Original Research
24 November 2015

Prevention of Hepatitis C by Screening and Treatment in U.S. Prisons

Publication: Annals of Internal Medicine
Volume 164, Number 2

Abstract

Background:

The prevalence of hepatitis C virus (HCV) in U.S. prisoners is high; however, HCV testing and treatment are rare. Infected inmates released back into society contribute to the spread of HCV in the general population. Routine hepatitis screening of inmates followed by new therapies may reduce ongoing HCV transmission.

Objective:

To evaluate the health and economic effect of HCV screening and treatment in prisons on the HCV epidemic in society.

Design:

Agent-based microsimulation model of HCV transmission and progression of HCV disease.

Data Sources:

Published literature.

Target Population:

Population in U.S. prisons and general community.

Time Horizon:

30 years.

Perspective:

Societal.

Interventions:

Risk-based and universal opt-out hepatitis C screening in prisons, followed by treatment in a portion of patients.

Outcome Measures:

Prevention of HCV transmission and associated disease in prisons and society, costs, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratio (ICER), and total prison budget.

Results of Base-Case Analysis:

Implementing risk-based and opt-out screening could diagnose 41 900 to 122 700 new HCV cases in prisons in the next 30 years. Compared with no screening, these scenarios could prevent 5500 to 12 700 new HCV infections caused by released inmates, wherein about 90% of averted infections would have occurred outside of prisons. Screening could also prevent 4200 to 11 700 liver-related deaths. The ICERs of screening scenarios were $19 600 to $29 200 per QALY, and the respective first-year prison budget was $900 to $1150 million. Prisons would require an additional 12.4% of their current health care budget to implement such interventions.

Results of Sensitivity Analysis:

Results were sensitive to the time horizon, and ICERs otherwise remained less than $50 000 per QALY.

Limitation:

Data on transmission network, reinfection rate, and opt-out HCV screening rate are lacking.

Conclusion:

Universal opt-out HCV screening in prisons is highly cost-effective and would reduce HCV transmission and HCV-associated diseases primarily in the outside community. Investing in U.S. prisons to manage hepatitis C is a strategic approach to address the current epidemic.

Primary Funding Source:

National Institutes of Health.

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Supplemental Material

Supplement. Supplementary Material

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Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 164Number 219 January 2016
Pages: 84 - 92

History

Published online: 24 November 2015
Published in issue: 19 January 2016

Keywords

Authors

Affiliations

Tianhua He, MD
From the University of Pittsburgh, Pittsburgh, Pennsylvania; Tsinghua University School of Medicine, Beijing, China; University of Texas Health Science Center at Houston, Houston, Texas; Rollins School of Public Health, Emory University, and H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia; and Institute for Technology Assessment, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts.
Kan Li, MS
From the University of Pittsburgh, Pittsburgh, Pennsylvania; Tsinghua University School of Medicine, Beijing, China; University of Texas Health Science Center at Houston, Houston, Texas; Rollins School of Public Health, Emory University, and H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia; and Institute for Technology Assessment, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts.
Mark S. Roberts, MD, MPP
From the University of Pittsburgh, Pittsburgh, Pennsylvania; Tsinghua University School of Medicine, Beijing, China; University of Texas Health Science Center at Houston, Houston, Texas; Rollins School of Public Health, Emory University, and H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia; and Institute for Technology Assessment, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts.
Anne C. Spaulding, MD, MPH
From the University of Pittsburgh, Pittsburgh, Pennsylvania; Tsinghua University School of Medicine, Beijing, China; University of Texas Health Science Center at Houston, Houston, Texas; Rollins School of Public Health, Emory University, and H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia; and Institute for Technology Assessment, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts.
Turgay Ayer, PhD
From the University of Pittsburgh, Pittsburgh, Pennsylvania; Tsinghua University School of Medicine, Beijing, China; University of Texas Health Science Center at Houston, Houston, Texas; Rollins School of Public Health, Emory University, and H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia; and Institute for Technology Assessment, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts.
John J. Grefenstette, PhD
From the University of Pittsburgh, Pittsburgh, Pennsylvania; Tsinghua University School of Medicine, Beijing, China; University of Texas Health Science Center at Houston, Houston, Texas; Rollins School of Public Health, Emory University, and H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia; and Institute for Technology Assessment, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts.
Jagpreet Chhatwal, PhD
From the University of Pittsburgh, Pittsburgh, Pennsylvania; Tsinghua University School of Medicine, Beijing, China; University of Texas Health Science Center at Houston, Houston, Texas; Rollins School of Public Health, Emory University, and H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia; and Institute for Technology Assessment, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Acknowledgment: The authors thank Kenneth Sherman and Rich Feffer for constructive comments that improved the quality of the manuscript and Jill Delsigne for editing the manuscript. Dr. Chhatwal had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Grant Support: In part by the National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR000146. Dr. He's effort was supported by the China Scholarship Council.
Disclosures: Dr. Chhatwal reports grants from National Institutes of Health during the conduct of the study, personal fees from Complete HEOR Solutions and Merck & Co., and grants and personal fees from Gilead Sciences outside the submitted work. Dr. Spaulding reports grants and personal fees from Gilead Sciences during the conduct of the study, personal fees from Janssen, grants from Boehringer, and grants from Bristol-Myers Squibb outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-0617.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Reproducible Research Statement: Study protocol: Not applicable. Statistical code and data set: Available from Dr. Chhatwal ([email protected]).
Corresponding Author: Jagpreet Chhatwal, PhD, Institute for Technology Assessment, Massachusetts General Hospital, 101 Merrimac Street, 10th Floor, Boston, MA 02114; e-mail, [email protected].
Current Author Addresses: Dr. He: 602 Mingri Dasha, 69 DongDan North Street, Beijing, China, 100005.
Mr. Li: 1200 Herman Pressler Drive, RAS E-803N, Houston, TX 77030.
Dr. Roberts: 130 De Soto Street, Suite A621, Pittsburgh, PA 15261.
Dr. Spaulding: 1518 Clifton Road, Room 3033, Atlanta, GA 30322.
Dr. Ayer: 417 Groseclose Building, 765 Ferst Drive, Atlanta, GA 30332.
Dr. Grefenstette: 702A Parran Hall, 130 DeSoto Street, Pittsburgh, PA 15261.
Dr. Chhatwal: Institute for Technology Assessment, Massachusetts General Hospital, 101 Merrimac Street, 10th Floor, Boston, MA 02114.
Author Contributions: Conception and design T. Ayer, J. Chhatwal, J.J. Grefenstette, T. He, K. Li, M.S. Roberts.
Analysis and interpretation of the data T. Ayer, J. Chhatwal, T. He, K. Li, M.S. Roberts, A.C. Spaulding.
Drafting of the article J. Chhatwal, T. He.
Critical revision for important intellectual content T. Ayer, J. Chhatwal, J.J. Grefenstette, T. He, K. Li, M.S. Roberts, A.C. Spaulding.
Final approval of the article T. Ayer, J. Chhatwal, J.J. Grefenstette, T. He, K. Li, M.S. Roberts, A.C. Spaulding.
Provision of study materials or patients J. Chhatwal.
Statistical expertise T. Ayer, J. Chhatwal, T. He, K. Li.
Obtaining of funding J. Chhatwal.
Collection and assembly of data J. Chhatwal, T. He, K. Li.
This article was published at www.annals.org on 24 November 2015.

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Tianhua He, Kan Li, Mark S. Roberts, et al. Prevention of Hepatitis C by Screening and Treatment in U.S. Prisons. Ann Intern Med.2016;164:84-92. [Epub 24 November 2015]. doi:10.7326/M15-0617

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