1 Source Heor, 2 University of Bristol, 3 Bristol Drugs Project, UK 01 January 2019 Cost-effectiveness of low dead space detachable syringes for the prevention of Hepatitis C Elizabeth Hancock1, Zoe Ward2, Rachel Ayres3, Jo Keston2, Jane Neale3, Matthew Hickman2, Peter Vickerman2 1 Source Heor, 2 University of Bristol, 3 Bristol Drugs Project, UK

PV has received research grants unrelated to this work from Gilead 01 January 2019 Disclosures PV has received research grants unrelated to this work from Gilead Unrelated to this work, PV has received honoraria from Abbvie, and MH has received honoraria from Merck, Abbvie and Gilead

Background – Syringe types 01 January 2019 Background – Syringe types People who inject drugs use two styles of syringes Syringes with fixed needles which have low dead space (LDSS) Syringes with detachable needles which have high dead space (HDSS) Detachable needles needed for Groin Injectors Using Filters Multiple tries to find vein

Background – New syringes 01 January 2019 Background – New syringes New lower dead space detachable options available These reduce the dead space compared to HDSS Standard HDSS Two lower dead space detachable options Standard LDSS

01 January 2019 Aims In Bristol (UK), the new detachable syringes with lower dead space were introduced and offered alongside standard HDSS and LDSS This study evaluated the cost-effectiveness of introducing these lower dead space detachable syringes in preventing Hepatitis C transmission

Intervention and Comparator 01 January 2019 Intervention and Comparator Prior to intervention 38% of all syringes distributed were HDSS or detachable (Comparator) Bristol Drugs Project started distributing detachable LDSS Education posters Training staff to promote new syringes In first year 3% of all syringes distributed were detachable LDSS replacing former HDSS

Increased syringe costs (£0.033 vs £0.025 for HDSS) 01 January 2019 Costs Direct costs of the intervention included staff time and training (41 hours) Increased syringe costs (£0.033 vs £0.025 for HDSS) Indirect costs of HCV care and treatment calculated from infectious disease model

Dynamic HCV transmission and progression model 01 January 2019 Model Dynamic HCV transmission and progression model Demographic and epidemiological parameters specific to Bristol Assume detachable LDSS decrease HCV transmission risk by 84% Used to calculate indirect costs of intervention and quality adjusted life years (QALYs) Decrease in transmission risk is based on evidence from HIV, where infectivity increased 9 times for every 1 log increase in viral load during vertical transmission and needlestick injuries. The relative volumes of blood in the different syringe type is then used to calculate the decrease in transmission risk for detached LDSS compared to HDSS. Vickerman (2013), DeCarli (2003), Thomas (2000)

01 January 2019 Analysis Methods The intervention modelled for 10 years and capture outcomes for a further 40 years Incremental cost-effectiveness ratio calculated and compared to UK willingness to pay threshold of £20,000 per QALY Threshold analysis on reduction in HCV transmission risk needed with detachable LDSS to ensure cost-effectiveness Probabilistic sensitivity analysis to assess impact of uncertainty around important parameters Test how increase in uptake of detachable LDSS impacts cost-effectiveness

Direct intervention costs: £6000 over 10 years 01 January 2019 Results Direct intervention costs: £6000 over 10 years Saves 261 QALYs over 50 years Averts £1.6 million in HCV treatment (68%) and care costs (32%) ICER is cost-saving which means the intervention gives more health benefit and costs less than the comparator

Probabilistic sensitivity analysis 01 January 2019 Probabilistic sensitivity analysis Incremental Costs (£million) Incremental QALYs 0 100 200 300 400 500 600 700 £0 All simulations in cost-saving quadrant -£2M -£4M

01 January 2019 Threshold analysis Base case assumed 84% reduction in HCV transmission risk (new detachable LDSS v’s traditional detachable HDSS): Result suggested intervention was cost saving If assume different percentage reductions in HCV transmission risk, then detachable LDSS only have to reduce transmission risk of HDSS by 0.3% to be cost saving 0.08% to be cost-effective at £20,000 per QALY threshold

Scenario Analysis of detachable LDSS uptake 01 January 2019 Scenario Analysis of detachable LDSS uptake Baseline scenario was an uptake from 0% to 3% of all needles and syringes being detachable LDSS – net monetary benefit of £6,830,258 Uptake to 10% increased the net monetary benefit by 241% Other scenarios looking at cheaper HCV treatment or higher treatment rates still cost-saving

01 January 2019 Discussion Expanding use of detachable LDSS could save money and reduce HCV transmission risk Evidence strongly advocates for their use to be expanded to meet preferences of PWID (i.e. groin injectors) for using detachable syringes However, there is uncertainty over potential role in reducing transmission Need better effectiveness data to understand the impact this intervention could have for controlling HCV