal HCV testing for all PWIDs (i.e., a testing rate of 100%) was assumed in year 0 and immediately followed by DAA treatment in year 0 for PWIDs diagnosed with HCV.

The current rate of HCV testing (8%) was obtained from published literature using MarketScan commercial database.5

Analytic Model Descriptions

This study specified the economic model framework to have a one-year cycle length and seven relevant clinical states including non-cirrhosis, cirrhosis, decompensated cirrhosis (DCC), hepatocellular carcinoma (HCC), liver transplant, post-liver transplant, and liver-related death (including cirrhosis, DCC, HCC, liver transplant, post-liver transplant related death) or non-liver-related death. In the model, all PWIDs with HCV started in either a non-cirrhotic or cirrhotic state. 21 From these health states, one would either remain in their beginning state of cirrhosis or transition into the next state as shown in Supplement Figure 1. Once in a progressive liver related state, patients could either remain in this state or progress to liver-related death or non-liver-related death (Supplement Figure 1). The current scenario model and the universal-testing scenario model were analyzed for 10 years, with a 5 to 20-year span considered in the sensitivity analyses.

Transition probabilities

Transition probabilities for PWIDs with HCV who progressed from non-cirrhosis (or cirrhosis) to one of the other states were derived from the literature (Table 1).10,13,14,22–32 PWIDs with HCV and cirrhosis could still progress to advanced end-stage liver disease even after being treated for HCV, though with a slower annual transition probability than those who were not treated for HCV.19,33 PWIDs with HCV without cirrhosis could progress to HCC after being treated for HCV.19,34 If one PWID was HCV infected but not tested for HCV, this study assumed that patient would follow the natural course of untreated HCV.10

Table 1.

Parameter input for economic model

Input parameter Value Sources
HCV Epidemiology
A hypothetic national representative cohort of commercially insured adult PWIDs who are free from end-stage liver disease (ESLD) in the United States (U.S.) 1,000 Model design
Mean age of the PWIDs 35 years Bull-Otterson et al., 2020
Proportion of male 50% Bull-Otterson et al., 2020
Proportion of PWIDs who have HCV 60% Fuster et al., 2016
Carey et al., 2017
Proportion of PWIDs with HCV who have cirrhosis at baseline 10% Jiang et al., 2021
Proportion of PWIDs receiving HCV testing who have not been diagnosed with HCV disease at baseline (Year 0) 100% (for universal-testing scenario) Assumption
8% (for Current scenario) Bull-Otterson et al., 2020
The sensitivity of positive HCV antibody test 100% Freiman et al., 2015
The sensitivity of positive HCV RNA test 100% Tang et al., 2017
Proportion of identified PWIDs with HCV with cirrhosis initiating DAAs 48% Park et al., 2021
Proportion of identified PWIDs with HCV without cirrhosis initiating DAAs 21% Park et al., 2021
Annual Transition Probability
HCC-related death for untreated patients a 0.72 Liu et al., 2014
DCC-related death for untreated patients 0.26 Liu et al., 2014
Liver transplant-related death for untreated patients 0.14 Liu et al., 2014
Posttransplant to liver death for untreated patients 0.05 Liu et al., 2014
Cirrhosis-related death for untreated patients 0.03 Bruno et al., 2009. Assoumou et al., 2020 Dienstag et al., 2011
Non-liver-related death for untreated patients with cirrhosis 0.048 Xu et al., 2015
Non-liver-related death for untreated patients without cirrhosis 0.015 Xu et al., 2015
HCC-related death for treated patients b 0.485 Younossi et al., 2018
DCC-related death for treated patients 0.042 Younossi et al., 2018
Liver transplant-related death for treated patients 0.14 Liu et al., 2014
Posttransplant to liver death for treated patients 0.05 Liu et al., 2014
Cirrhosis-related death for treated patients 0.01 Bruno et al., 2009
Non-liver-related death for treated patients with cirrhosis 0.048*(0.9) = 0. 043 Xu et al., 2015
Liu et al., 2014
Non-liver-related death for treated patients without cirrhosis 0.015*(0.9) = 0.0135 Xu et al., 2015
Liu et al., 2014
Patients with cirrhosis
From cirrhosis to DCC in untreated HCV patients 0.039 Rein et al., 2012
From cirrhosis to HCC in untreated HCV patients 0.025 Rein et al., 2012
From patients with DCC to HCC in untreated HCV patients 0.014 Fattovich et al., 1997 Mattingly II, 2020
From patients with DCC to liver transplant in untreated HCV patients 0.023 Backus LI et al., 2016
From patients with HCC to liver transplant in untreated HCV patients 0.04 Dienstag et al., 2011
From patients with liver transplant to posttransplant in untreated HCV patients 0.834 Mattingly II, 2020
untreated HCV patients
From cirrhosis to DCC in treated HCV patients 0.003 Dienstag et al., 2011
From cirrhosis to HCC in treated HCV patients 0.006 Morgan et al., 2013
From patients with DCC to HCC in treated HCV patients 0.003 Younossi et al., 2018
From patients with DCC to liver transplant in treated HCV patients 0.007 Younossi et al., 2018
From patients with liver transplant to posttransplant in treated HCV patients 0.834 Mattingly II, 2020
Patients without cirrhosis
From liver disease-free to cirrhosis in untreated HCV patients 0.115 Thein et al., 2008
From liver disease-free to DCC in untreated HCV patients 0.012 Dienstag et al., 2011
From liver disease-free to HCC in untreated HCV patients 0.011 Dienstag et al., 2011
From liver disease-free to HCC in treated HCV patients 0.003 Younossi et al., 2016
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HCV = hepatitis C virus; RNA = ribonucleic acid; DAAs = direct-acting antivirals; DCC = decompensated cirrhosis; HCC = hepatocellular carcinoma; HR= hazard ratio; PWIDs=persons who inject drugs

