We were fortunate to attend two very good lectures on HIV/AIDS in 2013, one by Dr Daniel Zimmerman of Northwestern Mutual at the annual AHOU meeting, and the other, by Dr Rogelio López-Vélez, at the ICLAM meeting in Madrid. Both speakers described the HIV/AIDS spectrum and the impact of HAART (highly active antiretroviral treatment – now available in fixed-dose combinations as a single pill, which makes for much better patient compliance), ending up by discussing the potential for insurability.
There is no doubt that modern treatment – for those for whom it is available – has transformed HIV/AIDS from a death sentence into a chronic, potentially manageable illness. Without treatment, average survival time after infection with HIV is still around ten years, and the onset of AIDS means survival prospects measured in months. But there are some impressive statistics that illustrate the progress that has been made via antiretroviral therapy (ART) in HIV infection. One study1 estimated that 20 year-olds diagnosed with HIV in 2003-5 had an average survival of 49 years compared with 36 years when diagnosed in 1996-9. Another2 concluded that a significant proportion of HIV-positive individuals experience mortality similar to that associated with other conditions requiring lifelong treatment, such as diabetes. Others3,4 have even concluded that in patients with no other risk factors mortality levels are similar to those in the general population.
There are other studies too, all painting a favourable picture. This sounds like it should augur well for insurability – and it does; but a degree of caution is called for. ART is not without its complications. Although many of the original side-effects have been eliminated there are still question marks over lipid abnormalities and insulin resistance (both of which predispose to atherosclerosis) and also low bone density. And presumably there is the scope for the virus to become resistant to treatment. For at least some of these reasons it is unclear how HIV-infected individuals will age. It is certainly true that there are plenty of patients around aged 50-plus but the data is not yet robust enough. And talking of data, many of the studies have been to a degree projecting mortality levels based on current experience. Will those projections become reality?
And while mortality levels at or close to those of the general population are exciting, it should not be forgotten that the general population contains a proportion with chronic and other significant illnesses and disabilities. Certainly, compared with an insured population that has undergone a typical selection process, there would be a significant number of extra deaths among even the better HIV risks. Kaulich-Bartz and colleagues5 calculated a mortality ratio of 459% among a European HIV-infected group compared with the general population. These were individuals who started antiretroviral therapy after 2000, had a six-month CD4 cell count of at least 350 cells/μl and HIV-1 RNA less than104 copies/ml, and with no history of AIDS. But given that the proportion of exposure time with relative mortality below 300%, 400%, 500% and 600% was 28%, 43%, 61% and 64% respectively, the authors suggest that more than 50% of patients (those with lower relative mortality) could be insurable.
The overall outcome of this study was that there is substantial excess mortality even among the better risks. However, that subgroups had lower mortality still – even as low as what underwriters would term +200 – points to the need for careful risk stratification. And while it is good to be able to offer cover to seriously impaired lives, albeit subject to substantial extra premiums, you do worry that if those offers are taken up you are being selected against – the customer knows more about the risk than you do. This is especially relevant for a risk like HIV, which must still be regarded as ‘experimental’.
Nevertheless, knowledge and understanding of HIV is increasing apace, and the time is surely right for the industry as a whole to be accepting these risks – subject to careful selection, of course, taking into account obvious factors such as mode of viral acquisition, CD4 count, viral load and treatment compliance, but also the bigger picture including occupation, social class and lifestyle. Policy class and term together with face amount should be of considerable interest too. Carriers might consider it prudent to avoid massive sums insured, but even in the realms of slightly more modest face amounts, which would you prefer: a short-duration policy for a relative high value or a longer one for a smaller sum insured?
We are reminded of the pioneering days when reinsurers began offering experimental terms for applicants with hypertension, diabetes and even coronary heart disease, conditions which hitherto had almost always meant a declinature. Perhaps it was easier to be adventurous then. With fatter margins, a cushion of with-profits savings plans, higher interest rates and a less demanding business environment, profit – including that from mortality – was a foregone conclusion. Those days are long past. Nevertheless, life insurers – and their reinsurers – have a strong track record of pushing successfully at the bounds of insurability for the benefit of society as a whole.
That tradition should be continued for HIV infection. Which will be the first reinsurer to put firm rating guidelines in its manual?
- Antiretroviral Therapy Cohort Collaboration. Hogg R, Lima V, Sterne JA, Grabar S, Battegay M et al. Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. Lancet 2008;372:293-299
- Antiretroviral Therapy Cohort Collaboration. Zwahlen M, Harris R, May M, Hogg R, Costagliola D et al. Mortality of HIV-infected patients starting potent antiretroviral therapy: Comparison with the general population in eight industrialized countries. Int J Epidemiol 2009;38:1624-1633
- Obel N, Omland LH, Kronborg G, Larsen CS, Pedersen C et al. Impact of non-HIV and HIV risk factors on survival in HIV-infected patients on HAART: a population-based nationwide cohort study. PLoS One. 2011;6(7):e22698
- van Sighem, A, Gras, L, Reiss, PB, Brinkman, KC, de Wolf, FD on behalf of the ATHENA national observational cohort study. Life expectancy of recently diagnosed asymptomatic HIV-infected patients approaches that of uninfected individuals. AIDS 2010;24(10):1527-35 5. Kaulich-Bartz J, Dam WA, May MT, LederbergerBC, Widmer, UA et al. Insurability of HIV-positive people treated with antiretroviral therapy in Europe: collaborative analysis of HIV cohort studies. AIDS 2013;27(10):1641-55