Model shows that HCV therapy for patients with more severe fibrosis cost-effective in Egypt

Michael Carter
Published:
24 February 2014

Lack of resources means that Egypt should prioritise hepatitis C virus (HCV) treatment for patients with more advanced disease, according to a mathematical model published in the online edition of Clinical Infectious Diseases. Therapy for individuals with fibrosis stages 2 to 4 (F2-F4) was both effective and cost-effective. The model assumed patients received dual therapy with pegylated interferon and ribavirin.

Treatment for patients with F1 fibrosis was also cost-effective, but the investigators did not believe that it was the best use of limited resources.

“Immediate treatment at stage F1 is only slightly more effective than waiting for disease to progress to stage F2 before starting treatment and is sensitive to forthcoming availability of new treatments.”  

An estimated 15% of the adult population in Egypt is infected with HCV – the highest prevalence in the world.

Efforts have been made to promote access to HCV therapy in Egypt. Use of a pegylated interferon bio-similar has reduced the cost of treatment to between $1500-2000 per patient. Since 2006, the government has opened 23 treatment centres. These have provided therapy to an estimated 190,000 patients. But this represents only a small proportion of the HCV-infected population.

Treatment guidelines issued in 2010 recommended treating patients with fibrosis stage F1 who have elevated alanine aminotransferase (ALT), as well as patients with fibrosis stage F2-F3 regardless of ALT level. Patients with F4 fibrosis are excluded from therapy.

Even though there is political will to tackle the HCV epidemic, Egypt cannot afford to treat all its HCV-infected patients. To see which patients should be prioritised, an international team of investigators developed a mathematical model to determine the effectiveness and cost-effectiveness of HCV treatment strategies taking into account fibrosis stage at the time of entry to care.

The model compared life expectancy, lifetime costs, quality-adjusted life-expectancy (QALE) and incremental cost-effectiveness (i.e. additional cost of a strategy compared to next least expensive option) for different treatment strategies for patients with fibrosis stages F1-F4.

Results of the model showed that immediate treatment for patients with fibrosis stages F1-F3 was less expensive and had more clinical efficacy than delaying therapy until stage F4 disease (e.g. QALE F1 = 18.32 years vs QALE F2 = 18.22 years).

Treating patients with F4 stage fibrosis was associated with more costs than not offering treatment. Nevertheless, therapy for patients with this stage disease was associated with a significant improvement in QALE compared to no treatment (10.33 vs 8.77 years, respectively). Therapy for patients with F4 disease was also shown to be cost-effective (ICER = $1915 per quality-adjusted life year).

The model also showed that it would be more cost-effective to delay treatment for patients with stage F1 fibrosis until affordable triple combinations of direct-acting agents became available within the next three years.

The investigators believe their findings could help other resource-limited countries develop their own HCV treatment strategies. But they emphasise that models will have to be individualised to each country, taking into account factors including the costs of HCV therapy and care and fibrosis progression rates.

The authors also acknowledge that prioritising treatment for F4 patients over patients with F1 disease is controversial given the lower chances of treatment success with advanced fibrosis and the increased probability of complications. “However, one should acknowledge that short-term HCV-related mortality in these patients is substantially higher than in F1 patients, who could benefit from treatment at later stages,” argue the authors. “Moreover, it has been shown that patients achieving SVR [sustained virological response] in F4 have a reduced liver-related morbidity and mortality than those not treated.”

They therefore conclude, “treating patients at the most severe stage of chronic HCV is both effective and cost-effective in Egypt. Since only a limited number of treatment slots and HCV treatment centres are available, and new and more efficacious treatment should be available in the near future, it is important to prioritise treatment of those in stages F2 to F4.”

Reference

Obach D et al. Effectiveness and cost-effectiveness of immediate vs. delayed treatment of HCV-infected patients in a country with limited resources: the case of Egypt. Clin Infect Dis, advanced online publication ahead of print, 7 February 2014.