a

untreated patients: PWIDs with HCV without direct-acting antiviral treatment

b

treated patients: PWIDs with HCV with direct-acting antiviral treatment

The non-liver-related mortality rates were different by DAA treatment status as well as the presence of cirrhosis at baseline. Each liver-related-mortality rate differed based on whether patients were on DAAs or not.23,35,36 Overall, the transition probabilities for mortality among patients treated with DAAs were lower than those without DAAs. This study identified the transition probabilities for mortality among DAA-treated and untreated patients from the literature (Table 1).10,13,22–24,26

Costs

Four types of costs were included in the model: HCV antibody testing cost, HCV RNA testing cost, DAA treatment cost, and liver-related medical cost (including cirrhosis, DCC, HCC, liver transplant, and post-liver transplant) (Table 2). The average cost for each HCV antibody test is $28 per person, and for each HCV RNA test is $43 per person, which were obtained from the Clinical Diagnostic Laboratory Fee Schedule (Supplement Table 1).37 The cost of DAA treatment per treatment course was estimated as $22,791 for a patient without cirrhosis (8-week regimen) and $28,136 for a patient with cirrhosis (12-week regimen) and were obtained from literature.13

Table 2.

Cost input for economic model

Cost Input a Value Sources
The cost of HCV antibody test ($) per person 28 2018 Clinical Diagnostic Laboratory Fee Schedule
The cost of HCV RNA ($) per person 43 2018 Clinical Diagnostic Laboratory Fee Schedule
Patients with cirrhosis
Unadjusted Annual cirrhosis-related cost for an untreated PWIDs with HCV ($) 3936.9 Garg et al., 2020
Unadjusted Annual cirrhosis-related cost for a treated PWIDs with HCV ($) 1968.5 Mattingly et al., 2020.
Garg et al., 2020
Unadjusted Annual DCC-related cost for an untreated PWIDs with HCV ($) 19,016.7 Garg et al., 2020
Unadjusted Annual HCC-related cost for an untreated PWIDs with HCV ($) 71,239.7 Garg et al., 2020
Unadjusted Annual liver transplant-related cost for an untreated PWIDs with HCV ($) 90,604.2 Garg et al., 2020
Posttransplant 52,051.4 Mattingly et al., 2020
DAA treatment cost per patient per treatment course ($) 28,135.6 Assoumou et al., 2020
Patients without cirrhosis
Unadjusted Annual DCC-related cost for an untreated PWIDs with HCV ($) 19,016.7 Garg et al., 2020
Unadjusted Annual HCC-related cost for an untreated PWIDs with HCV ($) 71,239.7 Garg et al., 2020
Unadjusted Annual liver transplant-related cost for an untreated PWIDs with HCV ($) 90,604.2 Garg et al., 2020
Posttransplant 52,051.4 Mattingly et al., 2020
DAA treatment cost per patient per treatment course ($) 22,791.33 Assoumou et al., 2020
Open in a new tab

HCV = hepatitis C virus; DCC = decompensated cirrhosis; HCC = hepatocellular carcinoma; RNA = ribonucleic acid; DAAs = direct-acting antivirals

a

