Epidemiology of hepatitis C virus infection in a country with universal access to direct‐acting antiviral agents: Data for designing a cost‐effective elimination policy in Spain

Accurate HCV prevalence estimates are necessary for guiding elimination policies. Our aim was to determine the HCV prevalence and assess the cost‐effectiveness of a screen‐and‐treat strategy in the Spanish population. A population‐based, cross‐sectional study (PREVHEP‐ETHON Cohort, Epidemiological sTudy of Hepatic infectiONs; NCT02749864) was performed from July 2015‐April 2017. Participants from three Spanish regions were selected using two‐stage conglomerate sampling, and stratified by age, with randomized subject selection. Anthropometric and demographic data were collected, and blood samples were taken to detect anti‐HCV antibodies/quantify HCV RNA. The cost‐effectiveness of the screening strategies and treatment were analysed using a Markov model. Among 12 246 participants aged 20‐74 (58.4% females), the overall anti‐HCV prevalence was 1.2% (95% CI 1.0‐1.4), whereas the detectable HCV‐RNA prevalence was 0.3% (0.2‐0.4). Infection rates were highest in subjects aged 50‐74 years [anti‐HCV 1.6% (1.3‐1.9), HCV RNA 0.4% (0.3‐0.6]. Among the 147 anti‐HCV + subjects, 38 (25.9%) had active infections while 109 (74.1%) had been cleared of infection; 44 (40.4%) had cleared after antiviral treatment, whereas 65 (59.6%) had cleared spontaneously. Overall, 59.8% of the anti‐HCV + participants were aware of their serological status. Considering a cost of treatment of €7000/patient, implementing screening programmes is cost‐effective across all age cohorts, particularly in patients aged 50‐54 (negative incremental cost‐effectiveness ratio which indicates a cost‐saving strategy). The current HCV burden is lower than previously estimated, with approximately 25% of anti‐HCV + individuals having an active infection. A strategy of screening and treatment at current treatment prices in Spain is cost‐effective across all age cohorts. The updated prevalence of hepatitis C in Spain is lower than expected: 0.3% had detectable viraemia, which represents only a quarter of patients with anti‐HCV seropositivity. Among the seropositive subjects, up to 40% had cleared the infection after treatment vs 60% who did so spontaneously. Those born between 1941 and 1965, subjects of non‐Spanish nationality and those with risk behaviours showed a higher prevalence of infection. A strategy of screening and treatment with current treatment prices in Spain is cost‐effective across all age cohorts.