MTV launched, the space shuttle Columbia landed, and a notice from the Centers for Disease Control and Prevention (U.S.) reported a new and mysterious immune system problem appearing among men in the Los Angeles area. The year was 1981. No one yet recognized the signs of AIDS (Acquired Immune Deficiency Syndrome), but since those early days, an estimated 70+ million have been infected with HIV globally and 35 million have died from HIV/AIDS.
Now for the good news: In the more than two decades since ART (Anti-Retroviral Therapy), also known as combination anti-retroviral therapy, first arrived, it has transformed HIV from a 100% fatal infection to a chronic condition. Individuals infected with HIV can now expect to live significantly longer and benefit from some of the financial protections provided by insurance.
Recently, RGA’s Dr. Dan Zimmerman spoke to the Association of Home Office Underwriters (AHOU) about the history of HIV/AIDS and insurance, and how risk modeling can reasonably conclude that some individuals with HIV can now be candidates for life insurance coverage. We sat down with Dr. Zimmerman to discuss his presentation and the paradigm shift in the availability of life insurance for people with HIV.
Dr. Zimmerman, in your remarks to AHOU you noted that much of what underwriters may have learned about HIV in the past may now be wrong. What do you mean? Are underwriting manuals out of date?
In the past, underwriters were actually taught very little about HIV. For many years, HIV was considered an uninsurable condition due to significant excess mortality and morbidity. Given sensitivities at the time, the underwriting of HIV-positive cases was often managed by company medical directors or other non-underwriter associates. Thus, there was little need to keep underwriters up to date with developments. It is not so much that the manuals were out of date, it’s simply that underwriters per se were not actually underwriting HIV/AIDS. Today, manuals are being updated with the new knowledge and understanding about the long-term survival potential for individuals with well-controlled HIV.
You noted that the average survival time from AIDS diagnosis to death was just 2.1 years in 1987, and that, by the mid-1990s, AIDS was projected to account for 10% of life insurance claims. What did the life insurance industry learn from this experience? Are there lessons we can apply moving forward?
First of all, the good news is that life expectancy of individuals infected with HIV improved rapidly in the 1990s because of the incredible success of new treatments such as protease inhibitors. The projected 10% level of life insurance claims never occurred. By no means, however, does that diminish the seriousness of the infection or its impact on millions of lives. The insurance industry learned a lot during this period, realizing that completely unanticipated risks can develop. People rely on our industry for financial protection and insurers need to maintain their solvency in order to meet that obligation. Moving forward, I think a good example to follow can be found in how insurers now consider and plan for potential pandemic diseases. Insurers model for these risks, trying to anticipate the spectrum of outcomes and planning accordingly.
You spoke about a “paradigm shift” in the insurability of individuals with HIV infection, but could you explain the persistent mortality and morbidity concerns that still exist?
To be clear, the paradigm shift refers to the fact that HIV infection used to be considered an uninsurable condition across the board. Now, through a lot of evidence-based research, we know that some people with very well-controlled HIV infections and otherwise essentially good health can be offered life coverage. However, it’s important to keep in mind even those who are doing well remain at increased risk for developing a number of other health conditions, all of which can contribute to persistent excess mortality and morbidity concerns. Treatment for HIV is at a state-of-the-art level, but it does not restore the immune system completely.
You shared that an estimated one in eight people with HIV, 12.5%, are unaware of their infection. What is the role of PrEP in preventing the spread of HIV?
PrEP, or pre-exposure prophylaxis, is a type of medication HIV-negative people who may be at increased risk of acquiring HIV can take to help reduce their risk of getting HIV. One risk, for example, might be having a partner who is known to have HIV infection. PrEP consists of two medicines combined in a single, once-a-day pill. As you mentioned, about 12.5% of people in the U.S. do not know they are infected with HIV. Thus, they could unknowingly pass it to an intimate partner. However, if someone is taking PrEP, their chances of becoming infected could be reduced by over 90%. While a vaccine would be better, these numbers are still very encouraging. It’s possible that PrEP could have a big impact on slowing the HIV epidemic and reducing the number of new infections.
What is the likelihood of a future vaccine for HIV/AIDS – and how should this affect insurers?An HIV vaccine has been the “Holy Grail” of HIV/AIDS research since the infection was first identified. Early on, there were hopes that an effective vaccine would be developed by the mid-1990s. Clearly, that did not happen. To this day we remain without an effective vaccine. Unfortunately, because HIV is a retrovirus, vaccine development is extremely difficult. However, there have been some advances and new directions in recent years on this front, so there is still hope for an eventual, successful vaccine in the future. At least in the meantime, PrEP is proving very helpful and may help bridge the gap until a vaccine is available.