All costs used in the model were reported in 2022 US dollars from a third-party payer’s perspective. A 3% inflation rate was used to adjust costs.

The per person per year (PPPY) cirrhosis, DCC, HCC, liver-transplant, and post-liver transplant related medical costs for PWIDs with untreated HCV were derived from the literature.31,38 For PWIDs with treated HCV, the cirrhosis-related PPPY cost was half of the cost for untreated patients and other liver-related costs remained the same once they develop end-stage liver disease (Table 2).31 All costs used in the model were reported in 2022 US dollars. A 3% annual discount rate was applied for costs.

Model Outputs

This study compared the current scenario and the universal-testing scenario in terms of costs related to (1) annual liver-related medical costs (including cirrhosis, DCC, HCC, liver-transplant, and post-liver transplant) from year 1 to year 10; (2) cumulative ten-year liver-related medical costs; (3) HCV testing and DAA treatment costs. The unit of measurement for the results was “per PWID”.

Sensitivity analyses

To assess the impact of key model parameters on the analysis results, one-way and two-way deterministic sensitivity analyses were conducted. A range of probabilities and values were used to determine the HCV testing rate (18%), HCV prevalence among PWIDs who have not been diagnosed with HCV (40%–80%), the percentage of patients with cirrhosis (5%–20%), sensitivity of HCV testing (96%), DAA cure rate (95%), DAA costs (−20%–+20%), cirrhosis-related cost (−20%–+20%), implementation cost ($16,890–$69,486) or HCV testing cost (−10%) in the universal-testing scenario, and the proportion of DAA treatment initiation by cirrhosis status (Supplement Table 2).

Results

Liver-Related Outcomes

Over a ten-year period, the annual number of prevented liver-related events increased from 16 cases in year 1 to 36 cases in year 10 when comparing the universal-testing scenario to the current scenario (Supplement Figure 2A). The annual number of all-cause deaths prevented also increased from 3 cases in year 1 to 4 cases in year 10 (Supplement Figure 2B).

Liver-Related Medical Costs

Overall, the PPPY annual liver-related savings increased from $230 in year 1 to $795 in year 10 comparing the universal-testing scenario to the current scenario. In PWIDs with cirrhosis, the PPPY annual savings were high in year 1 ($1,000) but then decreased to $814 in year 10, whereas in those without cirrhosis, the PPPY annual savings were less at the beginning ($145 in year 1), but then increased to $793 in year 10 (Figure 1). This study estimated that the cumulative ten-year liver-related medical savings would be $2,931 per PWID if universal HCV testing were conducted. The cumulative ten-year liver-related medical cost savings would be much more for PWIDs with cirrhosis ($5,893 per PWID) than for those without cirrhosis ($2,602 per PWID) (Figure 2).

Figure 1.

Figure 1.

