Model-based cost-effectiveness estimates of testing strategies for diagnosing hepatitis C virus infection in Central and Western Africa

• Published in: PloS one 2020-08, Vol.15 (8), p.e0238035-e0238035
• Main Authors: Duchesne, Lea, Hejblum, Gilles, Njouom, Richard, Toure Kane, Coumba, Toni, Thomas d'Aquin, Moh, Raoul, Sylla, Babacar, Rouveau, Nicolas, Attia, Alain, Lacombe, Karine
• Format: Article
• Language: English
• Subjects: Antibodies; Antigens; Biology and life sciences; Biomarkers; Blood; Core protein; Cost analysis; Decision trees; Diagnosis; Earth Sciences; Economic aspects; Economics; Feasibility studies; Health care costs; Hepatitis; Hepatitis C; Human health and pathology; Infections; Infectious diseases; Laboratories; Life Sciences; Low income groups; Medical diagnosis; Medical tests; Medicine and health sciences; Methods; Nucleotide sequence; Public health; Ribonucleic acid; RNA; Santé publique et épidémiologie; Sensitivity analysis; Serology; Social Sciences; Strategy; Studies; Virology; Viruses
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0238035

Whereas 72% of hepatitis C virus (HCV)-infected people worldwide live in low- and middle-income countries (LMICs), only 6% of them have been diagnosed. Innovative technologies for HCV diagnosis provide opportunities for developing testing strategies more adapted to resource-constrained settings. However, studies about their economic feasibility in LMICs are lacking. Adopting a health sector perspective in Cameroon, Cote-d'Ivoire, and Senegal, a decision tree model was developed to compare 12 testing strategies with the following characteristics: a one-step or two-step testing sequence, HCV-RNA or HCV core antigen as confirmative biomarker, laboratory or point-of-care (POC) tests, and venous blood samples or dried blood spots (DBS). Outcomes measures were the number of true positives (TPs), cost per screened individual, incremental cost-effectiveness ratios, and nationwide budget. Corresponding time horizon was immediate, and outcomes were accordingly not discounted. Detailed sensitivity analyses were conducted. In the base-case, a two-step POC-based strategy including anti-HCV antibody (HCV-Ab) and HCV-RNA testing had the lowest cost, [euro]8.18 per screened individual. Assuming a lost-to-follow-up rate after screening > 1.9%, a DBS-based laboratory HCV-RNA after HCV-Ab POC testing was the single un-dominated strategy, requiring an additional cost of [euro]3653.56 per additional TP detected. Both strategies would require 8-25% of the annual public health expenditure of the study countries for diagnosing 30% of HCV-infected individuals. Assuming a seroprevalence > 46.9% or a cost of POC HCV-RNA < [euro]7.32, a one-step strategy based on POC HCV-RNA dominated the two-step POC-based strategy but resulted in many more false-positive cases. POC HCV-Ab followed by either POC- or DBS-based HCV-RNA testing would be the most cost-effective strategies in the study countries. Without a substantial increase in funding for health or a dramatic decrease in assay prices, HCV testing would constitute an economic barrier to the implementation of HCV elimination programs in LMICs.