Modelled impact of antiviral therapy on Modelled impact of antiviral therapy on

the future burden of HCV disease the future burden of HCV disease

in Scotlandin Scotland

Testing/Treatment/Care Working Group, 11Testing/Treatment/Care Working Group, 11thth Sept 2007 Sept 2007

Effectiveness and cost-effectiveness Effectiveness and cost-effectiveness

of HCV antiviral therapyof HCV antiviral therapy

• Overall response rates of 50-60% with antiviral Overall response rates of 50-60% with antiviral

therapytherapy

• Cost-effectiveness studies have demonstrated that Cost-effectiveness studies have demonstrated that

antiviral therapy leads to gains in QALYs that justify antiviral therapy leads to gains in QALYs that justify

the additional cost of treatmentthe additional cost of treatment

• NICE & QIS recommend NICE & QIS recommend pegylated interferon plus pegylated interferon plus

ribavirin for patients with mild and moderate disease ribavirin for patients with mild and moderate disease

& compensated cirrhosis& compensated cirrhosis

Burden of HCV disease among IDUs in Scotland, 2008Burden of HCV disease among IDUs in Scotland, 2008

Chronic InfectionChronic Infection

Mild diseaseMild disease

Moderate diseaseModerate disease

Severe disease Severe disease (cirrhosis)(cirrhosis)

No infectionNo infection

Liver failureLiver failure

HCVHCVAll IDUs Former IDUs

35,700 28,400

21,800 15,700

11,900 10,800

2,000 1,900

105 per year

Hutchinson et al. Hepatology 2005

Modelled prevalent number of HCV infected IDUs in ScotlandModelled prevalent number of HCV infected IDUs in Scotland

according to stage of HCV disease, 1960-2030according to stage of HCV disease, 1960-2030

1960 1980 2000 2020

0

10

20

30

40

50

60

Liv

ing

IDU

s (t

ho

us

an

ds

)

2008

Calendar year

Mild disease

Moderate disease

Cirrhosis

Recovered from HCV

Cleared HCV from treatment

Hutchinson et al. Hepatology 2005

Cirrhosis prevented Cirrhosis prevented

from antiviral therapy*from antiviral therapy*

Liv

ing

ID

Us

wit

h c

irrh

osi

sL

ivin

g I

DU

s w

ith

cir

rho

sis

20102010 20202020 20302030

001,

000

1,00

02,

000

2,00

03,

000

3,00

0

20102010 20202020 20302030

001,

000

1,00

02,

000

2,00

03,

000

3,00

0

20102010 20202020 20302030

001,

000

1,00

02,

000

2,00

03,

000

3,00

0

Decompensated Decompensated

cirrhosiscirrhosisHCCHCC

* Excludes those prevented from antiviral therapy prior to 2008 * Excludes those prevented from antiviral therapy prior to 2008

Compensated Compensated

cirrhosiscirrhosis

Modelled number of IDUs with cirrhosis in ScotlandModelled number of IDUs with cirrhosis in Scotland

by different uptake rates of HCV antiviral therapy, 2008-2030by different uptake rates of HCV antiviral therapy, 2008-2030

Uptake of therapy Uptake of therapy

by 225 IDUs per yearby 225 IDUs per year

Uptake of therapy Uptake of therapy

by 1,000 IDUs per yearby 1,000 IDUs per year

Uptake of therapy by Uptake of therapy by

(up to) 2,000 IDUs per year(up to) 2,000 IDUs per year

Annual number of IDUs Annual number of IDUs

developing liver failuredeveloping liver failure

Cumulative number of liver failures Cumulative number of liver failures

prevented from therapyprevented from therapy

Modelled number of IDUs in Scotland with liver failure Modelled number of IDUs in Scotland with liver failure

with different uptake rates of HCV antiviral therapy, 2008-2030with different uptake rates of HCV antiviral therapy, 2008-2030

Assuming uptake of HCV Assuming uptake of HCV

antiviral therapy by:antiviral therapy by:

20102010 20152015 20202020 20252025 20302030

00

5050

100100

150150

An

nu

al n

um

ber

An

nu

al n

um

ber

20102010 20152015 20202020 20252025 20302030

00

200200

400400

600600

800800

1,0001,000

Cu

mu

lati

ve n

um

ber

Cu

mu

lati

ve n

um

ber

0 former IDUs per year0 former IDUs per year

225 former IDUs per year225 former IDUs per year

1,000 former IDUs per year1,000 former IDUs per year

(up to) 2,000 former IDUs per year(up to) 2,000 former IDUs per year

Co

ho

rt m

em

be

rs

Co

ho

rt m

em

be

rs

(liv

ing

/de

ad

)(l

ivin

g/d

ea

d)

