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.”