Cost and cost-effectiveness of Hepatitis C virus self-testing in four settings: an economic evaluation
Authors: Walker Josephine G. , Ivanova Elena , Jamil Muhammad S. , Ong Jason J. , Easterbrook Philippa , Fajardo Emmanuel , Johnson Cheryl Case , Luhmann Niklas , Terris-Prestholt Fern , Vickerman Peter , Shilton Sonjelle 
Published: August 2022

AbstractIntroductionGlobally, there are approximately 58 million people with chronic hepatitis C virus infection (HCV) but only 20% have been diagnosed. HCV self-testing (HCVST) could reach those who have never been tested and increase access and uptake of HCV testing services. We compared cost per HCV diagnosis or cure for HCVST versus facility-based HCV testing services.MethodsWe used a decision analysis model with a one-year time horizon to examine the key drivers of economic cost per diagnosis (viraemic infection) or cure following the introduction of HCVST in China (men who have sex with men), Georgia (men 40-49 years), Viet Nam (people who inject drugs, PWID), and Kenya (PWID). HCV antibody (HCVAb) prevalence ranged from 1%-60% across settings. Model parameters in each setting were informed by HCV testing and treatment programmes, HIV self-testing programmes, and expert opinion. In the base case, we assume a reactive HCVST is followed by a facility-based rapid diagnostic test (RDT) and then nucleic acid testing (NAT). We assumed oral-fluid HCVST costs of $5.63/unit ($0.87-$21.43 for facility-based RDT), 62% increase in testing following HCVST introduction, 65% linkage following HCVST, and 10% replacement of facility-based testing with HCVST based on HIV studies. Parameters were varied in sensitivity analysis. Outcomes are reported in 2019 US dollars ($).ResultsCost per HCV viraemic diagnosis without HCVST ranged from $35 (Viet Nam) to $361 (Kenya). With HCVST, diagnosis increased resulting in incremental cost per diagnosis of $104 in Viet Nam, $163 in Georgia, $587 in Kenya, and $2,647 in China. Differences were driven by HCVAb prevalence. Switching to blood-based HCVST ($2.25/test), increasing uptake of HCVST and linkage to facility-based care and NAT testing, or proceeding directly to NAT testing following HCVST, reduced the cost per diagnosis. The baseline incremental cost per cure was lowest in Georgia ($1,418), similar in Viet Nam ($2,033), and Kenya ($2,566), and highest in China ($4,956).ConclusionsHCVST increased the number of people tested, diagnosed, and cured, but at higher cost. Introducing HCVST is more cost-effective in populations with high prevalence.Key messagesWhat is already known on this topicA recent systematic review of the impact and cost of Hepatitis C virus (HCV) self-testing (HCVST) found no prior evaluations of the cost or cost-effectiveness of HCVST. Indirect evidence can be inferred from studies of HIV self-testing (HIVST), which support the affordability and cost-effectiveness of self-testing in low and middle-income (LMIC) settings in Asia and sub-Saharan Africa. Other recent studies related to HCVST demonstrate the feasibility and usability of HCVST in various LMIC settings.What this study addsThis study is the first to evaluate the cost or cost-effectiveness of HCVST. With quality-assured HCVST coming onto the market in the near future, we build on the best available evidence on potential costs for HCV testing and treatment from four LMIC settings in general and key population groups with HCVAb prevalence ranging from 1% - 60%, and show it is likely to be cost-effective (depending on willingness to pay threshold) particularly where prevalence is high.How this study might affect research, practice or policyThe results of this study indicate that introducing HCVST will help countries diagnose and treat more people with HCV and contribute to achieving elimination goals faster. However, such gains will require additional investment on top of the standard of care. Targeting HCVST toward populations and settings with high HCV burden will be the most affordable option for countries. Efforts to reduce HCV treatment costs, optimize HCVST delivery and linkage services are needed to achieve greatest public health impact of offering this new approach.