A Cost-effectiveness Analysis of Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus Screening in an Emergency Department in Ireland.

Abstract

Background: The acceptability and utility of screening for HIV, HBV, and HCV in the ED has been demonstrated. Previous studies have reported cost-effectiveness of screening for either HIV mono-infection or HBV/HCV co-infection in the ED. To our knowledge, this is the first cost-effectiveness analysis of panel screening for all three BBVs in this setting. These BBVs have common modes of transmission, affect similar population groups and co-infection can result in faster rates of disease progression. Integrated screening for these BBVs also reflects existing patterns of service deliver.

Objective: The main objective of this study was to determine the cost-effectiveness of an opt-out BBV panel screening programme (i.e. screening for HIV, HBV, and HCV) in an inner-city ED setting. The secondary objective was to determine the range of combined seroprevalence over which ED screening is cost-effective.

Methods: A bespoke Markov model was programmed in TreeAge Pro 2020® (TreeAge Software Inc, Williamstown, MA, USA). The intervention under investigation was opt-out BBV panel screening for HIV, HBV (HBsAg), and HCV (Ab+/-RNA) in the ED. The comparator was standard of care (i.e. no BBV-panel screening). HIV, HBV, and HCV prevalence (base-case combined seroprevalence of 4.8%) was informed from real-world individual patient-level data from the Emergency Department Viral Screen (EDVS) Programme in our institution. All other fixed and time-dependent variables were derived from local, national, and international data.

The mean per-patient cost of screening was informed from real-world data from the EDVS programme. Mean annual per-patient treatment pathway costs for HIV, HBV, and HCV were derived from national micro-costing studies (9,10). It was assumed that those patients, who required treatment for the respective viruses, would be treated according to national guidance. Irish drug-cost data was used to estimate drug-acquisition costs. Health state utility data was derived from published data.

In line with practice in Ireland, cost-effectiveness was determined at a health-state payer threshold of €45,000/QALY.

In sensitivity analysis, the combined-seroprevalence range over which the BBV panel screening programme remained cost-effective was established.

Results: In the base-case analysis, the BBV panel screening programme was cost-effective with an incremental cost-effectiveness ratio (ICER) of €9,130/QALY.

The BBV-panel screening programme remained cost-effective when the combined seroprevalence was within a range of 3.5% to 7.8% inclusive.

Conclusions: The Emergency Department BBV-panel screening programme was cost-effective in our setting. Exploratory analysis indicates that cost-effectiveness was maintained where a combined seroprevalence was within the range of 4.5% to 7.8%.

We are aware that seroprevalence in this study setting may change in the future. As a result of ongoing changes in demographics and migration patterns, the universal childhood HBV vaccination programme, increased availability of therapeutics including P(R)EP for HIV and DAAs for HCV there may be a future shift in background seroprevalence in this study setting. Impact of changes in drug acquisition costs may also need to be investigated in the future. Given that the ICER was sensitive to a change in combined seroprevalence, a re-evaluation of BBV panel screening in the ED, and by proxy the EDVS Programme, may be warranted in the future.