20102010 20302030 20502050 20702070

00

10,00010,000

20,00020,000

30,00030,000

Modelled follow-up of 35,000 IDUs in Scotland with chronic Modelled follow-up of 35,000 IDUs in Scotland with chronic

HCV disease (mild/moderate/compensated cirrhosis) in 2008HCV disease (mild/moderate/compensated cirrhosis) in 2008

Scenario for entire IDU population: Uptake of therapy by 225 IDUs per yearScenario for entire IDU population: Uptake of therapy by 225 IDUs per year

Cleared HCV from Cleared HCV from

antiviral therapyantiviral therapy

Mild diseaseMild disease

Moderate diseaseModerate disease

CirrhosisCirrhosis

HCV-related deathHCV-related death

Non-HCV-related Non-HCV-related

deathdeath

Co

ho

rt m

emb

ers

Co

ho

rt m

emb

ers

(liv

ing

/dea

d)

(liv

ing

/dea

d)

20102010 20302030 20502050 20702070

00

10,00010,000

20,00020,000

30,00030,000

Modelled follow-up of 35,000 IDUs in Scotland with chronic Modelled follow-up of 35,000 IDUs in Scotland with chronic

HCV disease (mild/moderate/compensated cirrhosis) in 2008HCV disease (mild/moderate/compensated cirrhosis) in 2008

Cleared HCV from Cleared HCV from

antiviral therapyantiviral therapy

Mild diseaseMild disease

Moderate diseaseModerate disease

CirrhosisCirrhosis

HCV-related deathHCV-related death

Non-HCV-related Non-HCV-related

deathdeath

In 2030, 7% of 19,500 living cohort members estimated to In 2030, 7% of 19,500 living cohort members estimated to

have cleared HCV from antiviral therapyhave cleared HCV from antiviral therapy

Scenario for entire IDU population: Uptake of therapy by 225 IDUs per yearScenario for entire IDU population: Uptake of therapy by 225 IDUs per year

Co

ho

rt m

em

be

rs (

livin

g/d

ead

)C

oh

ort

me

mb

ers

(liv

ing

/dea

d)

20102010 20302030 20502050 20702070

00

10,00010,000

20,00020,000

30,00030,000

20102010 20302030 20502050 20702070

00

10,00010,000

20,00020,000

30,00030,000

Modelled follow-up of 35,000 IDUs in Scotland with chronic Modelled follow-up of 35,000 IDUs in Scotland with chronic

HCV disease (mild/moderate/compensated cirrhosis) in 2008HCV disease (mild/moderate/compensated cirrhosis) in 2008

Uptake of therapy by Uptake of therapy by

1,000 IDUs per year1,000 IDUs per yearUptake of therapy by Uptake of therapy by

(up to) 2,000 IDUs per year(up to) 2,000 IDUs per year

31% of the 19,800 alive cleared 31% of the 19,800 alive cleared HCV from antiviral therapyHCV from antiviral therapy

50% of the 20,100 alive cleared 50% of the 20,100 alive cleared HCV from antiviral therapyHCV from antiviral therapy

Co

ho

rt m

emb

ers

Co

ho

rt m

emb

ers

(liv

ing

/dea

d)

(liv

ing

/dea

d)

20102010 20302030 20502050 20702070

00

10,00010,000

20,00020,000

30,00030,000

Modelled follow-up of 35,000 IDUs in Scotland with chronic Modelled follow-up of 35,000 IDUs in Scotland with chronic

HCV disease (mild/moderate/compensated cirrhosis) in 2008HCV disease (mild/moderate/compensated cirrhosis) in 2008

Cleared HCV from Cleared HCV from

antiviral therapyantiviral therapy

Mild diseaseMild disease

Moderate diseaseModerate disease

CirrhosisCirrhosis

HCV-related deathHCV-related death

Non-HCV-related Non-HCV-related

deathdeath

16% died from HCV-related cause during 2008-207016% died from HCV-related cause during 2008-2070 260 HCV-related deaths averted from antiviral therapy260 HCV-related deaths averted from antiviral therapy

Scenario for entire IDU population: Uptake of therapy by 225 IDUs per yearScenario for entire IDU population: Uptake of therapy by 225 IDUs per year

Co

ho

rt m

em

be

rs (

livin

g/d

ead

)C

oh

ort

me

mb

ers

(liv

ing

/dea

d)

20102010 20302030 20502050 20702070

00

10,00010,000

20,00020,000

30,00030,000

20102010 20302030 20502050 20702070

00

10,00010,000

20,00020,000

30,00030,000

Modelled follow-up of 35,000 IDUs in Scotland with chronic Modelled follow-up of 35,000 IDUs in Scotland with chronic

HCV disease (mild/moderate/compensated cirrhosis) in 2008HCV disease (mild/moderate/compensated cirrhosis) in 2008

