Abstract
The Human Immunodeficiency Virus (HIV), and its subsequent diseaseprogression Acquired Immune Deficiency Syndrome (AIDS), havepresented significant and unprecedented challenges to the insuranceindustry. These conditions led to concerns of mounting and unfundedliabilities and essentially changed the way that insurance was underwritten. Fortunately, with the development of new therapies, individuals with HIV areliving much longer lives and the dire predictions for excess mortality lossesfor insurers did not materialize. For decades, individuals with HIV wereconsidered uninsurable; however, a paradigm shift has recently occurredin the way insurers view HIV, based upon a growing body of evidencedemonstrating improving mortality outcomes for infected individuals. HIV is now transitioning to an insurable condition, but despite treatmentsuccess, it remains a complex disease, and designing insurance productswith the right inclusion and exclusion criteria is a challenging task. Insurancemedical directors and underwriting manual developers will need to followmedical literature closely and amend their guidelines as needed. This articlediscusses the main risk factors requiring assessment when coverage for individualswith HIV is being considered.
Introduction
HIV has resulted in millions of deaths globally since first reported in 1981.Today, according to the World Health Organization (WHO), 37 million peoplearound the world were living with a diagnosis of HIV at the end of 2014, 25.8million of whom were located in sub-Saharan Africa (which is also where70% of all new infections occur)1.
With the advent of anti-retroviral therapy (ART) in the mid-1990s, HIV hasbecome a controllable (albeit still chronic) disease. Life expectancies forthe HIV-infected, once measured in months or even weeks, are now in thedecades for those receiving ART. Indeed, annual death rates for newly infectedHIV patients on ART currently approach those of the generalpopulation in short-term follow up. In the longer term, epidemiological studieshave reported mortality ratios for those with HIV approaching those observedin individuals with other insurable chronic diseases. Morbidity risk for theseindividuals, however, continues and is yet to be quantified2.
As ART is increasingly allowing those living with HIV to remain activemembers of society – that is, to continue to work, run businesses, havefamilies and purchase homes – they are needing life insurance cover toprotect themselves, their families, and their businesses.
More than 10 years ago, insurers in South Africa and Europe began offeringlife cover to treated HIV-infected individuals on a limited-term basis. Morerecently, life insurers in the U.S. and Canada have also begun to develop andoffer products to cover HIV-positive individuals.
Depending on inclusion and exclusion criteria selected as defining the better risk, offers canbe made on a reasonable percentage of HIV positive applicants. Underwriting ratings canbe determined by extrapolating data from various medical studies to ensure the additionalpremium assessed is fair. Due to the relatively high ratings for many of these applicants andthe typical limited-term duration of these products, the placement ratio has been low, but isincreasing.
Of note, in some countries durations of policies available to HIV-positive individuals havebeen extended to renewable term and whole of life products. Still, with low numbers of inforcepolicies covering HIV-positive insured people, credible claims experience is yet to bedetermined. This data will need to be followed carefully.
Life Expectancy/Mortality
Deaths from HIV have decreased dramatically over the past two-plus decades. Recentarticles reviewing research on HIV mortality outcomes show that people are living longer andthe majority of deaths occurring among those on treatment are now no longer due to AIDS definingillnesses3, 4. These articles, along with the following three studies, can serve asexcellent reviews for anyone researching HIV mortality outcomes in the course of developingunderwriting guidelines.
The Antiretroviral Therapy Cohort Collaboration (ART-CC) found that between 1996 and2005, estimated life expectancy at age 20 had increased from 36.1 years to 49.4 years, andthe number of those who survived from age 20 to age 44 increased to 85.7% by 20055. TheUK Collaborative HIV Cohort (UK CHIC) study of patients (excluding injection drugusers) infected with HIV-1 (the most prevalent form of the virus) who started ART in2000-08 found that on commencement of treatment, estimated life expectancies for theseindividuals at age 35 were6:
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A study which looked at U.S. and Canadian participants in the North American AIDSCohort Collaboration on Research and Design (NA-ACCORD) on ART between January2000 and December 2007 found that overall life expectancy estimates increased from 36.1to 51.4 years from 2000-2002 to 2006-20077. Table 2 (below) provides a breakdown:
Despite improved life expectancies, HIV-infected individuals still experience a higher rate ofnon-AIDS-related deaths than the general population. This discrepancy in life expectanciescould be attributed either to the active HIV infection or to other underlying factors suchas higher rates of alcohol use and smoking, co-infection of hepatitis C, or as a result ofcardiovascular, cancer or liver disease. The presence of these comorbidities also needs tobe assessed by insurers, regardless of undetectable viral load or high CD4 cell counts.
Comorbidities
Increased T-cell turnover in HIV infection causes increased generalized inflammation andendothelial damage. As a result, HIV-infected individuals are at greater risk of developingage-related diseases earlier than the general population.
The most frequently reported cardiac disease manifestations in HIV patients are
cardiomyopathy, pulmonary hypertension and pericardial disease. Increased cardiovascularrisk may be due to inflammatory lipid alteration, indicated by a higher carotid intimal-mediathickness (IMT) in HIV patients8. Older retroviral medications such as zidovudine (Retrovir)and stavudine (Zerit) are also more likely to cause dyslipidemia.
