Universal prenatal hepatitis C virus (HCV) screening was found to be cost-effective and improved health outcomes in women diagnosed with HCV infection and identification of HCV exposure in neonates, according to a study published in Obstetrics & Gynecology.
A research team used a stochastic microsimulation model to analyze the health outcomes and cost-effectiveness of universal testing for HCV infection during prenatal care. Lifetimes of 250 million pregnant women matched at baseline with the US population on age, injection use behaviors, and HCV infection status were simulated. Two scenarios were considered: current practice screening of a small percentage of women during prenatal care, and universal testing for HCV infection at the first clinical encounter for each pregnancy.
HCV disease progression was modeled according to stages of liver fibrosis as categorized by METAVIR scores. HCV testing was modeled at the first prenatal visit with serum HCV antibody testing followed by HCV RNA testing. Treatment was modeled with a 12-week regimen based on sofosbuvir and velpatasvir for those with cirrhosis and an 8-week regimen of glecaprevir and pibrentasvir for those without cirrhosis. Clinical trial and real-world effectiveness data were used to determine treatment adherence and sustained virologic response rates between 93% and 99% depending on HCV genotype and stage of fibrosis. Age-stratified healthcare costs were estimated using the Medicare Reimbursement Fee Schedule.
The simulation continues until each member of the original cohort dies; short-term effects of testing for HCV were also predicted by conducting 5- and 10-year simulations. Incremental cost-effective ratios were estimated as the ratio of the difference in discounted, lifetime medical costs between the strategies and the difference in discounted, quality-adjusted life years (QALY) lived under each strategy.
Members of the generated cohort were on average 28 years of age, and the overall prevalence of HCV infection in the cohort was 0.38%. A diagnosis of HCV resulted in 4.7 years of lost life expectancy and 2.88 years of lost discounted quality-adjusted life expectancy under the current practice scenario. This scenario identified 90% of all HCV infections over the lifetime of the cohort; 63% initiated treatment and 60% achieved sustained virologic response.
Universal prenatal testing increased the percentage of all HCV infections identified to 92%, and small improvements were found in treatment initiation (66%) and sustained virologic response (63%). Universal testing resulted in 1.21 additional years of life expectancy and 0.5 additional years of quality-adjusted life expectancy compared with current practice. Universal testing in prenatal settings reduced HCV-related mortality by 16% over the lifetime of the cohort. Universal testing more than doubled the proportion of neonates born to women with HCV who were identified as exposed to HCV compared with current practice (92% vs 44%, respectively). This also resulted in a 6% decrease in the proportion of neonates born with HCV exposure.
Average lifetime health care costs per pregnant woman were $387,071 and $387,194 for current practice and universal prenatal testing, respectively. Discounted lifetime health care costs were $153,168 and $153,246 for current practice and universal prenatal testing strategies, respectively. The differences ($123, undiscounted; $78, discounted) represent the total net increase in lifetime health care costs per patient. Compared with current practice, universal prenatal testing resulted in an average gain of 0.002 QALY at the discounted cost; this corresponds to a cost-effectiveness ratio of $41,000 per QALY gained. Incremental cost-effectiveness ratios remained below $100,000 per QALY gained in most sensitivity analyses; exceptions include a mean time to cirrhosis of 70 years, a cost greater than $500,000 per false-positive diagnosis, or population of HCV infection prevalence below 0.16%.
“Universal prenatal HCV testing should be considered in plans for the elimination of viral hepatitis C as a public health threat,” the authors concluded.
Tasillo A, Eftekhari Yazdi G, Nolen S, et al. Short-term effects and long-term cost-effectiveness of universal hepatitis C testing in prenatal care. Obstet Gynecol. 2019;133(2):289-300.