Uptake of therapy by Uptake of therapy by

1,000 IDUs per year1,000 IDUs per yearUptake of therapy by Uptake of therapy by

(up to) 2,000 IDUs per year(up to) 2,000 IDUs per year

13% died from HCV-related cause 13% died from HCV-related cause 1,250 HCV-related deaths averted1,250 HCV-related deaths averted

11% died from HCV-related cause 11% died from HCV-related cause 2,000 HCV-related deaths averted2,000 HCV-related deaths averted

Health service costs & quality of life (QOL) associated with Health service costs & quality of life (QOL) associated with stages of chronic HCV disease, 2005stages of chronic HCV disease, 2005

Stage Annual cost per patient QOL

Mild disease UndiagnosedDiagnosed

During therapySVR

£0 £144 ** **

0.820.770.650.82

Moderate disease UndiagnosedDiagnosed

During therapySVR

£0 £749 ** **

0.720.660.550.72

Compensated cirrhosis

UndiagnosedDiagnosed

During therapySVR

£0 £1,188

** **

0.600.550.450.62

Decompensated cirrhosis £9,521 0.45

HCC £8,485 0.45

Liver Transplant Transplant costs1st yr follow-up2nd yr follow-up

£28,533 £9,874 £1,446

-0.670.67

Treatment costs (Peg Interferon & Rib therapy & monitoring costs)

£8,781** -

Cost-effectiveness analysis of increasing uptake of HCV Cost-effectiveness analysis of increasing uptake of HCV

antiviral therapy in Scotlandantiviral therapy in Scotland

Entire IDU Entire IDU populationpopulation

IDU cohort:IDU cohort: Cumulative cost*Cumulative cost*

(2008-2070)(2008-2070)

Uptake of antiviral therapy Uptake of antiviral therapy

by former IDUsby former IDUsManagement/Management/

MonitoringMonitoring

of HCV of HCV

diseasedisease

HCV antiviral HCV antiviral

therapytherapyTotalTotal

N per yearN per year Cumulative Cumulative number during number during

2008-2070 2008-2070

(% of 35,000)(% of 35,000)

00 00 £276 million£276 million £0£0 £276 million£276 million

225225 5,100 (15%)5,100 (15%) £263 million£263 million £26 million£26 million £289 million£289 million

1,0001,000 21,300 (61%)21,300 (61%) £220 million£220 million £112 million£112 million £332 million£332 million

2,0002,000 29,100 (83%)29,100 (83%) £185 million£185 million £177 million£177 million £362 million£362 million

* Discounted at 3.5%* Discounted at 3.5%

Cost-effectiveness analysis of increasing uptake of HCV Cost-effectiveness analysis of increasing uptake of HCV

antiviral therapy in Scotlandantiviral therapy in Scotland

Entire IDU Entire IDU populationpopulation

IDU cohort:IDU cohort:

Incremental Incremental

Cost*Cost*

(2008-2070)(2008-2070)

Incremental Incremental

gain in gain in

QALYS* QALYS*

(2008-2070)(2008-2070)

IncrementalIncremental

Cost Cost

Effectiveness Effectiveness

Ratio**Ratio**

(£/ QALY)(£/ QALY)

Uptake of antiviral therapy Uptake of antiviral therapy

by former IDUsby former IDUs

N per yearN per year Cumulative Cumulative number during number during

2008-2070 2008-2070

(% of 35,000)(% of 35,000)

225225 5,100 (15%)5,100 (15%) £13 million£13 million 1,7001,700 £7,800£7,800

1,0001,000 21,300 (61%)21,300 (61%) £43 million£43 million 5,8005,800 £7,500£7,500

2,0002,000 29,100 (83%)29,100 (83%) £30 million£30 million 5,8005,800 £5,100£5,100

* Discounted at 3.5%* Discounted at 3.5%

** Defined as additional cost per additional gain in quality adjusted life year ** Defined as additional cost per additional gain in quality adjusted life year (QALY) for a given scenario compared to the next less effective scenario(QALY) for a given scenario compared to the next less effective scenario

• Current uptake of antiviral therapy will have limited Current uptake of antiviral therapy will have limited

impact on severe HCV-related liver disease in the futureimpact on severe HCV-related liver disease in the future

• Uptake of therapy by 1,000-2,000 persons per year will Uptake of therapy by 1,000-2,000 persons per year will

potentially prevent 500-1,000 liver failures during 2008-2030potentially prevent 500-1,000 liver failures during 2008-2030

• Increasing uptake of HCV antiviral therapy in Scotland to Increasing uptake of HCV antiviral therapy in Scotland to

1,000-2,000 persons per year leads to gains in QALYs that 1,000-2,000 persons per year leads to gains in QALYs that

justify the additional cost of treatmentjustify the additional cost of treatment

Summary ResultsSummary Results