1. 1 Source Heor, 2 University of Bristol, 3 Bristol Drugs Project, UK
01 January 2019
Cost-effectiveness of low dead space detachable syringes for the prevention of Hepatitis C
Elizabeth Hancock1, Zoe Ward2, Rachel Ayres3, Jo Keston2, Jane Neale3, Matthew Hickman2, Peter Vickerman2
1 Source Heor, 2 University of Bristol, 3 Bristol Drugs Project, UK

2. PV has received research grants unrelated to this work from Gilead
01 January 2019
Disclosures
PV has received research grants unrelated to this work from Gilead
Unrelated to this work, PV has received honoraria from Abbvie, and MH has received honoraria from Merck, Abbvie and Gilead

3. Background – Syringe types
01 January 2019
Background – Syringe types
People who inject drugs use two styles of syringes
Syringes with fixed needles which have low dead space (LDSS)
Syringes with detachable needles which have high dead space (HDSS)
Detachable needles needed for
Groin Injectors
Using Filters
Multiple tries to find vein

4. Background – New syringes
01 January 2019
Background – New syringes
New lower dead space detachable options available
These reduce the dead space compared to HDSS
Standard HDSS
Two lower dead space detachable options
Standard LDSS

5. 01 January 2019
Aims
In Bristol (UK), the new detachable syringes with lower dead space were introduced and offered alongside standard HDSS and LDSS
This study evaluated the cost-effectiveness of introducing these lower dead space detachable syringes in preventing Hepatitis C transmission

6. Intervention and Comparator
01 January 2019
Intervention and Comparator
Prior to intervention 38% of all syringes distributed were HDSS or detachable (Comparator)
Bristol Drugs Project started distributing detachable LDSS
Education posters
Training staff to promote new syringes
In first year 3% of all syringes distributed were detachable LDSS replacing former HDSS

7. Increased syringe costs (£0.033 vs £0.025 for HDSS)
01 January 2019
Costs
Direct costs of the intervention included staff time and training (41 hours)
Increased syringe costs (£0.033 vs £0.025 for HDSS)
Indirect costs of HCV care and treatment calculated from infectious disease model

8. Dynamic HCV transmission and progression model
01 January 2019
Model
Dynamic HCV transmission and progression model
Demographic and epidemiological parameters specific to Bristol
Assume detachable LDSS decrease HCV transmission risk by 84%
Used to calculate indirect costs of intervention and quality adjusted life years (QALYs)
Decrease in transmission risk is based on evidence from HIV, where infectivity increased 9 times for every 1 log increase in viral load during vertical transmission and needlestick injuries. The relative volumes of blood in the different syringe type is then used to calculate the decrease in transmission risk for detached LDSS compared to HDSS.
Vickerman (2013), DeCarli (2003), Thomas (2000)

9. 01 January 2019
Analysis Methods
The intervention modelled for 10 years and capture outcomes for a further 40 years
Incremental cost-effectiveness ratio calculated and compared to UK willingness to pay threshold of £20,000 per QALY
Threshold analysis on reduction in HCV transmission risk needed with detachable LDSS to ensure cost-effectiveness
Probabilistic sensitivity analysis to assess impact of uncertainty around important parameters
Test how increase in uptake of detachable LDSS impacts cost-effectiveness

10. Direct intervention costs: £6000 over 10 years
01 January 2019
Results
Direct intervention costs: £6000 over 10 years
Saves 261 QALYs over 50 years
Averts £1.6 million in HCV treatment (68%) and care costs (32%)
ICER is cost-saving which means the intervention gives more health benefit and costs less than the comparator

11. Probabilistic sensitivity analysis
01 January 2019
Probabilistic sensitivity analysis
Incremental Costs (£million)
Incremental QALYs £0
All simulations in cost-saving quadrant
-£2M
-£4M

12. 01 January 2019
Threshold analysis
Base case assumed 84% reduction in HCV transmission risk (new detachable LDSS v’s traditional detachable HDSS):
Result suggested intervention was cost saving
If assume different percentage reductions in HCV transmission risk, then detachable LDSS only have to reduce transmission risk of HDSS by
0.3% to be cost saving
0.08% to be cost-effective at £20,000 per QALY threshold

13. Scenario Analysis of detachable LDSS uptake
01 January 2019
Scenario Analysis of detachable LDSS uptake
Baseline scenario was an uptake from 0% to 3% of all needles and syringes being detachable LDSS – net monetary benefit of £6,830,258
Uptake to 10% increased the net monetary benefit by 241%
Other scenarios looking at cheaper HCV treatment or higher treatment rates still cost-saving

14. 01 January 2019
Discussion
Expanding use of detachable LDSS could save money and reduce HCV transmission risk
Evidence strongly advocates for their use to be expanded to meet preferences of PWID (i.e. groin injectors) for using detachable syringes
However, there is uncertainty over potential role in reducing transmission
Need better effectiveness data to understand the impact this intervention could have for controlling HCV