Modelled impact of antiviral therapy on the future burden of HCV disease in Scotland Testing/Treatment/Care Working Group, 11 th Sept 2007

Effectiveness and cost-effectiveness of HCV antiviral therapy Overall response rates of 50-60% with antiviral therapy Overall response rates of 50-60% with antiviral therapy Cost-effectiveness studies have demonstrated that antiviral therapy leads to gains in QALYs that justify the additional cost of treatment Cost-effectiveness studies have demonstrated that antiviral therapy leads to gains in QALYs that justify the additional cost of treatment NICE & QIS recommend pegylated interferon plus ribavirin for patients with mild and moderate disease & compensated cirrhosis NICE & QIS recommend pegylated interferon plus ribavirin for patients with mild and moderate disease & compensated cirrhosis

Burden of HCV disease among IDUs in Scotland, 2008 Chronic Infection Mild disease Moderate disease Severe disease (cirrhosis) No infection Liver failure HCV All IDUsFormer IDUs 35,70028,400 21,80015,700 11,90010,800 2,000 1, per year Hutchinson et al. Hepatology 2005

Modelled prevalent number of HCV infected IDUs in Scotland according to stage of HCV disease, Living IDUs (thousands) 2008 Calendar year Mild disease Moderate disease Cirrhosis Recovered from HCV Cleared HCV from treatment Hutchinson et al. Hepatology 2005

Cirrhosis prevented from antiviral therapy* Living IDUs with cirrhosis ,000 2,000 3, ,000 2,000 3, ,000 2,000 3,000 Decompensated cirrhosis HCC * Excludes those prevented from antiviral therapy prior to 2008 Compensated cirrhosis Modelled number of IDUs with cirrhosis in Scotland by different uptake rates of HCV antiviral therapy, Uptake of therapy by 225 IDUs per year Uptake of therapy by 1,000 IDUs per year Uptake of therapy by (up to) 2,000 IDUs per year

Annual number of IDUs developing liver failure Cumulative number of liver failures prevented from therapy Modelled number of IDUs in Scotland with liver failure with different uptake rates of HCV antiviral therapy, Assuming uptake of HCV antiviral therapy by: Annual number ,000 Cumulative number 0 former IDUs per year 0 former IDUs per year 225 former IDUs per year 225 former IDUs per year 1,000 former IDUs per year (up to) 2,000 former IDUs per year

Cohort members (living/dead) ,000 20,000 30,000 Modelled follow-up of 35,000 IDUs in Scotland with chronic HCV disease (mild/moderate/compensated cirrhosis) in 2008 Scenario for entire IDU population: Uptake of therapy by 225 IDUs per year Cleared HCV from antiviral therapy Mild disease Moderate disease Cirrhosis HCV-related death Non-HCV-relateddeath

Cohort members (living/dead) ,000 20,000 30,000 Modelled follow-up of 35,000 IDUs in Scotland with chronic HCV disease (mild/moderate/compensated cirrhosis) in 2008 Cleared HCV from antiviral therapy Mild disease Moderate disease Cirrhosis HCV-related death Non-HCV-relateddeath In 2030, 7% of 19,500 living cohort members estimated to have cleared HCV from antiviral therapy Scenario for entire IDU population: Uptake of therapy by 225 IDUs per year

Cohort members (living/dead) ,000 20,000 30, ,000 20,000 30,000 Modelled follow-up of 35,000 IDUs in Scotland with chronic HCV disease (mild/moderate/compensated cirrhosis) in 2008 Uptake of therapy by 1,000 IDUs per year Uptake of therapy by (up to) 2,000 IDUs per year 31% of the 19,800 alive cleared HCV from antiviral therapy 50% of the 20,100 alive cleared HCV from antiviral therapy

Cohort members (living/dead) ,000 20,000 30,000 Modelled follow-up of 35,000 IDUs in Scotland with chronic HCV disease (mild/moderate/compensated cirrhosis) in 2008 Cleared HCV from antiviral therapy Mild disease Moderate disease Cirrhosis HCV-related death Non-HCV-relateddeath  16% died from HCV-related cause during  260 HCV-related deaths averted from antiviral therapy Scenario for entire IDU population: Uptake of therapy by 225 IDUs per year

Cohort members (living/dead) ,000 20,000 30, ,000 20,000 30,000 Modelled follow-up of 35,000 IDUs in Scotland with chronic HCV disease (mild/moderate/compensated cirrhosis) in 2008 Uptake of therapy by 1,000 IDUs per year Uptake of therapy by (up to) 2,000 IDUs per year  13% died from HCV-related cause  1,250 HCV-related deaths averted  11% died from HCV-related cause  2,000 HCV-related deaths averted

Health service costs & quality of life (QOL) associated with stages of chronic HCV disease, 2005 StageAnnual cost per patientQOL Mild diseaseUndiagnosed Diagnosed During therapy SVR £0 £144 ** Moderate diseaseUndiagnosed Diagnosed During therapy SVR £0 £749 ** Compensated cirrhosis Undiagnosed Diagnosed During therapy SVR £0 £1,188 ** Decompensated cirrhosis£9, HCC£8, Liver TransplantTransplant costs 1 st yr follow-up 2 nd yr follow-up £28,533 £9,874 £1, Treatment costs (Peg Interferon & Rib therapy & monitoring costs) £8,781**-

Cost-effectiveness analysis of increasing uptake of HCV antiviral therapy in Scotland Entire IDU population IDU cohort: Cumulative cost* ( ) Uptake of antiviral therapy by former IDUs Management/ Monitoring of HCV disease HCV antiviral therapy Total N per year Cumulative number during (% of 35,000) 00 £276 million £0 £0 £276 million ,100 (15%) 5,100 (15%) £263 million £26 million £289 million 1,000 21,300 (61%) £220 million £112 million £332 million 2,000 29,100 (83%) £185 million £177 million £362 million * Discounted at 3.5%

Cost-effectiveness analysis of increasing uptake of HCV antiviral therapy in Scotland Entire IDU population IDU cohort: Incremental Cost* ( ) Incremental gain in QALYS* ( )Incremental Cost Effectiveness Ratio** (£/ QALY) Uptake of antiviral therapy by former IDUs N per year Cumulative number during (% of 35,000) ,100 (15%) 5,100 (15%) £13 million 1,700£7,800 1,000 21,300 (61%) £43 million 5,800£7,500 2,000 29,100 (83%) £30 million 5,800£5,100 * Discounted at 3.5% ** 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 impact on severe HCV-related liver disease in the future Current uptake of antiviral therapy will have limited impact on severe HCV-related liver disease in the future Uptake of therapy by 1,000-2,000 persons per year will potentially prevent 500-1,000 liver failures during Uptake of therapy by 1,000-2,000 persons per year will potentially prevent 500-1,000 liver failures during Increasing uptake of HCV antiviral therapy in Scotland to 1,000-2,000 persons per year leads to gains in QALYs that justify the additional cost of treatment Increasing uptake of HCV antiviral therapy in Scotland to 1,000-2,000 persons per year leads to gains in QALYs that justify the additional cost of treatment Summary Results