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
09 December 2018
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
09 December 2018
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. NIHR funded study into needle and syringe provision
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. Stratified dynamic transmission model
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
Baseline Characteristics
Bristol
Dundee
Walsall
Proportion High risk (crack injecting or homelessness)
80-95% +
26-42% #
50-65% +
Proportion OST
77-86% -
65-79% #
61-82% +
Proportion HCNSP
38-82% + *
34-79% #
21-42% +
Treatments per year
18 &
40 (from 2015) 2
+ 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 Deaths Averted Infections Averted Median
2.5% CrI
97.5% CrI
Bristol
20.5
4.3
51.1
199.5
42.5
505.2
Dundee
2.1
0.2
24.4 84 12
663
Walsall
5.8
1.2
14.9
92.7
22.3
200.5
CrI – Credible Interval

12. Health impacts of NSP Deaths Averted Infections Averted Median
2.5% CrI
97.5% CrI
Bristol
20.5
4.3
51.1
199.5
42.5
505.2
Dundee
2.1
0.2
24.4 84 12
663
Walsall
5.8
1.2
14.9
92.7
22.3
200.5
CrI – Credible Interval

13. Health impacts of NSP Deaths Averted Infections Averted Median
2.5% CrI
97.5% CrI
Bristol
20.5
4.3
51.1
199.5
42.5
505.2
Dundee
2.1
0.2
24.4 84 12
663
Walsall
5.8
1.2
14.9
92.7
22.3
200.5
CrI – Credible Interval

14. Cost Impacts of NSP in millions GBP
Projected total health-related costs over 50-year time horizon
 NSPs 
No NSPs 
Mean
2.5% CrI
97.5% CrI
Bristol
Healthcare costs
130.4
60.0
289.8
131.6
60.3
292.6
HCV treatment cost
39.9
23.5
58.8
41.1
24.3
60.6
HCV treatment PWID cost
9.3
6.6
11.2
6.7
NSP cost
6.0
3.7
8.3
3.8
2.3
5.3
OST Cost
112.3
86.8
142.5
112.2
142.4
Total Cost
297.8
298.0
Dundee
32.2
16.4
68.0
32.6
16.7
69.2
11.4
7.2
12.0
7.5
17.9
8.8
5.2
14.1
5.6
21.7
2.9
1.6
4.4
1.9
1.0
2.8
OST cost
37.1
32.1
42.3
92.5
95.0

15. Cost Impacts of NSP in millions GBP
Projected total health-related costs over 50-year time horizon
 NSPs 
No NSPs 
Mean
2.5% CrI
97.5% CrI
Bristol
Healthcare costs
130.4
60.0
289.8
131.6
60.3
292.6
HCV treatment cost
39.9
23.5
58.8
41.1
24.3
60.6
HCV treatment PWID cost
9.3
6.6
11.2
6.7
NSP cost
6.0
3.7
8.3
3.8
2.3
5.3
OST Cost
112.3
86.8
142.5
112.2
142.4
Total Cost
297.8
298.0
Dundee
32.2
16.4
68.0
32.6
16.7
69.2
11.4
7.2
12.0
7.5
17.9
8.8
5.2
14.1
5.6
21.7
2.9
1.6
4.4
1.9
1.0
2.8
OST cost
37.1
32.1
42.3
92.5
95.0

16. Cost Impacts of NSP in millions GBP
Projected total health-related costs over 50-year time horizon
 NSPs 
No NSPs 
Mean
2.5% CrI
97.5% CrI
Bristol
Healthcare costs
130.4
60.0
289.8
131.6
60.3
292.6
HCV treatment cost
39.9
23.5
58.8
41.1
24.3
60.6
HCV treatment PWID cost
9.3
6.6
11.2
6.7
NSP cost
6.0
3.7
8.3
3.8
2.3
5.3
OST Cost
112.3
86.8
142.5
112.2
142.4
Total Cost
297.8
298.0
Dundee
32.2
16.4
68.0
32.6
16.7
69.2
11.4
7.2
12.0
7.5
17.9
8.8
5.2
14.1
5.6
21.7
2.9
1.6
4.4
1.9
1.0
2.8
OST cost
37.1
32.1
42.3
92.5
95.0

17. Cost Effectiveness Results
Total Cost
Incremental Cost
Total QALYs
Incremental QALYs
ICER
Bristol
no NSP
£297,970,375
187,663
NSP
£297,832,426
-£137,949
188,165
502
dominant
Dundee
£94,951,896
83,904
£92,455,470
-£2,496,426
84,099
195
Walsall
£153,697,867
142,702
£153,812,309
£114,442
142,894
192
£596

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
09 December 2018
Scenario Analysis Results
NSP remains cost-effective even when HCV treatment is cheaper
Increasing treatment increases cost-effectiveness of NSP

25. Conclusions/implications
09 December 2018
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
Josie Smith (PHW)
Peter Vickerman
Rachel Ayres (Bristol Drugs Project)
Matthew Hickman
LSHTM
Ingrid Hainey (Dundee Cairn Centre)
Sedona Sweeney
Lucy Platt
Tracy Chamberlin (Addaction Walsall)
Lorna Guinness
Lisa Maher (UNSW)
Vivian Hope (LJMU)

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 Hepatitis 22(4):
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 Dependence 126(3):
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 Hepatitis 14(8):
Micallef, J. M., et al. (2006). "Spontaneous viral clearance following acute hepatitis C infection: a systematic review of longitudinal studies." J Viral Hepat 13(1):