Cost and cost-effectiveness of alternative screening and diagnostic pathways for achieving hepatitis C elimination in the country of Georgia

We evaluated the cost and cost-effectiveness of alternative screening pathways during 2018–2022 within Georgia’s hepatitis C elimination program, which started in 2015. We calculated patient-level costs (2022 USD$) of hepatitis C treatment with centralized and decentralized diagnostic testing in hospitals, primary healthcare (PHC), harm reduction providers (HRP), or specialized providers (SP) from reimbursement records including the value of donated direct-acting antivirals (DAAs). We model hepatitis C case-finding, transmission, and progression over a 20-year time horizon to project cost-effectiveness of treatment for each screening pathway in terms of cost per quality adjusted life year (QALY), compared to a willingness-to-pay threshold of $1,337. Unit costs of treatment decreased from $3942–$4247 across screening pathways in 2018 to $300–$338 in 2022, primarily due to reductions in DAA costs. The cascade of care varied by screening pathway, with highest hepatitis C virus (HCV) antibody prevalence and percent linked to viremia testing among HRP and SP, while total number of patients screened was highest in hospitals. While DAA costs decreased, the cost of case finding increased during 2018–2022, with the biggest increase in hospital settings mainly due to decreasing yield. The program was not cost-effective with full DAA costs, but excluding DAA costs or using lower 2022 costs make all pathways cost-effective and SP, HRP, and PHC potentially cost-saving. Donated drugs allowed Georgia’s HCV elimination program to be cost-effective, while future programs with generic drug costs are likely to be cost-effective. Reductions in yield from hospital screening suggest that later stages of elimination programs should prioritise targeted pathways.