1. According to a model simulation, implementation of an opt-out prison screening protocol would diagnose at least 81,000 hepatitis C cases over the next 30 years.
2. Opt-out screening would also reduce hepatitis C-associated healthcare costs by at least $510 million over 30 years.
Evidence Rating Level: 2 (Good)
Study Rundown: In the U.S. prison population, many inmates are seropositive for hepatitis C virus (HCV), where the most common mode of transmission is intravenous drug use. Despite its high prevalence, screening for HCV is only conducted in a quarter of prisons nationwide. The current study used a microsimulation model to compare risk-based and opt-out HCV screening approaches. Primary outcome measures included prevention of HCV transmission and associated disease, costs, quality-adjusted life years (QALYs), and impact on total prison budget. The model found that an opt-out protocol would diagnose more new HCV cases, prevent more HCV infections, and reduce healthcare costs associated with HCV more than a risk-based protocol. Although all of the opt-out screening strategies proposed were more expensive than the risk-based strategy, they were just as cost-effective; all strategies had incremental cost-effectiveness ratios (ICERs) below $50,000 per additional QALY after sensitivity analyses. This study was limited primarily in that its model relied on many assumptions about HCV screening practices and transmission rates in U.S. prisons. However, it is clear that hepatitis C screening may reduce transmission and infection in prisoner populations.
Relevant Reading: Ending hepatitis C in the United States: the role of screening
In-Depth [model simulation]: The model used in this study was developed to simulate HCV transmission, natural history, screening in inmates and treatment. It also estimated the number of inmates moving between prison and the general community. All of these aspects of the model were projected on a monthly basis for the next 30 years. The results of the simulation showed that risk-based screening for 1 year would diagnose 41 900 (95%CI 40 700-43 200) new HCV cases over 30 years, while 1-year, 5-year and 10-year opt-out screening strategies would diagnose 81 100 (95%CI 79 600-82 700), 106 600 (95%CI 104 700-108 500) and 122 700 (95%CI 120 800-124 600) new HCV cases, respectively, over the same time period. The 1-year risk based, 1-year opt-out, 5-year-opt out and 10-year opt-out strategies would prevent 5 500 (95%CI 4 400-6 600), 8 000 (95%CI 6 800-9 000), 10 900 (95%CI 9 700-12 000) and 12 700 (95%CI 11 500-13 900) new HCV infections, respectively, compared to no screening. Notably, 89%-92% of these prevented infections would have affected patients in the general population. Lastly, compared with no screening program, the 1-year risk based, 1-year opt-out, 5-year opt-out and 10-year opt-out programs would decrease HCV-associated healthcare costs by $260 million (95%CI $220-$300 million), $510 million (95%CI $470-$560 million), $680 million (95%CI $620-$740 million) and 760 million (95%CI $700-$820 million), respectively.
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