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Clinical Benefits and Cost-effectiveness

Felicitas C. Kuehne, MSc; Ullrich Bethe, MD,MSc; Kenneth Freedberg, MD,MSc; Sue J. Goldie, MD,MPH

Arch Intern Med. 2002;162:2545-2556.

Background  Hepatitis C virus (HCV) is an important cause of liver disease in human immunodeficiency virus (HIV)–infected patients.

Objective  To assess the cost-effectiveness of alternative management strategies for chronic HCV in co-infected patients with moderate hepatitis.

Methods  A state-transition model was used to simulate a cohort of HIV-infected patients with a mean CD4 cell count of 350 cells/µL and moderate chronic hepatitis C stratified by genotype. Strategies included interferon alfa (48 weeks), pegylated interferon alfa (48 weeks), interferon alfa and ribavirin (24 and 48 weeks), pegylated interferon alfa and ribavirin (48 weeks), and no treatment. Outcomes included life expectancy, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios.

Results  Treatment for moderate chronic HCV with combination therapy using an interferon-based regimen reduced the incidence of cirrhosis and provided gains in quality-adjusted life expectancy ranging from 6.2 to 13.9 months, depending on genotype. Regardless of genotype, the cost-effectiveness of interferon alfa and ribavirin for patients with moderate hepatitis was lower than $50 000 per QALY vs the next best strategy. With genotype 1, pegylated interferon alfa (vs interferon alfa) and ribavirin therapy provided an additional 1.6 quality-adjusted life-months for $40 000 per QALY. Because treatment is more effective with non-1 genotypes, pegylated interferon (vs interferon alfa) and ribavirin provided only 3 additional quality-adjusted life-months for $105 300 per QALY. For patients who were intolerant of ribavirin, monotherapy with pegylated interferon was always the most cost-effective option.

Conclusions  Combination therapy for moderate hepatitis in coinfected patients will increase quality-adjusted life expectancy and have a cost-effectiveness ratio comparable to that of other well-accepted clinical interventions.

From the Center for Risk Analysis, Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (Ms Kuehne and Drs Freedberg and Goldie); the Department of Internal Medicine, University of Cologne, Cologne, Germany (Dr Bethe); and the Divisions of General Medicine and Infectious Diseases and the Partner's AIDS Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (Dr Freedberg).

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