Abstract
BACKGROUND AND AIMS: In 2024, < 10% of hepatitis C virus (HCV) cases were treated in Eastern Europe and Central Asia (EECA) and the burden remains high. We aimed to estimate the cost-effectiveness of treating anyone with HCV ('treat all') or targeting people who inject drugs (PWID) in 14 middle-income EECA countries. METHODS: We gathered costs of screening, confirmatory tests, direct-acting antiviral (DAA) treatment and monitoring from published country-specific data, Georgian costs from previous analyses, and UNICEF. We combined decision tree modelling with a dynamic transmission model of HCV calibrated for each EECA country to calculate quality-adjusted life years (QALYs) gained by 2030 from 100 DAA treatments in 2024, for treat all compared to targeting PWID. We calculated incremental cost-effectiveness ratios (ICERs, cost per QALY gained) relative to gross domestic product (GDP) per capita. RESULTS: QALYs gained from 100 treatments ranged from 29-55 if treat all and 25-90 if targeting PWID. Using country-level costs, Bulgaria and Russia had ICERs above GDP per capita due to high DAA costs. For other countries, ICERs ranged from 18% to 89% of GDP (treat all) and 4%-89% (PWID). Using lower Georgian costs and UNICEF costs, the treat all ICERs were below 84% and 24% of GDP for all countries, respectively, except Bosnia, while the ICERs when targeting PWID were below 64% and 16% of GDP, respectively. CONCLUSIONS: Strategies that treat all persons with HCV and target PWID are both likely to be cost-effective in middle-income EECA countries, particularly with broad access to low-cost generic treatments such as through UNICEF procurement.