{"id":7618,"date":"2015-08-23T22:03:15","date_gmt":"2015-08-24T02:03:15","guid":{"rendered":"http:\/\/blogs.nejm.org\/hiv-id-observations\/?p=7618"},"modified":"2015-08-24T11:19:17","modified_gmt":"2015-08-24T15:19:17","slug":"post-exposure-prophylaxis-for-hcv-cant-be-cost-effective-but-we-might-end-up-recommending-it-anyway","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/post-exposure-prophylaxis-for-hcv-cant-be-cost-effective-but-we-might-end-up-recommending-it-anyway\/2015\/08\/23\/","title":{"rendered":"Post-Exposure Prophylaxis for HCV Can&#8217;t Be Cost-Effective &#8212; But We Might End Up Recommending It Anyway"},"content":{"rendered":"<p>An email query from a colleague:<\/p>\n<blockquote><p>Hi Paul,<br \/>\nJust got a call from one of our surgeons who got a needlestick from a suture\u00a0needle, small amount of\u00a0blood. Patient is HCV +.\u00a0Any post-exposure prophylaxis recommended?<br \/>\nThanks,<br \/>\nDan<\/p><\/blockquote>\n<p>The quick answer is no, it&#8217;s not recommended.\u00a0<a href=\"http:\/\/www.hcvguidelines.org\/full-report\/management-acute-hcv-infection\">From the guidelines:<\/a><\/p>\n<p><a href=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/08\/MANAGEMENT_OF_ACUTE_HCV_INFECTION___Recommendations_for_Testing__Managing__and_Treating_Hepatitis_C-jpg.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter wp-image-7621 size-full\" src=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/08\/MANAGEMENT_OF_ACUTE_HCV_INFECTION___Recommendations_for_Testing__Managing__and_Treating_Hepatitis_C-jpg.jpg\" alt=\"MANAGEMENT_OF_ACUTE_HCV_INFECTION___Recommendations_for_Testing__Managing__and_Treating_Hepatitis_C jpg\" width=\"585\" height=\"117\" srcset=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/08\/MANAGEMENT_OF_ACUTE_HCV_INFECTION___Recommendations_for_Testing__Managing__and_Treating_Hepatitis_C-jpg.jpg 585w, https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/08\/MANAGEMENT_OF_ACUTE_HCV_INFECTION___Recommendations_for_Testing__Managing__and_Treating_Hepatitis_C-jpg-300x60.jpg 300w\" sizes=\"auto, (max-width: 585px) 100vw, 585px\" \/><\/a><\/p>\n<p>But it&#8217;s a natural question to ask for several reasons &#8212; on first blush, PEP for HCV seems like a no-brainer, because:<\/p>\n<ul>\n<li>It works for HIV.<\/li>\n<li>There&#8217;s no vaccine.<\/li>\n<li>Rate of transmission is approximately 10-fold higher than with HIV.<\/li>\n<li>The HCV drugs are practically side-effect free.<\/li>\n<li>It feels better doing something rather than nothing.<\/li>\n<\/ul>\n<p>But\u00a0despite the above issues that favor PEP today for HCV occupational exposures, there is absolutely zero chance this makes sense from a cost-effectiveness perspective. It&#8217;s just not possible.<\/p>\n<p>A little refresher on\u00a0basic principles of\u00a0cost-effectiveness analysis:\u00a0 something is cost-effective if you get good value for your healthcare dollar. You spend more\u00a0money, and you prolong life. How much you spend compared to standard-of-care, and how more much life you get in return gives you the numerator and denominator in that all-important cost-effectiveness ratio. In the USA, if we spend &lt;$100,000 for an extra year of life, that&#8217;s considered cost-effective; &lt;$50,000, <em>very<\/em> cost effective.<\/p>\n<p>So let&#8217;s consider the HCV needlestick scenario, with 100 exposures; all assumptions will be biased in favor of PEP, just to make the point:<\/p>\n<ul>\n<li>The risk of acquiring HCV from a needlestick is 2-8%, depending on the nature of the exposure; some will clear it spontaneously. So if we do nothing, around 5 of these 100 exposures will end up with chronic HCV.<\/li>\n<li>Let&#8217;s assume that two\u00a0weeks\u00a0of PEP with sofosbuvir\/ledipasvir will be 100% effective in preventing HCV acquisition. There are no data, but let&#8217;s give it the benefit of the doubt. And note that the HIV PEP protocol is 4 weeks, but at least one\u00a0pilot study is using 2 weeks for HCV. (Why? Not sure.)<\/li>\n<li>Two\u00a0weeks of PEP\u00a0will cost $15,000 per patient &#8212; actually, a bit more, but let&#8217;s round it to $15K or a total of 1.5\u00a0million dollars for our 100 exposures.<\/li>\n<li>If we didn&#8217;t give PEP\u00a0after the exposures, we&#8217;d need to treat the 5 people who contracted HCV with 12 weeks of sofosbuvir\/ledipasvir, which would cost $450,000. All would be cured.