Table 4.

Cost-Effectiveness of Treating All Patients Versus Delaying Treatment to Later Fibrosis Stage or to Later Diagnosis and Fibrosis Stage: People Who Inject Drugs (PWID).

Reference	Country	Genotype	Analysis		Model Features			Population			LMIC	Newest Drug(s)	Comparator(s)	ICER ($/QALY Gained)	Currency (Year)	Notes
			Fibrosis Stratified	Delay Considered	Model Typea	Transmission	Reinfection	PWID Focus	Incarcerated	Highly Stratified
Bennett, 201664	UK	1, 3	Yes	No	DT	Yes	Yes	Yes	No	No	No	SOF-DCV to treat PWIDs at high uptake rates	TVR-based treatment; PR treatment at different uptake rates	Cost saving	£ (2013)	Dependent on patient genotype, the cost-effectiveness of HCV treatment using daclatasvir plus sofosbuvir improved by 36% to 79% versus conventional analysis, at 10% to 100% treatment uptake in the PWID population.
Martin, 201665	UK	1–4	Yes	Implicit	DT	Yes	Yes	Yes	Yes	No	No	Double testing rates and provide all-oral DAA in prison	Status quo	15,090	£ (2014)	Delay is implicit if lower screening rates imply later detection (and hence more advanced fibrosis progression).
Martin, 201658	UK	1–4	Yes	Yes	DT	Yes	Yes	Yes	No	No	No	Treat all, targeting PWID/ex-PWID	Delay treatment until advanced fibrosis and/or exclude PWID	PWID HCV prevalence ≤40%, ≥F2 PWID and ex-PWID: <20,000 PWID HCV prevalence = 60%, ≥F2 ex-PWID: <20,000; including any PWID is not cost-effective	£ (2014)	When reinfection risk is high and transmission not substantially cut due to high HCV prevalence, immediate treatment targeting PWID is less cost-effective.
Scott, 201660	Australia	1, 2, 3	Yes	Yes	DT	Yes	Yes	Yes	No	No	No	Treatment expansion to active PWIDs with less advanced fibrosis	No expansion or expansion to reduce either mortality or incidence alone	25,121	Aus$ (2014)
Scott, 201661	Australia	1, 2, 3	Yes	Yes	DT	No	Yes	Yes	No	No	No	Treat early fibrosis	Treat late fibrosis; no treatment	17,090	Aus$ (2014)	Assumes an exogenous rate of reinfection (that treatment will not be scaled up sufficiently to impact infection risk to others).
Van Santen, 201663	Netherlands	1–4	Yes	Implicit	MS with DT	Yes	Yes	Yes	No	No	No	Dual DAAs with 3× treatment uptake via screening	Dual DAAs or status quo treatment at lower screening/uptake levels	<4,115	€ (2014)	With an epidemic in decline (as in Amsterdam, Netherlands), the ICER is 4,115. With a stable epidemic (greater risk of transmission without treatment), the ICER is lower and treatment of PWID is more cost-effective. Delay is implicit if lower screening rates imply later detection (and hence more advanced fibrosis progression).
Visconti, 201362	Australia	1/non-1	Yes	No	M	No	Yes	Yes	No	No	No	Treat ≥F1	Treat ≥F4; treat ≥F2; best supportive care only	Non-injectors: 4,221 Active injectors: 7,719 Former injectors: 5,919	Aus$ (2011)

DAA, direct-acting antiviral; DCV/ASV, daclatasvir/asunaprevir; F0, F1, F2, F3, F4, indicates severity of patient’s liver disease using metavir fibrosis scale (“≥F2” indicates all patients with at least F2 fibrosis which is F2, F3, and F4); HCV, hepatitis C virus; ICER, incremental cost effectiveness ratio; LMIC, low- and middle-income countries; PWID, people who inject drugs; QALY, quality-adjusted life year; SOF, sofosbuvir; SOF-DCV, sofosbuvir/daclatasvir; TVR, telaprevir.

^a.Model type: M, Markov model; DT, dynamic transmission model; MS, microsimulation; AB, agent-based simulation.