The future disease burden of hepatitis C virus infection in Sweden and the impact of different treatment strategies

Figures & data

Table I. Estimated SVR by genotype and stage of fibrosis at baseline dual therapy (PEG-IFN + RBV), first wave (PEG-IFN + RBV + first generation PI for genotype 1), second wave (NUC + second wave PI or NS5A inhibitor for genotype 1, NUC + RBV for genotype 2/3, and NUC + PEG-IFN + RBV for a few patients) and third wave of new DAAs (IFN-free regimens in different combinations). Real-life SVR estimates for treatment-naïve and -experienced patients are combined to a common estimate.

	Estimated efficacy (SVR, %)				Currently treated? (blank = treated)
	Baseline dual	First wave DAA	Second wave DAA	Third wave DAA
Genotype 1
F0–F1	–	70	90	90	No
F2	55	70	80	90
F3	45	45	75	90
F4	20	40	70	90
F3/F4	37	43	73	90
Decomp	–	–	–	70^d	Not until IFN free
HCC^a	20	40	70	90
Liver transplant	30	30^b	70^c	70^e
Genotype 2
F0–F1	80	80	95	95	No
F2	75	75	90	95
F3	65	70	85	95
F4	60	60	80	95
F3/F4	63	67	83	93
Decomp	–	–	75^d	75^d	Not until IFN free
HCC^a	60	60	80	95
Liver transplant	60	60	75	75^e
Genotype 3
F0–F1	75	75	80	90	No
F2	70	70	75	90
F3	65	65	75	90
F4	30	30	70	90
F3/F4	54	54	73	90
Decomp	–	–	70^d	70^d	Not until IFN free
HCC^a	30	30	70	90
Liver transplant	60	60	70	70^e

Abbreviations: DAA = Direct-acting antiviral; Decomp = Decompensated liver cirrhosis; HCC = Hepatocellular carcinoma; PEG-IFN = PEGylated interferon; PI = Protease inhibitor; NUC = Nucleotide NS5B polymerase inhibitor; RBV = Ribavirin; SVR = Sustained virological response.

^aSimilar SVR rates as for compensated cirrhosis were assumed due to lack of data.

^bUsage of dual therapy was assumed.

^cIFN-free regimen with only NUC and RBV.

^dEstimated SVR rates from the liver transplanted were used, due to lack of data.

^eEstimated SVR rates from combination of NUC and RBV were used, due to lack of data.

Figure 1. Age and gender distribution of viremic HCV infections in Sweden in 2010 is shown. Abbreviation: HCV = Hepatitis C virus.

Figure 2. Prediction of future HCV infections and related complications under different treatment strategies is shown: A. prevalence of viremic HCV infections; B. incidence of HCC; C. prevalence of decompensated cirrhosis; D. liver-related mortality. The treatment strategies are: 1. base, dual/triple therapy with PEG-IFN + RBV and first-generation PI for genotype 1, at an annual treatment rate of 1130. Strategies 2–5 consider treatment with future DAAs restricted to F3–F4 fibrosis with different treatment uptake as follows, 2. treat 380 (maintained budget), 3. treat 1130 (maintained number of treated), 4. treat 1430 (a 30% increase), and 5. treat 2260 patients (a doubled increase). Abbreviations: DAA = Direct-acting antiviral; HCC = Hepatocellular carcinoma; HCV = Hepatitis C virus; PEG-IFN = PEGylated interferon; PI = Protease inhibitor; RBV = Ribavirin.

Table II. The impact of different HCV treatment strategies on the liver-related morbidity, mortality, and total viremic infections by 2030, using either no therapy, IFN-based therapies (base, dual/triple) for 1130 patients, or new DAAs in IFN-free regimens for 380 patients (restriction to maintain budget), 760 patients (doubled budget), 1130 (unchanged number), 1430 (30% increase), or 2260 patients (doubled number). The DAA scenarios were treating patients only with fibrosis score ≥F2 or ≥F3.

	Forecasted estimates of patients with HCV infection, liver disease, and death in 2030
Scenario	HCC incidence	Prevented HCC cases 2014–2030*	Liver-related death	Prevented liver deaths 2014–2030*	Decomp cirrhosis	Cirrhosis	Fibrosis F2–F3	Total viremic
No treatment from 2014	150	–	250	–	570	5350	12,100	41,200
Base, dual/triple – Treat 1130 pts	105	340	175	535	360	3430	7990	31,800
DAA – Treat 380 pts with ≥F2	105	330	180	505	400	3790	9830	37,000
DAA – Treat 380 pts with ≥F3	100	430	160	665	355	3470	10,500	37,300
DAA – Treat 760 pts with ≥F2	70	620	120	935	250	2430	7620	33,200
DAA – Treat 760 pts with ≥F3	55	800	85	1255	170	1820	8930	33,700
DAA – Treat 1130 pts with ≥F2	55	690	90	1125	145	1440	6350	28,100
DAA – Treat 1130 pts with ≥F3**	50	855	70	1460	120	1330	8020	28,500
DAA – Treat 1430 pts with ≥F2***	40	830	65	1360	105	1040	3770	24,300
DAA – Treat 1430 pts with ≥F3****	40	935	60	1570	100	1050	4380	24,600
DAA – Treat 2260 pts with ≥F2*****	35	960	55	1570	90	870	3490	14,900
DAA – Treat 2260 pts with ≥F3******	35	1000	55	1655	85	820	3690	16,500

*Compared to no treatment.

** Because of shortage of ≥F3 patients, it was necessary to allow treatment of ≥F2 patients, beginning in 2024.

*** Treatment of ≥F1 patients was necessary, beginning in 2027.

**** Treatment of ≥F2 patients was necessary, beginning in 2020 and treatment of ≥F1 patients was necessary, beginning in 2027.

*****Treatment of ≥F1 was necessary, beginning in 2020, and ≥F0, beginning in 2028.

******Treatment of ≥F2 was necessary, beginning in 2017, and ≥F1, beginning in 2020.

Abbreviations: DAA = Direct-acting antiviral; Decomp cirrhosis = Decompensated cirrhosis; HCC = Hepatocellular carcinoma; HCV = Hepatitis C virus; IFN = Interferon; pts = Patients.

Figure 3. The effects of treating persons with F0–F4 fibrosis compared with restricting treatment to persons with F2–F4 on the future prevalence of viremic HCV infections and incidence of HCC, beginning in 2015 are shown. The therapies in the figure are: “Dual therapy” with PEG-IFN and ribavirin for 1130 patients annually; “Triple therapy”, adding a first-generation protease inhibitor for genotype 1, treating 1130 patients; “Increased SVR” treating 1130 patients with new highly effective DAAs (IFN-free); and “Doubled treatment” treating 2260 patients with DAAs. Abbreviations: DAA = Direct-acting antiviral; HCC = Hepatocellular carcinoma; HCV = Hepatitis C virus; PEG-IFN = PEGylated interferon; SVR = Sustained virological response.