Cost-effectiveness of alternative approaches to hepatitis C diagnosis and treatment initiation for treatment-naive people who inject drugs in Australia: a model-based economic evaluation

Background Eliminating hepatitis C virus (HCV) requires efficient testing and treatment strategies. We evaluated cost-effectiveness of alternative HCV diagnosis and treatment initiation approaches for treatment-naive people who inject drugs attending Australian community settings. Methods We compared seven strategies differing by use of antibody screening, laboratory and/or point-of-care tests; and point of treatment commencement. Outcomes were treatment initiation and completion. We considered costs from a healthcare sector perspective at a one-year time horizon. We used decision analytical models parameterized with publicly available estimates. Results Standard of care laboratory antibody then RNA testing on separate samples was cheapest but least effective. Laboratory antibody then reflex RNA testing on one sample provided higher effectiveness and was the only strategy to reduce average cost per completion ($6,141 2023AUD; 95%CI: $3,924–$10,382). Combined point-of-care antibody and RNA testing, point-of-care RNA alone, and point-of-care antibody with immediate treatment initiation in turn provided incremental improvements in completion at higher average costs per completion (point estimates: $6,976–$11,707). Changes in treatment uptake of at least 16 percentage points were required to achieve equivalence between reflex laboratory and point-of-care strategies. Although treatment of non-viremic individuals contributed to higher costs of point-of-care strategies, reflex laboratory testing remained less costly per completion at generic medication costs. Conclusions Reflex RNA testing was the most efficient strategy and can be implemented within the existing Australian laboratory framework. Point-of-care approaches may provide additional benefit at higher near-term costs. Studies accounting for transmission and disease sequelae are needed to understand cost-effectiveness in the longer term.