Prevention of Hepatitis C by Screening and Treatment in U.S. Prisons

Abstract

BACKGROUND: The prevalence of hepatitis C virus (HCV) in U.S. prisoners is high; however, HCV testing and treatment are rare. Infected inmates released back into society contribute to the spread of HCV in the general population. Routine hepatitis screening of inmates followed by new therapies may reduce ongoing HCV transmission. OBJECTIVE: To evaluate the health and economic effect of HCV screening and treatment in prisons on the HCV epidemic in society. DESIGN: Agent-based microsimulation model of HCV transmission and progression of HCV disease. DATA SOURCES: Published literature. TARGET POPULATION: Population in U.S. prisons and general community. TIME HORIZON: 30 years. PERSPECTIVE: Societal. INTERVENTIONS: Risk-based and universal opt-out hepatitis C screening in prisons, followed by treatment in a portion of patients. OUTCOME MEASURES: Prevention of HCV transmission and associated disease in prisons and society, costs, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratio (ICER), and total prison budget. RESULTS OF BASE-CASE ANALYSIS: Implementing risk-based and opt-out screening could diagnose 41,900 to 122,700 new HCV cases in prisons in the next 30 years. Compared with no screening, these scenarios could prevent 5500 to 12,700 new HCV infections caused by released inmates, wherein about 90% of averted infections would have occurred outside of prisons. Screening could also prevent 4200 to 11,700 liver-related deaths. The ICERs of screening scenarios were $19,600 to $29,200 per QALY, and the respective first-year prison budget was $900 to $1150 million. Prisons would require an additional 12.4% of their current health care budget to implement such interventions. RESULTS OF SENSITIVITY ANALYSIS: Results were sensitive to the time horizon, and ICERs otherwise remained less than $50,000 per QALY. LIMITATION: Data on transmission network, reinfection rate, and opt-out HCV screening rate are lacking. CONCLUSION: Universal opt-out HCV screening in prisons is highly cost-effective and would reduce HCV transmission and HCV-associated diseases primarily in the outside community. Investing in U.S. prisons to manage hepatitis C is a strategic approach to address the current epidemic. PRIMARY FUNDING SOURCE: National Institutes of Health.