Advancements in the treatment of HIV and Aids has improved the prognosis of sufferers, driving insurers to be more inclusive in providing cover, explains Julie Hopkins
The protection industry should look to offer cover to as many individuals as possible. We have to challenge ourselves to continue to change cultural attitudes and encourage inclusive behaviour. This is why developments in survival of HIV positive individuals have been followed with great interest.
Indeed, Hannover Re has been reviewing and analysing the published medical, statistical and research data on HIV and Aids over the past few years. The advent of successful new treatments has given HIV positive individuals a significantly better prognosis. With the new highly active anti-retroviral therapy (Haart) regime being extremely successful for some patients, it is hoped that the prognosis of being HIV positive can move towards that of being a chronic condition and away from a fatal one.
The South African market has started to offer cover to HIV positive individuals. Insurance terms are now available in the market both before and after the start of drug therapy. In Europe, with the formation of the Dutch Insurers Working Group on Aids, an insurer in the Netherlands has been offering terms to HIV positive lives for several years.
Closer to home, the topic of HIV is still very much in the insurance news with the Association of British Insurers (ABI) HIV and Insurance working party releasing a Statement of Best Practice in May 2008.
An evaluation of the recent good quality data and studies being released show that it is possible to offer life cover to a select group of HIV positive lives who meet certain criteria (see recent medical papers below).
HIV has proved to be a formidable foe with certain strains of HIV developing drug resistance. Haart is not a cure and serious side effects can occur. Several different regimes of the treatment may be tried if the first fails.
Recent medical papers are encouraging. One study, Aim's Survival of Persons with and without HIV Infection in Denmark 1995-2005, matched each HIV positive person in Denmark against 99 people from the general population of similar sex, date of birth, and area of residence. The study is relevant as HIV care is likely to be very similar to the UK in that treatment is free to all and of very high quality.
Tables were constructed with age as the time scale to estimate survival from age 25. Survival has changed dramatically over time with the introduction of Haart, particularly with its later treatments. This study is also useful as it gives age specific mortality rates for five-year age bands for recent 2000 to 2005 cohorts with mortality rate compared alongside the general population. A major limitation is that survival values beyond 10 years are based on extrapolation only. This study clearly demonstrates that we are still some way off achieving general population mortality.
Another study, this time from JAMA and entitled Changes in the Risk of Death After HIV Seroconversion Compared with Mortality in the General Population, examined the mortality of 16,524 individuals, including some from the UK, following HIV seroconversion and compares mortality and excess mortality to that of the general population. Seroconversion is when the HIV was transmitted and infected the individual.
The paper concludes mortality rates for HIV positive persons have become closer to general population mortality rates since the introduction of Haart. It is noted that in industrialised countries, mortality rates are similar to the general population for the first five years since infection, though a mortality excess remains as the duration of infection lengthens. Individuals who contracted HIV through intravenous drug use (IDU) were seen to have significantly worse mortality as were those of an older age.
The paper illustrates how close modern Haart treatment has made the mortality rate to that of the general population in the immediate years following seroconversion.
In Lancet's 2008 study, Life Expectancy of Individuals on Combination Antiretroviral Therapy in High-Income Countries: a collaborative analysis of 14 cohort studies, a life table for the combination of 14 HIV cohort studies from Europe and North America was constructed. Patients were included if over 16 years old for treatment naive (first treatment) when starting combination antiretroviral therapy.
At a high level, the study concluded that the life expectancy of HIV-infected patients treated with combination antiretroviral therapy increased between 1996 and 2005, although there was considerable variability in subgroups of patients. However, it was estimated that the typical life expectancy of a 20-year-old HIV positive person was two-thirds of that in the general population in these countries.
However, it is clear from these studies that a certain sub group of HIV positive people responding well to the latest Haart therapy are now an insurable risk like many other medical conditions. The longer-term success of current treatments is unknown although some studies show continuing improvements in mortality. These trends in excess of 10 years are not based on reliable data but on extrapolation of the results to date.
With this in mind, clients can be supported through offering life cover with a term of up to 10 years. Other key criteria will include: lives resident in the UK; maximum sum assured £250,000.
To reduce the risk of drug resistance, the offer will be subject to a good history of high CD4 count and low viral load on Haart treatment. Individuals with co-morbidities will be looked at on a case-by-case basis.
Hopefully, more terms will be extended as more data is released if this shows the current recent improvements continuing.
Of course, some individuals will not be offered terms but this could be for a variety of reasons such as certain co-morbidities or a poor history of adherence to treatment. Medical studies have shown that CD4 count after 24 weeks is also a highly significant prognostic factor.
Finally, let us return to our theme of inclusion. Insurance is about the pooling of risks and extending cover to include as many of these risks as possible. There has clearly been a shift in the survival of HIV positive individuals due to modern HAART treatments and we have an obligation to include those risks that we can support. The time is now right to offer terms. It is a good message and hopefully one of comfort to be able to offer life cover to individuals who previously would be excluded.
Julie Hopkins is head of underwriting and claims strategy at Hannover Re
Case Study One
She is a female aged 36 with young children and wishes to take out cover of £75k for 10 years. She reveals that she likely contracted HIV four years ago and has been on Haart for two years.
She was diagnosed before any Aids symptoms developed and she is mostly healthy with a viral load just above undetectable. Medical history is fairly good; she is a smoker with a mild history of asthma. CD4 count is still gradually increasing and was just over 250 at 24 weeks after the start of Haart. A full history of all medical appointments attended and sequential test results of CD4 and viral loads are presented. The terms she can be offered are higher than in case study two as she is older, has been infected for a longer period of time and her CD4 count is lower.
Overall, Hannover Re can offer a loading of £5 per £1,000 of cover for a 10-year policy on its smoker rates. Equating to £31.25 a month additional premium.
Case Study Two
He is a 27-year-old HIV positive man who wishes to take out a £100k term policy for 10 years. Full medical information is requested to assess the application.
He was diagnosed one year ago on a routine HIV test; he also had a negative test two years ago, and has no symptoms of a weak immune system and otherwise appears fully healthy.
In addition, he has no evidence of intravenous drug use and tested negative for hepatitis C. He has been on Haart treatment for 45 weeks and we ask to see his viral load and CD4 history.
Viral load is the amount of HIV measured in the blood and described as the number of copies of HIV RNA per millilitre (copies/ml). A viral load above 100,000 copies/ml is considered high, and below 10,000 copies/ml is considered low. If the viral load is less than 50 copies/ml it is not shown up by modern detection tests it is still present but said to be undetectable.
He has made a great response to the Haart regime which has reduced his viral load to an undetectable level by 24 weeks. Furthermore, he is not suffering any serious drug side effects.
The other key measure is his CD4 count. The HIV retrovirus inhibits the human immune system from working properly. In particular it infects and reduces the number of CD4 white blood cells which coordinate the immune system's response against infection.
CD4 cells are measured per cubic millimetre of blood (cells/mm3). A CD4 cell count between 200 and 500 indicates that damage to the immune system has occurred. A HIV positive individual has their CD4 count monitored regularly and if it falls to 350 or below they are recommended to start anti HIV treatment.
When he was diagnosed he had a CD4 count of around 300 but with the successful Haart it has increased steadily to around 550 at the last test.
Overall, Hannover Re can offer him cover with a loading of £3 per £ 1,000 of cover on its standard rates. Equating to £25 a month additional premium.
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