Jail-Based HCV Testing, Treatment May Deliver Substantial Community Returns

Jail-based hepatitis C virus (HCV) elimination interventions in people who inject drugs could be a cost-effective approach to reduce infections and deaths, according to a simulation analysis.

Combining HCV testing and treatment while in jail with connections to community services after release would reduce person-years of infection by 35%, incidence by 47%, and HCV-related deaths by 40% in people who inject drugs, researchers led by Lin Zhu, PhD, of the University of Miami in Florida, reported in JAMA Internal Medicine.

Delivering all three of those interventions would cost $2,531 per person-year detained and deliver an incremental cost-effectiveness ratio (ICER) of $11,000 per quality-adjusted life year (QALY) gained — a sum well below a community willingness-to-pay threshold of $25,000 per QALY gained.

“The findings suggest that jails might be a highly effective venue for expanding HCV testing and treatment efforts toward elimination,” Zhu and colleagues wrote. “Despite the restricted budgets of many jails, jail-based HCV treatment might offer substantial economic value at the community level, particularly when integrated into broader public health and local government funding frameworks.”

Injection drug use is both a potent risk factor for incarceration and the primary transmission route for HCV. That could make jail-based HCV treatment both feasible and a good return on public health spending, said Benjamin Howell, MD, MPH, of Yale School of Medicine in New Haven, Connecticut, and Byron Kennedy, MD, PhD, MPH, of the Connecticut Department of Correction in Wethersfield, in an accompanying editorial.

“Jail incarceration provides a cost-effective opportunity to identify and treat HCV in previously untreated people,” they noted. “Implementing these programs should align with broader efforts to identify interventions that reach this population before contact with the criminal justice system.”

Putting HCV screening and treatment programs into jails nationwide wouldn’t be easy, Howell and Kennedy cautioned. HCV treatment costs “are shouldered directly by the jails and jurisdictions themselves, requiring difficult trade-offs or increased jail budgets, both of which are politically challenging.” Reforms to allow Medicaid coverage for inmates would help, they added.

Zhu and colleagues developed a model that simulated medium- to large-sized jails in an urban community setting. The model incorporated elements of the Philadelphia FIGHT program, which delivers jail-based HCV testing and treatment, and coordinates post-release health services. The researchers compared five approaches: HCV testing; testing and HCV treatment; testing and post-release service coordination; testing, treatment, and service coordination, and no jail-based intervention.

The jail-based model included 1,552 simulated people who inject drugs, with a mean initial age of 32 years. The researchers simulated jail detention rates, HCV transmission, and liver disease progression among that population. They estimated health outcomes over a 60-year period using QALYs.

Without jail-based HCV interventions, the model predicted there would be 21,349 person-years of infection, 662 incident infections, and 240 HCV-related deaths per 1,000 people who inject drugs over 60 years.

Compared with no jail-based HCV interventions, the estimated additional cost of HCV testing at jail entry would be $1,037 per person-year detained during the first 2 years of the testing intervention. Testing and post-release coordination would cost $1,435, while testing and treatment would cost $2,468 per person-year detained.

All four interventions delivered more QALYs than no jail-based intervention. While no intervention led to 13.44 QALYs over 60 years, testing alone delivered 13.7 QALYs, testing and treating led to 13.87 QALYs, testing and care coordination produced 13.88 QALYs, and combining all three interventions resulted in 13.99 QALYs.

Study limitations include the model’s lack of coordinating staff and startup costs. The researchers also didn’t analyze how HCV interventions would impact jails’ budgets or calculate cost-effectiveness from a jail perspective.