Cost-effectiveness and budget impact analysis of facility-based screening and treatment of hepatitis C in Punjab state of India

Objective Despite treatment availability, chronic hepatitis C virus (HCV) public health burden is rising in India due to lack of timely diagnosis. Therefore, we aim to assess incremental cost per quality-adjusted life year (QALY) for one-time universal screening followed by treatment of people infected with HCV as compared with a no screening policy in Punjab, India. Study design Decision tree integrated with Markov model was developed to simulate disease progression. A societal perspective and a 3% annual discount rate were considered to assess incremental cost per QALY gained. In addition, budgetary impact was also assessed with a payer's perspective and time horizon of 5 years. Study setting Screening services were assumed to be delivered as a facility-based intervention where active screening for HCV cases would be performed at 22 district hospitals in the state of Punjab, which will act as integrated testing as well as treatment sites for HCV. Intervention Two intervention scenarios were compared with no universal screening and treatment (routine care). Scenario I-screening with ELISA followed by confirmatory HCV-RNA quantification and treatment. Scenario II-screening with rapid diagnostic test (RDT) kit followed by confirmatory HCV-RNA quantification and treatment. Primary and secondary outcome measures Lifetime costs; life years and QALY gained; and incremental cost-effectiveness ratio for each of the above-mentioned intervention scenario as compared with the routine care. Results Screening with ELISA and RDT, respectively, results in a gain of 0.028 (0.008 to 0.06) and 0.027 (0.008 to 0.061) QALY per person with costs decreased by -1810 Indian rupees (-3376 to -867) and -1812 Indian rupees (-3468 to -850) when compared with no screening. One-time universal screening of all those >= 18 years at a base coverage of 30%, with ELISA and RDT, would cost 8.5 and 8.3 times more, respectively, when compared with screening the age group of the cohort 40-45 years old. Conclusion One-time universal screening followed by HCV treatment is a dominant strategy as compared with no screening. However, budget impact of screening of all >= 18-year-old people seems unsustainable. Thus, in view of findings from both cost-effectiveness and budget impact, we recommend beginning with screening the age cohort with RDT around mean age of disease presentation, that is, 40-45 years, instead of all >= 18-year-old people.

Automated summary

The study suggests that implementing a one-time universal screening followed by treatment for HCV infected individuals in Punjab, India, is a cost-effective strategy when compared to no screening policy. However, the budget impact of screening all individuals >= 18 years old may be unsustainable. Therefore, the recommendation is to start with screening the age cohort of 40-45 years old with rapid diagnostic tests (RDT) based on both cost-effectiveness and budget impact findings.