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Annual Liver-Related Cost Savings from a Universal Testing Scenario for 1,000 Commercially Insured Adult Persons Who Inject Drugs, Stratified by Cirrhosis Status

Figure 2.

Figure 2.

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The Cumulative Ten-Year Liver-Related Cost Savings from a Universal Testing Scenario for 1,000 Commercially Insured Adult Persons Who Inject Drugs, Stratified by Cirrhosis Status

HCV Testing and DAA Treatment Costs

The cost of HCV testing and DAA treatment per PWID would increase by $3,173 if HCV testing became universal. The cost of DAA treatment per PWID would account for most of the increase, increasing by $3,123 (98%), while the cost of HCV testing per PWID would only increase by $50 (2%). The additional cost would be much more for PWIDs with cirrhosis ($7,505 per PWID) than for those without cirrhosis ($2,692 per PWID) (Supplement Figure 3).

Economic Impact

After comparing the cumulative ten-year liver-related medical cost savings with the increased costs of HCV testing and DAA treatment, this model indicates that testing 1,000 commercially insured PWIDs, followed by DAA treatment, would not achieve the cost savings, adding an additional $242 per PWID to third party payers’ health care budgets during the 10 years. PWIDs without cirrhosis would add an additional $89 per PWID when tested universally while PWIDs with cirrhosis would add an additional $1,612 per PWID to the health care budget over the current 8% testing rate, with the cost of DAAs contributing the most to the spending.

Sensitivity Analyses

Sensitivity analyses demonstrated values ranging from $1,656 additional costs to $1,085 cost savings across all varied parameters and scenarios. One-way sensitivity analyses show that twenty-year model will save an additional $1,085 per PWID, although the five-year model would not achieve cost savings if HCV testing becomes universal. Ten-year model with reduced DAA cost (i.e., 80% of the current DAA costs) indicates cost savings by $383 per PWID. Two-way sensitivity analyses show that if cirrhosis-related cost for an untreated HCV patient is increased by 20% and cirrhosis-related cost for a treated HCV patient is reduce by 20%, universal HCV testing would save $120 per person. If DAA cost is decreased by 20% and cirrhosis-related cost for an untreated HCV patient is decreased or increased by 20%, universal HCV testing would save $92 and $674 respectively.

All other sensitivity analyses indicated that universal HCV testing among PWIDs would not achieve cost savings (Supplement Figure 4).

Discussion

This study examined the ten-year clinical and economic impact of universal HCV testing with DAA treatment among commercially insured middle aged PWIDs. This study found that as the number of prevented liver-related complications increase over time, the annual medical cost savings continued to increase. However, the ten-year accumulated medical cost savings would not outweigh the cost of HCV testing and DAAs, adding an additional $242 per PWID to third party payers’ health care budgets.

A prior study showed that universal HCV testing compared to no HCV testing for PWIDs was cost-effective over a 10-year time horizon using a societal perspective in the US.12 This study found that universal HCV testing among PWIDs would not achieve cost savings, although the most up-to-date, lower DAA price was incorporated. However, ten-year economic model with 80% of the current DAA costs would achieve cost savings by $383 per PWID, suggesting that varying DAA cost has the biggest impact on the budget.39 Of note, the actual DAA costs may be less due to contracts and rebates negotiated between pharmaceutical companies and payers. This study, therefore, suggests that, with an expectation of a decrease in DAA drug price over time, total cost savings for third-party payers will be thus achieved for testing PWIDs for HCV universally.

This study also found PWIDs with HCV and cirrhosis would not achieve cost savings even at 80% of the current DAA costs (data not shown) over the 10-year time-horizon. This is due to longer DAA treatment periods with a lower cure rate for treating those with HCV and cirrhosis, which would lead to higher treatment costs offsetting the cost savings from avoided adverse liver-related outcomes. To realize the cost benefit, PWIDs with HCV must be tested and treated early in their course of infection before they develop cirrhosis.

