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Authors: Natasha K. Martin, Peter Vickerman, Matthew Hickman
Journal: Hepatology (2016)

We were very impressed with the 90% uptake reported through implementation of opt-out blood-borne virus screening among new entrants achieved through pre- and postscreening counseling in three major Italian prisons. This uptake is substantially higher than that achieved among the select pilot prisons implementing opt-out blood-borne virus screening in England, and therefore would substantially improve the cost-effectiveness of such programs.1 Additionally, the efforts of the authors to develop an established network with Infectious Disease, Hepatology, and Liver Transplantation units to reduce loss to follow-up and improve continuity of care after release is an important step toward ensuring cost-effectiveness of any prison testing and treatment program, as shown in our previous work.2 Additionally, the high proportion of people who inject drugs (PWID) among those identified through the testing program supports the concept that prison is an ideal setting for hepatitis C virus (HCV) prevention and potentially HCV treatment as prevention. These factors would likely improve cost-effectiveness of an opt-out HCV testing program in prison, although any associated additional program costs would need to be considered. However, the decision to prioritize HCV direct-acting antiviral (DAA) treatment for F3/F4 individuals (based on Italian guidelines) is likely to have several important implications for cost-effectiveness as well as potential treatment as prevention benefits. First, targeting people with severe disease is likely to limit prevention benefit, because the majority of ongoing transmission occurs among PWID, who normally have mild disease3 unless injecting duration until cessation is prolonged or they have significant HIV coinfection. This is contrary to evidence that suggests prioritizing PWID for early treatment is cost-effective in settings with <60% chronic HCV among PWID—but of course, while HCV treatment costs remain high, targeting people with severe disease is the first priority.4 Second, the restriction of treatment to patients with F3/F4 and patients with over 3 months remaining on their sentence will limit the effective treatment rate, potentially reducing the cost-effectiveness of the opt-out testing program.1 This is illustrated in the Italian data, where only 29 patients were treated with DAAs out of a total of 191 chronic infections, because many patients were not eligible for DAA therapy. Overall, we are encouraged by the high success of the HCV testing programs in the Italian prisons reported in this study and the clear efforts to achieve completion, sustained viral response, and continuity of care among patients who are eligible for HCV DAA treatment. Additional data on uptake and outcomes among PWID would enable quantification of the impact and cost-effectiveness of such a strategy, including both individual benefits (on liver disease progression) and population benefits (on prevention of HCV transmission). Natasha K. Martin, D.Phil.1,2 Peter Vickerman, D.Phil.2 Matthew Hickman, Ph.D.2 1Division of Global Public Health University of California, San Diego San Diego, CA 2School of Social and Community Medicine University of Bristol Bristol, United Kingdom