Screening for acute hepatitis C virus (HCV) infection in HIV-positive men who have sex with men (MSM) prolongs life expectancy and is cost-effective, according to results of a multilayered modeling study. Depending on HCV incidence, regular screening with liver function tests, with or without HCV antibody tests, was the optimal strategy.
Outbreaks of acute HCV have occurred in HIV-positive MSM in Europe, the United States, and Australia since 2000.
Researchers hypothesized that identifying and treating acute HCV may be a better strategy than treating chronic HCV because therapy for acute HCV is generally more effective. They undertook this study to see if and when screening for acute HCV infection in HIV-positive MSM is cost-effective.
The model considered one-time screening for HCV at enrollment in care, followed by (1) symptom-based screening or (2) screening with liver function tests (LFTs), HCV antibody screening, or HCV RNA screening in various combinations and intervals. The investigators considered treatment with pegylated interferon plus ribavirin (PEG/RBV) alone or with PEG/RBV plus an HCV protease inhibitor. The analysis assumed a societal willingness to pay $100,000 per quality-adjusted life-year (QALY) gained.
Compared with symptom-based screening alone, all strategies analyzed increased life expectancy (from 0.49 to 0.94 life-months), increased quality-adjusted life expectancy (from 0.47 to 1.00 quality-adjusted life-months), and increased costs (from $1900 to $7600).
Compared with symptom-based screening, the incremental cost-effectiveness ratio of screening with 6-month LFTs and a 12-month HCV antibody test was $43,700 per QALY for PEG/RBV alone and $57,800 per QALY for PEG/RBV plus an HCV protease inhibitor.
Compared with 6-month LFTs plus a 12-month HCV antibody test, the incremental cost-effectiveness ratio for 3-month LFTs was $129,700 per QALY for PEG/RBV alone and $229,900 per QALY for PEG/RBV plus an HCV protease inhibitor.
With PEG/RBV plus an HCV protease inhibitor, screening with 6-month LFTs and a 12-month HCV antibody test proved the optimal strategy when HCV infection incidence (the new diagnosis rate) was at or below 1.25 cases per 100 person-years. When HCV incidence lay above that threshold, the 3-month LFT strategy was optimal.
The modelers conclude that “one-time screening for prevalent HCV infection at enrollment in HIV care is not adequate.” Adopting “routine periodic screening for newly acquired HCV infection,” they stress, “extends life expectancy and is cost-effective.”
The investigators call for “evidence-based guidelines . . . to inform screening for acute HCV infection in HIV-infected MSM.”