Cost-Effectiveness of Needle and Syringe Provision in Preventing Hepatitis C Transmission in UK PWID

1. The cost-effectiveness of needle and syringe provision in preventing transmission of Hepatitis C Virus in people who inject drugs in the UK Zoë Ward1, Sedona Sweeney2, Lucy Platt2, Matthew Hickman1, Peter Vickerman1 1University of Bristol 2London School of Hygiene and Tropical Medicine

2. Disclosures and acknowledgements • Work funded by NIHR • NKM and PV were supported by the National Institute for Drug Abuse. • NKM was additionally funded by the University of California San Diego Center for AIDS Research (CFAR), a National Institute of Health (NIH) funded program. • Lisa Maher is supported by an Australian National Health and Medical Research Council (NHMRC) Fellowship. • PV and MH have received honoraria from Abbvie, MSD, Janssen and Gilead

3. Background/Aims • Over 80% of new HCV infections in UK are in PWID • Needle and syringe programmes (NSP) are the main harm reduction strategy for blood borne viruses • No evidence of cost-effectiveness of NSP against HCV in UK • Investigate cost-effectiveness of current levels of high coverage needle and syringe provision (HCNSP - a clean needle for every injection)

4. Background • NIHR funded study into needle and syringe provision • Pooled analysis of UK and Australian NSP data sets • Systematic review of NSP and HCV data • Costings of NSP at 3 UK settings • Modelling of impact and cost-effectiveness of NSP at 3 UK settings Matt Hickman is presenting the systematic review results directly after this talk

5. What is Cost Effectiveness Analysis?

6. Methods • Stratified dynamic transmission model • Injecting duration • High Coverage Needle and Syringe Provision (HCNSP) and OST intervention • High/low injecting risk • Disease progression states • Follow ex-injectors in disease progression states

7. Cost Effectiveness Analysis • Baseline scenario – levels of HCNSP, OST etc. remain constant • Counterfactual scenario – no HCNSP for 10 years then reinstated at the previous level. • QALYs and costs associated with disease progression states taken from literature • Costs associated with HCNSP taken from costings analysis for each setting • 50 year time horizon and 3.5% discounting of costs and QALYs • Mean Incremental Cost Effectiveness Ratio calculated for each setting and compared to UK willingness to pay threshold of £20,000 per QALY

8. Parameterisation • UAM survey for Bristol and Walsall • Community surveys for Bristol 2004, 2006 and 2009 • NESI survey for Dundee • Population estimates from recent literature and local updates from collaborators • Odds ratios for HCNSP and OST effectiveness taken from the pooled analysis and systematic review Systematic Review and Pooled analysis carried out by Lucy Platt LSHTM

9. Epidemiological characteristics + Data extracted from unlinked anonymous monitoring survey (Public Health England 2016), - Mills, Colijn et al. 2012, * Jones, Welton et al. 2016, # Data extracted from Needle Exchange Surveillance Initiative (Information Services Division Scotland 2015), & Martin, Foster et al. 2015

10. Cost inputs Cost analysis by Sedona Sweeney LSHTM

11. Health impacts of NSP CrI – Credible Interval

12. Health impacts of NSP CrI – Credible Interval

13. Health impacts of NSP CrI – Credible Interval

14. Cost Impacts of NSP in millions GBP

15. Cost Impacts of NSP in millions GBP

16. Cost Impacts of NSP in millions GBP

17. Cost Effectiveness Results

18. Cost Effectiveness Results

19. Cost Effectiveness Results

20. Cost Effectiveness Results

21. Walsall and Dundee Results • Dundee also cost saving • Walsall cost-effective with mean ICER £594 per QALY • Results robust to sensitivity analysis on time horizon, discount rate, HCV treatment cost and undiagnosed healthcare cost

22. Cost Effectiveness Acceptability Curve

23. Cost Effectiveness Acceptability Curve

24. Scenario Analysis Results NSP remains cost-effective even when HCV treatment is cheaper Increasing treatment increases cost-effectiveness of NSP

25. Conclusions/implications • NSPs highly cost effective or cost saving in the UK • NSPs still cost effective when HCV treatment is cheaper • NSPs more cost effective when HCV treatment rate is increased • NSPs: Prevention is necessary alongside cure

26. Co-Author Acknowledgements • University of Bristol • Peter Vickerman • Matthew Hickman • LSHTM • Sedona Sweeney • Lucy Platt • Lorna Guinness • Lisa Maher (UNSW) • Vivian Hope (LJMU) • Josie Smith (PHW) • Rachel Ayres (Bristol Drugs Project) • Ingrid Hainey (Dundee Cairn Centre) • Tracy Chamberlin (Addaction Walsall)

27. References • Information Services Division Scotland (2015). Injecting equipment provision in Scotland survey 2013/14. Scotland. • Jones, H. E., N. J. Welton, A. Ades, M. Pierce, W. Davies, B. Coleman, T. Millar and M. Hickman (2016). "Problem drug use prevalence estimation revisited: heterogeneity in capture–recapture and the role of external evidence." • Martin, N. K., G. R. Foster, J. Vilar, S. Ryder, M. E. Cramp, F. Gordon, J. F. Dillon, N. Craine, H. Busse, A. Clements, S. J. Hutchinson, A. Ustianowski, M. Ramsay, D. J. Goldberg, W. Irving, V. Hope, D. De Angelis, M. Lyons, P. Vickerman and M. Hickman (2015). "HCV treatment rates and sustained viral response among people who inject drugs in seven UK sites: real world results and modelling of treatment impact." Journal of Viral Hepatitis22(4): 399-408. • Mills, H. L., C. Colijn, P. Vickerman, D. Leslie, V. Hope and M. Hickman (2012). "Respondent driven sampling and community structure in a population of injecting drug users, Bristol, UK." Drug and Alcohol Dependence126(3): 324-332. • Public Health England (2016). People who inject drugs: HIV and viral hepatitis unlinked anonymous monitoring survey tables (pyschoactive): 2016 update. London. • Sweeting, M. J., et al. (2007). "The burden of hepatitis C in England." Journal of Viral Hepatitis14(8): 570-576. • Micallef, J. M., et al. (2006). "Spontaneous viral clearance following acute hepatitis C infection: a systematic review of longitudinal studies." J Viral Hepat13(1): 34-41.