The Veterans Aging Cohort Study (VACS), conducted in the U.S. from 2003-2009, foundthat male HIV patients were at a 50% increased risk of myocardial infarction (MI) versusnon-infected individuals9. More than half of all HIV patients may have ECG abnormalitiessuch as a prolonged QT interval, which can be associated with sudden death10.
Older HIV patients needing concomitant drugs for age-related conditions may have ahigher risk of drug interactions with outcomes such as gastrointestinal intolerance, centralnervous system disorders, liver toxicity, dyslipidemia, and loss of bone mass11.
Liver disease is also a major cause of death, and tuberculosis (TB) remains a leadingcause of death among HIV-infected individuals in developing nations 11, 12. HIV infection hasadditionally been linked to a risk of insulin resistance with nucleoside reverse transcriptaseinhibitors (NRTIs) further increasing insulin resistance and the risk of diabetes10.
Finally, there has been a documented increase in cancers of the anus, liver, and lung, andin Hodgkin’s lymphoma since ART’s introduction in 1995. Zidovudine (azidothymidine)and the now discontinued zalcitabine (Hivid) have both been cited as contributing to thecarcinogenic effects of ART. Other links have also been made between HIV and non-AIDS definingcancers specifically caused by infections such as Heliobacter pylori in gastriccancer, Chlamydia pneumoniae in lung cancer, and human papilloma virus (HPV) in cervicalcancer 13.
Key Prognosticators of Mortality in Applicants with HIV and Risk Selection
Most insurance underwriting guidelines require that an HIV-infected applicant be currentlyunder treatment with ART and can demonstrate adherence to treatment and follow-up forat least six months. Some insurers require a longer period of time to ensure appropriatecompliance and medication effectiveness.
Key prognosticators to keep in mind are:
- Current Viral Load
Undetectable viral load is an absolute requirement, although consideration could begiven if there is a history of viral “blips” – e.g., a transient viral load of up to 400 copiesper milliliter which then normalizes quickly.
- Nadir CD4 Count
Most underwriting guidelines take a less than favourable view of covering HIV-positiveindividuals if a history exists of a CD4 + T-cell count of less than 200 cells/μL (AIDS,by definition) or of AIDS-defining clinical conditions (per the CDC), as this commonlymeans there has been significant damage to the immune system and irreversibledamage to body systems. An exception to this might be an applicant with comorbidpulmonary TB that has been treated without sequelae.It should be noted that CD4 counts continue to rise with ongoing ART therapy, thusthe nadir CD4 count may be of less importance over time if CD4 recovery has beendemonstrably stable. A recent paper demonstrated that after five years of ART, mortalityoutcomes of patients with low baseline CD4 counts converged with mortality ofpatients with intermediate and high baseline CD4 counts14.
- Current CD4 Count
A current (within six months of application) CD4 count of at least 350 cells/μL is
a minimum requirement for consideration of coverage. However, with new clinicaltreatment guidelines promoting the commencement of treatment to everyone worldwidewith HIV regardless of CD4 count, best-case thresholds for those with CD4 countsgreater than 500 cells/μL are now being seen.While CD4 cell count at diagnosis can be highly predictive of mortality in the first year,this predictive value becomes no longer statistically significant three to four yearsafter ART is initiated. An analysis of patient data from 15 of the 19 cohorts in theART Cohort Collaboration study found that among 14,208 patients, CD4 cell countsand viral loads at the drug’s initiation were no longer prognostic of full-blown AIDSor of death after 36 months15. Another study, of 14,932 HIV patients in South Africa,found the effect of time on mortality was constant after 36 months on ART for all CD4counts16.
- Comorbid Risk Factors and Disease
Significant comorbidities generally preclude coverage of HIV-infected individuals.Companies vary as to what qualifies as a “significant” comorbidity. For example, peopleco-infected with HIV and hepatitis viruses tend not to do wellclinically. The medical literature also shows that HIV patients aredeveloping and dying prematurely from vascular disease, so amore cautious view should be taken if the applicant also smokes,has diabetes, or has already developed cardiovascular disease.There is a significant body of literature demonstrating very highmortality in HIV-infected individuals who are also intravenous drugabusers. Comorbid alcohol or drug abuse is a concern, althoughsome underwriting latitude may be permissible for those usingmedically prescribed marijuana (depending on the indication). Asthere is also an increased suicide risk in HIV-infected individuals,insurers should also be concerned about any significantpsychiatric history.
Determining Underwriting Ratings and Premiums
As with any impairment, there must be evidence to support anyproposed extra premium being charged when an applicant has HIV.Care should be taken to be sure products for this block are fairly underwritten, priced andmarketable, and will not damage company solvency.
Rating guidelines developed for covering HIV-positive individuals will depend on the following:
- Type of insurance product
- Term of coverage
- Selection criteria
- Insurable age: Few deaths are expected among very young people, thus it does not takemany extra deaths in this cohort to make that group potentially uninsurable
- Smoking status: Even though an applicant with HIV might be assessed for smoker rates,additional loading may also need to be considered
These criteria and ratings will most likely vary by country, depending on availability of testing andaccess to affordable antiviral therapy and treating specialists.
Conclusion
The recent paradigm shift in the insurability of HIV has been a long-awaited event. Nevertheless, HIV remains a complex and potentially serious disease. Medical insurance directors will need towork closely with their companies’ actuarial, business development and marketing departmentsto ensure that insurance coverage is accurately assessed and priced and that consumer needsand expectations are addressed appropriately.