Hepatitis C in Lebanon: the burden of the disease and the value of comprehensive screening and treatment

Figures & data

Figure 1 Model schematic of the natural history of chronic hepatitis C.

Notes: F0–F3, Metavir fibrosis score 0–3.
Abbreviations: CC, compensated cirrhosis (Metavir fibrosis score F4); D, all-cause death; DCC, decompensated cirrhosis; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; LrD, liver-related death (ie, death from DCC, HCC, or LT); LT, liver transplant; SVR, sustained virologic response.

Table 1 Proportion of patients in each fibrosis stage

Fibrosis stage	18–39 years age group	40–80 years age group
F0	65.0%	9.5%
F1	23.2%	14.2%
F2	5.3%	12.2%
F3	2.6%	13.5%
F4	3.9%	50.7%

Figure 2 Screening scenario in the 18–39 (A) and 40–80 years age groups (B).

Abbreviation: HCV, hepatitis C virus.

Table 2 Annual transition probabilities in different studies

Health states		Input	References
F0→	F1	0.117	Thein et al^Citation54 (2008)
	SVR	0.000	Assumption
F1→	F2	0.085	Thein et al^Citation54 (2008)
F2→	F3	0.120	Thein et al^Citation54 (2008)
F3→	CC	0.116	Thein et al^Citation54 (2008)
CC→	DCC	0.040	Liu et al^Citation55 (2012)
	HCC	0.034	Alazawi et al^Citation56 (2010)
DCC→	HCC	0.020	Liu et al^Citation55 (2012)
	LT	0.017	Razavi et al^Citation57 (2013)
	LrD	0.260	Liu et al^Citation55 (2012)
HCC
1st year→	LT	0.017	Razavi et al^Citation57 (2013)
	LrD	0.410	Singal et al^Citation58 (2010)
Subsequent year→	LT	0.017	Razavi et al^Citation57 (2013)
	LrD	0.190	Singal et al^Citation58 (2010)
LT
1st year→	LrD	0.117	Thuluvath et al^Citation59 (2010)
Subsequent year→	LrD	0.056	Thuluvath et al^Citation59 (2010)

Notes: F0–F3, Metavir fibrosis score 0–3.

Abbreviations: CC, compensated cirrhosis (Metavir fibrosis score F4); D, all-cause death; DCC, decompensated cirrhosis; HCC, hepatocellular carcinoma; LrD, liver-related death (ie, death from DCC, HCC, or LT), LT, liver transplant; SVR, sustained virologic response.

Table 3 Different SVR₁₂s assumed according to therapy and liver fibrosis stage

Therapy	F0	F1	F2	F3	CC	References
IFN+RBV	45.6%	45.6%	43.5%	43.5%	33.3%	Jacobson et al^Citation60 (2011)
IFN+RBV+PI	65.9%	65.9%	65.9%	65.9%	31.3%	Poordad et al^Citation61 (2011)
IFN-based DAA	91.7%	91.7%	91.7%	91.7%	80.8%	Lawitz et al^Citation62 (2013)
All-oral DAA	97.0%	97.0%	97.0%	97.0%	97.0%	Ferenci et al^Citation63 (2014), Feld et al^Citation64 (2014), Poordad et al^Citation65 (2014)

Abbreviations: DAA, direct-acting antiviral; IFN, interferon, PI, protease inhibitor; RBV, ribavirin; SVR₁₂, sustained virologic response 12 weeks after treatment.

Table 4 Newly diagnosed HCV patients between 2016 and 2036 in the 18–39 and 40–80 age groups

Health states	New patients diagnosed with HCV infection between 2016 and 2036
	18–39 years age group	40–80 years age group	Overall
Low variant
F0	283	90	373
F1	572	325	897
F2	353	342	695
F3	234	421	655
CC	180	1,039	1,219
Total	1,621	2,217	3,838
Medium variant
F0	511	141	652
F1	919	482	1,401
F2	524	488	1,012
F3	323	582	905
CC	250	1,445	1,695
Total	2,526	3,139	5,665
High variant
F0	739	196	935
F1	1,267	658	1,925
F2	695	660	1,355
F3	411	780	1,191
CC	320	1,943	2,263
Total	3,432	4,237	7,669

Abbreviations: CC, compensated cirrhosis; HCV, hepatitis C virus.

Figure 3 Hepatic complications from HCV (cumulative cases) for the 18–40 (A) and 40–80 years age groups (B).

Abbreviations: CC, compensated cirrhosis; DCC, decompensated cirrhosis; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; LrD, liver-related death.

Figure 4 Cumulative cost of HCV complications in the 18–39 (A) and 40–80 years age groups (B).

Note: A, no treatment at all; B, alloral, IFN-free DAAs given to F3–F4 patients only; C, all-oral, IFN-free DAAs given to F2–F3–F4 patients only; and D, all oral, IFN-free DAAs given to all, ie, F0–F1–F2–F3–F4 patients. (Strategy A, green; Strategy B, red; Strategy C, blue; Strategy D, navy blue).
Abbreviation: HCV, hepatitis C virus.

