This study explored the cost-effectiveness of expanding Hepatitis C Virus (HCV) screening and subsequent treatment in Swiss custodial settings, given the availability of rapid antibody saliva tests (Oraquick®) and dried blood spot tests (semi-quantitative viremia and viral genotype), and recent therapeutic advances which have higher cure rates and shorter treatment courses (1).

A comprehensive strategy offering screening to all detainees was compared to the current setup of screening high-risk individuals (for example, from endemic countries, active or former injecting drug users). A decision tree simulated the diagnosis pathway, and results from a Markov model were included to predict treatment effects and natural progression over a lifetime time-horizon. Input data were derived from clinical studies, literature reviews, custodial health services and expert opinion (2). The net monetary benefit (NMB) and incremental cost-effectiveness ratio (ICER) of comprehensive compared to current screening were calculated. Deterministic and probabilistic sensitivity analyses were performed to explore parameter uncertainty and whether variations informed by expert opinion changed the cost-effectiveness of comprehensive screening.

At a willingness-to-pay threshold of CHF100,000 (USD99,500) per Quality-Adjusted Life-Year (QALY), comprehensive screening had an 83 percent probability of being cost-effective, with a corresponding NMB of CHF33,451,972 (USD33,284,712) and ICER of CHF7,168/QALY (USD7,132/QALY). Results were most sensitive to the QALYs gained from the treatment model (both treatment and no treatment arms), respective HCV prevalence in the current and comprehensive screening populations, treatment initiation rates, and screening offer acceptance rates. Compared to the current practice of screening high-risk individuals, comprehensive screening is likely to be cost-effective due to the increase in testing rates, which were conservatively estimated in this study. Furthermore, comprehensive HCV screening of prisoners may prove more cost-effective in countries where prisoners are not routinely screened.

Comprehensive screening programs could be considered in prison units with a large proportion of high-risk individuals and where detainees are incarcerated for enough time to complete a treatment course during their sentence.