The cost-effectiveness of improved hepatitis C virus therapies in HIV/hepatitis C virus coinfected patients

Linas, Benjamin P.a,b; Barter, Devra M.a; Leff, Jared A.c; DiLorenzo, Madelined,e; Schackman, Bruce R.c; Horsburgh, Charles R.a,b; Assoumou, Sabrina A.a; Salomon, Joshua A.f; Weinstein, Milton C.g; Kim, Arthur Y.e; Freedberg, Kenneth A.b,d,e,g

doi: 10.1097/QAD.0000000000000093
Clinical Science

Objectives: To evaluate the effectiveness and cost–effectiveness of strategies to treat hepatitis C virus (HCV) in HIV/HCV coinfected patients in the United States.

Participants: Simulated cohort of HIV/HCV genotype 1 coinfected, noncirrhotic, HCV treatment-naive individuals enrolled in US HIV guideline-concordant care.

Design/interventions: Monte Carlo simulation comparing five strategies: no treatment; dual therapy with pegylated-interferon (PEG) and ribavirin (RBV); ‘PEG/RBV trial’ in which all patients initiate dual therapy and switch to triple therapy upon failure; ‘IL28B triage’ in which patients initiate either dual therapy or triple therapy based on their IL28B allele type; and PEG/RBV and telaprevir (TPV) triple therapy. Sensitivity analyses varied efficacies and costs and included a scenario with interferon (IFN)-free therapy.

Main measures: Sustained virologic response (SVR), life expectancy, discounted quality-adjusted life expectancy (QALE), lifetime medical costs, and incremental cost-effectiveness ratios (ICERs) in $/quality-adjusted life years (QALY) gained.

Results: ‘PEG/RBV trial,’ ‘IL28B triage,’ and ‘triple therapy’ each provided 72% SVR and extended QALE compared with ‘dual therapy’ by 1.12, 1.14, and 1.15 QALY, respectively. The ICER of ‘PEG/RBV trial’ compared with ‘dual therapy’ was $37 500/QALY. ‘IL28B triage’ and ‘triple therapy’ provided little benefit compared with ‘PEG/RBV trial,’ and both had ICERs exceeding $300 000/QALY. In sensitivity analyses, IFN-free treatment attaining 90% SVR had an ICER less than $100 000/QALY compared with ‘PEG/RBV trial’ when its cost was $109 000 or less (125% of the cost of PEG/RBV/TVR).

Conclusion: HCV protease inhibitors are most efficiently used in HIV/HCV coinfection after a trial of PEG/RBV, sparing protease inhibitors for those who attain rapid virologic response and SVR. The cost-effectiveness of IFN-free regimens for HIV/HCV coinfection will depend on the cost of these therapies.

aSection of Infectious Diseases, Department of Medicine, Boston Medical Center

bDepartment of Epidemiology, Boston University School of Public Health, Boston, Massachusetts

cDepartment of Public Health, Weill Cornell Medical College, New York, New York

dDivision of General Medicine, Massachusetts General Hospital

eDivision of Infectious Diseases, Massachusetts General Hospital

fDepartment of Global Health and Population

gDepartment of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA.

Correspondence to Benjamin P. Linas, MD, MPH, HIV Epidemiology and Outcomes Research Unit, Boston Medical Center, 850 Harrison Avenue, Dowling-3N Room 3205, Boston, MA 02118, USA. Tel: +1 617 414 5238; fax: +1 617 414 7062; e-mail: Benjamin.Linas@BMC.org

Received 13 August, 2013

Revised 19 September, 2013

Accepted 19 September, 2013

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© 2014 Lippincott Williams & Wilkins, Inc.