<\/li>\n<li>The PEP strategy therefore costs $1,050,000\u00a0more than the no PEP one (1.5 million minus 450,000), and prevents\u00a05 cases of HCV. That&#8217;s $210,000\/case prevented &#8212; so a lot.<\/li>\n<li>What about survival, the denominator part of the cost-effectiveness ratio? The projected survival of those in whom HCV was prevented by PEP vs later cured with HCV treatment should be roughly the same<i>\u00a0<\/i>(no one is getting cirrhosis or hepatocellular carcinoma with early treatment) &#8212;\u00a0but maybe there&#8217;s some &#8220;disutility&#8221; to getting HCV, even if it&#8217;s rapidly cured. So let&#8217;s give the PEP strategy a bit of a quality-adjusted survival\u00a0advantage &#8212; how about 10 weeks, since that&#8217;s the extra time on treatment for an actual case? Of course we can only apply this\u00a0to the 5 cases of HCV prevented in our 100 person cohort, so it&#8217;s an overall advantage of 0.5 weeks (10 weeks times 0.05), or roughly 0.01 years.<\/li>\n<li>Finally, we arrive at our\u00a0cost effectiveness ratio, which is $1,050,000\/0.01 years, or <strong>$105 million\/quality-adjusted life year.<\/strong><\/li>\n<\/ul>\n<p>More than 100 million dollars for a quality-adjusted life year? Yep. I told you it couldn&#8217;t possibly be cost-effective.<\/p>\n<p>Now\u00a0again, I biased everything <em>in favor<\/em> of PEP. What if it doesn&#8217;t always work? What if failures of PEP lead to resistance? What if the PEP regimen needs to be 4 weeks long? What if the quality-of-life adjustment is an overestimate? What if some of the patients who get HCV have a very low HCV RNA, and can be cured with 8 weeks, not 12?<\/p>\n<p>Well, then you&#8217;d be spending <em>even more<\/em> than $105 million dollars per year of life saved.\u00a0But whether it&#8217;s $105 million, or even half my back-of-the-envelope estimates (which could be wrong &#8212; I was an English major, after all), the point remains: This can&#8217;t be a cost-effective intervention.<\/p>\n<p>But as I was sharing these thoughts with my brilliant friend and colleague <a href=\"https:\/\/connects.catalyst.harvard.edu\/Profiles\/display\/Person\/15654\" target=\"_blank\">Rochelle Walensky<\/a>, who does this stuff for a living, she reminded me of this important fact:<\/p>\n<blockquote>\n<div>I might encourage you to acknowledge that many of these kinds of decisions (PEP, safety of the blood supply) are not made on cost-effectiveness\u00a0grounds &#8230; Most of the cost-effectiveness\u00a0data for the screening for the blood supply demonstrates it&#8217;s not at all cost effective. You may want to acknowledge that point (we pay more for lots of things that cost-effectiveness\u00a0suggests we shouldn&#8217;t, including keeping health workers safe given their dedication to care, keeping blood supply safe etc).<\/div>\n<\/blockquote>\n<div>Acknowledged &#8212; I told you she was brilliant. Which is why, despite the fuzzy math above, it wouldn&#8217;t surprise me a bit if in the not-too-distant future,\u00a0we are actually recommending PEP for HCV.Nice 6 minute lecture here. Enjoy!<\/p>\n<\/div>\n<p>[youtube http:\/\/www.youtube.com\/watch?v=RSBaEz10sQk&amp;w=560&amp;h=315]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>An email query from a colleague: Hi Paul, Just got a call from one of our surgeons who got a needlestick from a suture\u00a0needle, small amount of\u00a0blood. Patient is HCV +.\u00a0Any post-exposure prophylaxis recommended? Thanks, Dan The quick answer is no, it&#8217;s not recommended.\u00a0From the guidelines: But it&#8217;s a natural question to ask for several [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,5,8,9],"tags":[408,706,1069],"class_list":["post-7618","post","type-post","status-publish","format-standard","hentry","category-health-care","category-infectious-diseases","category-patient-care","category-policy","tag-hcv","tag-pep","tag-sofosbuvirledipasvir"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/7618","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=7618"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/7618\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=7618"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=7618"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=7618"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}