Chronic Hepatitis C Virus (HCV) Burden in Rhode Island: Modelling Treatment Scale-up and Elimination Ayorinde Soipe, MBBS Homie Razavi, PhD Devin Razavi-Shearer, BS,BA Omar Galárraga, PhD Lynn E. Taylor, MD Brandon DL Marshall, PhD
Disclosure No disclosures.
Background Illness and death due to chronic HCV has increased as baby boomers continue to age. Objective: to identify the most effective HCV treatment and prevention policies that will lead to a substantial decrease, and eventual elimination, of chronic HCV infection in Rhode Island (RI). Relevance: first study to utilize state-specific estimates in making projections on the future burden of HCV
Background Medicaid: health insurance program in the US.
Drug coverage data readily available Direct Acting Antiviral (DAA) agents such as SOFOSBUVIR now covered by Medicaid Regimens are curative and reduce all-cause and liver-related mortality.
Background • US states Medicaid HCV treatment policies (SOFOSBUVIR) Liver disease stage: documentation of stage 3 or 4 hepatic fibrosis Substance use: 6 months free from alcohol or intravenous drug use. HIV co-infection: receiving ART or have suppressed HIV RNA levels. Prescriber type: Gastroenterologist, Hepatologist or Infectious Disease physician
National representation of Medicaid reimbursement criteria for sofosbuvir, based on fibrosis stage
ME
OR IA
IL
RI (F3)
CA OK
FL
Barua et al Restrictions for Medicaid reimbursement of sofosbuvir for the treatment of hepatitis C virus infection in the United States. Annals of internal medicine. 2015;163(3):215-23.
Methods Mathematical model was constructed in Excel, and model input estimates were subjected to various sensitivity analysis.
State-specific estimates were used to parameterize the model (wherever possible). Estimates were abstracted from existing literature and also sourced through expert consultations
Methods Model adapted from a previously validated and published framework A system dynamics model that tracks disease progression among subgroups of people Projections were made on HCV disease burden up to year 2030.
Methods: Treatment Scenarios 1. Current HCV treatment paradigm continues (~120 patients treated annually, restricted to Medicaid fibrosis stage F3 and above) 2. An immediate scale-up of treatment (to 360 annually, and treat fibrosis stage F2 and above) 3. An immediate treatment scale-up to 360 and no fibrosis stage restriction (treat F0 and above) 4. An “elimination” scenario (i.e., a continued treatment scale-up needed to achieve >90% reduction in viremic cases by 2030, no restriction).
Results: Predicted number of patients for treatment
Number of Infections
Results : Chronic HCV Infection 16000 14000 12000 10000 8000 6000 4000 2000 0 F0 F3 HCC
F1 Cirrhosis Total Viremic
F2 Decomp Cirrhosis
Results : Total Viremic Infections
-20%
-85%
Results : Cirrhotic Cases -16% -25%
-72%
Results : Liver-Related Deaths -14% -23%
-68%
Limitations
Discussion
Modelling output is dependent on validity of input data and assumptions We assumed constant incidence (number of new infections may be underestimated) Model did not account for transmission Uncertainty associated with estimates accounted for in sensitivity analyses
Conclusion Current Medicaid HCV treatment criteria is not sufficient to reduce the burden of HCV. Ramping up treatment is needed to achieve a significant impact on HCV burden (treat approximately 2000 persons yearly by 2025) Increased screening of at-risk populations is also needed.
Acknowledgements Funding from Rhode Island Defeats Hepatitis C. In-kind support from Center for Disease Analysis (http://www.centerforda.com/), Center For Aids Research, Brown University Graduate School, and Brown School of Public Health. Special thanks to Jesse Yedinak, MPA for administrative support.
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Table 1. Estimated total prevalence of hepatitis C in RI for populations under-represented by or excluded from the NHANES Population
HCV Prevalence
Point-estimate of Population Size in RI
Estimated Range of HCV Cases in RI
Homeless
22.2% - 52.5%
1048
233 - 550
Incarcerated
20.0% - 25.0%
3191
638 - 798
Veterans
5.40% - 10.7%
73420
3965 - 7856
0.48%
1490
7
0.90% - 3.60%
59894
539 - 2156
4.50%
8040
362
Chronic Hemodialysis
2.30% - 7.90%
1041
24 - 82
Hemophiliacs with Transfusions Before 1992
76.3% - 100%
*
43 - 57
Total
5811 -11868
Active Military Duty Healthcare Workers Nursing Home Residents
Sensitivity Analyses: Liver-Related Deaths Liver Related Deaths Liver Related Deaths
250 250
200 200 150 150 100 100 50
500 0
Number of chronic of chronic Number infections infections
Sensitivity Analyses: Chronic Infections 20,000 20,000 15,000 15,000 10,000 10,000
5,000 5,000 0
0