The Centers for Disease Control and Prevention (CDC) and the US Preventive Services Task Force (USPSTF) recently updated their recommendations to suggest all adults be tested for HCV at least once, and those with ongoing risky behaviors such as PWIDs be routinely and periodically tested.40,41 To achieve the universal HCV testing goal, financial and personnel resources are required to successfully implement the universal HCV testing program. Thus, this study included sensitivity analyses with the implementation costs from the social or health department or provider’s perspective.42–45 Targeted interventions to enhance HCV testing among PWIDs include integrated HCV care, medications for opioid use disorders (MOUD), and mental health services delivered by a multidisciplinary team (e.g.: infectious disease specialists, addiction specialists, and primary care physicians) with case management services.6,46 However, declining funding and limited billing capacity are the most common barrier to integrate HCV testing services, especially in addiction treatment centers.8 Furthermore, identifying and treating PWIDs for opioid use disorder has already been challenging due to stigma and lack of public funding for MOUD.47 Offering HCV testing thus may not be perceived as a principal mission of addiction treatment centers.7 To increase the on-site HCV testing for PWIDs, sustainable funding streams, upgraded billing options, and policies that enhance HCV testing are recommended.8

The twenty-year economic model indicated that the cost savings from averted liver-related complications outweighed the costs of HCV testing and DAA treatment by $1,085 per PWID (no cost savings for PWIDs with HCV and cirrhosis). Nevertheless, no cost savings within 10 years could discourage the commercial payers to incorporate HCV service into their insurance benefit design among PWIDs, especially when the median length of patient enrollment for private payers is less than 10 year.33 However, recent literature indicates that many individuals are reenrolled with the same insurer within 5 years of disenrollment, which should be factored into the benefit design.48 On the other hand, for public payers such as Medicaid/Medicare and the Veterans Administration, the length of enrollment is longer, thus such payers may achieve economic savings.33 Given that Medicaid is the nation’s largest payer for PWIDs49, providing a budget for universal HCV testing to all Medicaid beneficiaries with PWIDs followed by DAA treatment for those testing positive may provide value for the money invested in the HCV testing and DAAs, especially when the beneficiaries do not have cirrhosis.33

This study has several strengths. As one of the first to directly investigate the economic impact of testing PWIDs for HCV, this study applied the proportion of DAA treatment initiation based on cirrhosis status, which reflects the distribution of DAA utilization in the real world as patients with advanced liver disease are more likely to obtain access to DAAs.50 Previous modeling studies did not account for the difference in transition probability and the length of time needed to treat those with and without cirrhosis, which significantly change the costs of treatment.10 Additionally, this study applied the most current liver-related costs and DAA costs to represent real world costs.13,31,38

This study also has several limitations. First, this study’s findings may be limited, because the model was developed from a mix of available data sources that were not necessarily intended for research purposes. For example, this study was not able to incorporate all transition probabilities for PWIDs with a mean age of 35 years, so it is not able to account for some acceleration in liver-related disease that may occur in this population.19,34 Thus, this study may have underestimated the rate of disease progression among untested or untreated PWIDs. Second, to predict future costs, the model was based on a variety of assumptions that may also potentially limit economic evaluations. For example, this study did not consider HCV reinfection due to the low HCV reinfection rates among PWIDs (1.14 per 100 person-years).51 Third, this study did not consider the improved clinical benefits beyond liver-related outcomes following DAA treatment including reduced HCV-associated extrahepatic manifestations, non-hepatic cancer outcomes and substance use disorder-related utilization.21,52,53 Therefore, this study may underestimate the saved medical costs following DAA. Fourth, this study did not consider indirect costs, for example, costs for education and outreach programs to reach untested PWIDs. However, this study incorporated the implementation costs in the sensitivity analyses and found that the results were consistent with the main analysis. Fifth, this study does not incorporate periodic HCV testing among PWIDs. Previous literature demonstrated that testing all people including annual HCV testing of PWIDs is highly cost-effective within 20 years.54 Finally, this study did not differentiate between long term and short term PWIDs due to the limitation of the claims-based algorithms.5 HCV prevalence among PWIDs varies depending on the duration of drug use. Nevertheless, the sensitivity analyses with different HCV prevalence corroborated the findings in the main analysis.