Table 5 Clinical burden – number and percent of life-years spent in SVR

	No treatment, value (%)	All-oral, IFN-free DAAs for F3–F4, value (%)	All-oral, IFN-free DAAs for F2–F4, value (%)	All-oral, IFN-free DAAs for F0–F4, value (%)
18–39 years group
Number of patients who achieved SVR	0 (0)	1,458 (42.5)	2,213 (64.5)	3,274 (95.4)
From F0	0 (0)	0 (0)	0 (0)	727 (22.2)
From F1	0 (0)	0 (0)	0 (0)	1,223 (37.4)
From F2	0 (0)	0 (0)	1,545 (69.8)	656 (20.0)
From F3	0 (0)	1,167 (80.1)	378 (17.1)	378 (11.5)
From F4	0 (0)	291 (19.9)	291 (13.1)	291 (8.9)
40–80 years group
Number of patients who achieved SVR	0 (0)	3,321 (78.4)	3,744 (88.4)	4,154 (98.0)
From F0	0 (0)	0 (0)	0 (0)	192 (4.6)
From F1	0 (0)	0 (0)	0 (0)	645 (15.5)
From F2	0 (0)	0 (0)	1,074 (28.7)	646 (15.6)
From F3	0 (0)	1,415 (42.6)	764 (20.4)	764 (18.4)
From F4	0 (0)	1,906 (57.4)	1,906 (50.9)	1,906 (45.9)

Abbreviations: DAA, direct-acting antiviral; IFN, interferon; SVR, sustained virologic response.

Table 6 Economic burden – health care costs

	HCV-related overall costs (18–39 years) (EUR)	HCV-related overall costs (40–80 years) (EUR)	Total HCV-related overall costs (EUR)
No treatment
Medical	44,097,060	149,004,066	193,101,126
Serious adverse events	0	0	0
Treatment	0	0	0
Total	44,097,060	149,004,066	193,101,126
All-oral, IFN-free DAAs for F3–F4			0
Medical	15,928,504	19,429,436	35,357,940
Serious adverse events	0	0	0
Treatment	48,507,649	102,867,974	151,375,623
Total	64,436,153	122,297,410	186,733,563
All-oral, IFN-free DAAs for F2–F4			0
Medical	10,978,004	15,485,609	26,463,613
Serious adverse events	0	0	0
Treatment	71,784,150	115,302,946	187,087,096
Total	82,762,154	130,788,555	213,550,709
All-oral, IFN-free DAAs for F0–F4			0
Medical	3,539,699	12,410,630	15,950,329
Serious adverse events	0	0	0
Treatment	102,946,279	127,114,860	230,061,139
Total	106,485,978	139,525,490	246,011,468

Abbreviations: DAA, direct-acting antiviral; HCV, hepatitis C virus; IFN, interferon.

Table 7 The return on investment, the percent of person LYs spent in SVR, and the budget impact of the 4 treatment strategies considered over the 2016–2036 time frame in the 18–39 and the 40–80 years age groups

	No treatment	All-oral, IFN-free DAAs for F3–F4	All-oral, IFN-free DAAs for F2–F4	All-oral, IFN-free DAAs for F0–F4
18–39 years group
Return on investment (cost of treatment)
Cost of treatment/LYs in SVR12	NA	4,996 EUR	4,212 EUR	3,112 EUR
LYs in SVR12/€100,000	NA	20.015	23.744	32.138
LYs in SVR12/patient who achieved SVR	NA	6.66	7.70	10.10
LYs in SVR12/patient treated	NA	6.00	7.12	9.64
Incremental analysis (incremental cost/LYs gained in SVR12)
vs. No screening	NA	2,338 EUR	2,407 EUR	1,957 EUR
vs. No treatment		2,095 EUR	2,269 EUR	1,886 EUR
vs. All-oral, IFN-free for F3–F4			2,498 EUR	1,799 EUR
vs. All-oral, IFN-free for F2–F4				1,479 EUR
40–80 years group
Return on investment (cost of treatment)
Cost of treatment/LYs in SVR12	NA	3,062 EUR	2,924 EUR	2,761 EUR
LYs in SVR12/€100,000	NA	32.658	34.204	36.218
LYs in SVR12/patient who achieved SVR	NA	10.12	10.53	11.08
LYs in SVR12/patient treated	NA	9.80	10.26	10.87
Incremental analysis (incremental cost/LYs gained in SVR12)
vs. No screening	NA	−743 EUR	−417 EUR	−168 EUR
vs. No treatment		−795 EUR	−462 EUR	−206 EUR
vs. All-oral, IFN-free for F3–F4			1,453 EUR	1,384 EUR
vs. All-oral, IFN-free for F2–F4				1,324 EUR

Abbreviations: DAA, direct-acting antiviral, IFN, interferon; LYs, life-years; NA, not applicable; SVR₁₂, sustained virologic response 12 weeks after treatment.

Figure 5 One-way deterministic sensitivity analyses on the cost of treatment/LYs in SVR₁₂ for all-oral, IFN-free DAAs for F0–F4 in the 18–39 (A) and 40–80 years age groups (B).

Abbreviations: CC, compensated cirrhosis; DAA, direct-acting antiviral; DCC, decompensated cirrhosis; HCC, hepatocellular carcinoma; IFN, interferon; LYs, life-years; SVR, sustained virologic response; TP, transition probability; SVR₁₂, sustained virologic response 12 weeks after treatment.

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