UC San Diego

Background: With the World Health Organization (WHO) hepatitis C virus (HCV) global elimination goals to reduce HCV incidence and mortality by 2030, there is an urgent need to consider disproportionately affected populations including people who inject drugs (PWID) and HIV-infected individuals. Although curative direct-acting antiviral (DAA) treatments for HCV are now available, barriers to access and affordability have slowed progress towards achieving the WHO goals, particularly in low-middle income country (LMIC) settings where the vast majority of HCV burden resides. This thesis uses modeling to inform HCV elimination programs among vulnerable populations in LMIC settings.

Objectives: Specific aims of this dissertation include: (1) to determine what combination intervention scale-up is needed to achieve the WHO HCV elimination goals among current and former PWID in Tijuana, Mexico; (2) to evaluate the cost-effectiveness of HCV incidence elimination strategies among PWID in Tijuana, Mexico; (3) to evaluate real-world cost and cost-effectiveness of DAAs for HCV/HIV-coinfected individuals in Dawei, Myanmar.

Methods: In Chapter 2, I used a dynamic, deterministic model of HCV transmission, progression, and harm reduction. In Chapter 3, I extended the model in Chapter 2 to perform a cost-effectiveness analysis of HCV elimination strategies from a healthcare provider perspective among PWID in Tijuana, Mexico. In Chapter 4, I performed a micro-costing analysis of an HCV treatment program among HIV-infected individuals in Dawei, Myanmar and used a Markov model to evaluate the cost-effectiveness of this program compared to no treatment.

Results: In Chapter 2, findings showed that achieving both HCV incidence and mortality elimination goals in Tijuana required additional DAA investment. Further, combination harm reduction scale-up plus DAAs required fewer treatments compared to DAAs alone, so may be more feasible given limited treatment allocation nationally. In Chapter 3, results showed that all elimination strategies were cost-effective in Tijuana. While a treatment only strategy was the least costly, combination harm reduction and treatment provided more health benefits compared to treatment alone and is cost-effective. Chapter 4 findings demonstrated that HCV DAA treatment for HCV/HIV-coinfected individuals was cost-effective in Myanmar, and even more so with simplified treatment algorithms.

Conclusions: Findings from these studies highlight the feasibility and cost-effectiveness of HCV elimination programs for PWID and HIV-positive individuals in two LMIC settings. Expansion of HCV screening and treatment programs for these populations are urgently required, coupled with evidence-based harm reduction interventions to prevent reinfection and ensure that the WHO HCV elimination goals are achieved by 2030.