Conclusion

From a third-party payer’s perspective, among commercially insured middle aged PWIDs, universal HCV testing followed by immediate DAA treatment results in an increase of $242 per PWID economic impact on their budget over ten years. Nevertheless, the cost savings would be fully achieved within 20 years or when the costs of DAA further declines. Therefore, to promote universal HCV testing among PWIDs following the CDC and USPSTF recommendations, decreasing DAA costs and sustainable funding streams for HCV testing should be considered.

Supplementary Material

Supplementary materials

Supplement Figure 1. Markov Model of Chronic HCV Infection and Progression

DCC = decompensated cirrhosis; HCC = hepatocellular carcinoma; HCV = hepatitis C virus

Arrows show the transition between health states

Supplement Figure 2. Annual Averted Clinical Outcomes from a Universal Testing Scenario During the 10-year Period After HCV Testing for 1,000 Commercially Insured Adult Persons Who Inject Drugs

HCV = hepatitis C virus; DAAs = direct-acting antivirals; PWIDs=persons who inject drugs

a Liver related events include cirrhosis, decompensated cirrhosis, hepatocellular carcinoma, liver transplant, and post-liver transplant related diseases.

Supplement Figure 3. Additional HCV Testing and Treatment Costs from a Universal Testing Scenario for 1,000 Commercially Insured Adult Persons Who Inject Drugs (PWID), Stratified by Cirrhosis Status. A) HCV Antibody Testing Cost Per PWID. B) HCV RNA Testing Cost per PWID. C) HCV Treatment Cost Per PWID. D) HCV Testing and Treatment Cost per PWID.

HCV = hepatitis C virus; RNA = ribonucleic acid; DAAs = direct-acting antivirals

Supplement Figure 4. Sensitivity Analyses for Cost Savings Per Commercially Insured Persons Who Inject Drugs compared Between the Universal-testing Scenario and the Current Scenario

HCV = hepatitis C virus; DAAs = direct-acting antivirals

Acknowledgments:

The authors thank Peng Gao for providing assistance in formatting references.

Footnotes

CONFLICT OF INTEREST: The authors declare that there is no conflict of interest regarding the publication of this article.

Financial Disclosure statement: No financial disclosures were reported by the authors of this paper.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary materials

Supplement Figure 1. Markov Model of Chronic HCV Infection and Progression

DCC = decompensated cirrhosis; HCC = hepatocellular carcinoma; HCV = hepatitis C virus

Arrows show the transition between health states

Supplement Figure 2. Annual Averted Clinical Outcomes from a Universal Testing Scenario During the 10-year Period After HCV Testing for 1,000 Commercially Insured Adult Persons Who Inject Drugs

HCV = hepatitis C virus; DAAs = direct-acting antivirals; PWIDs=persons who inject drugs

a Liver related events include cirrhosis, decompensated cirrhosis, hepatocellular carcinoma, liver transplant, and post-liver transplant related diseases.

Supplement Figure 3. Additional HCV Testing and Treatment Costs from a Universal Testing Scenario for 1,000 Commercially Insured Adult Persons Who Inject Drugs (PWID), Stratified by Cirrhosis Status. A) HCV Antibody Testing Cost Per PWID. B) HCV RNA Testing Cost per PWID. C) HCV Treatment Cost Per PWID. D) HCV Testing and Treatment Cost per PWID.

HCV = hepatitis C virus; RNA = ribonucleic acid; DAAs = direct-acting antivirals

Supplement Figure 4. Sensitivity Analyses for Cost Savings Per Commercially Insured Persons Who Inject Drugs compared Between the Universal-testing Scenario and the Current Scenario

HCV = hepatitis C virus; DAAs = direct-acting antivirals

NIHMS1884413-supplement-Supplementary_materials.docx (1.5MB, docx)

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