UNDERWRITING HIV: THE FAIRY TALE HAS BECOME REALITY Midwestern Underwriting Conference 2016 Jean-Marc Fix, FSA, MAAA VP, R&D, Optimum Re Insurance Co.
AGENDA Where are we with HIV? The risk The ideal case What to look out for? Reality: case studies 2
FACE OF A KILLER 3 Source: CDC image library
4 INFECTIOUS PATHWAY Men having sex with men Heterosexual Intravenous drug user Blood product (transfusion, hemophilia) Occupational
INFECTIOUS PATHWAY -MEN not reported Blood 19% transfusion 0% High risk sex 7% Hemophilia 0% MSM+IDU 5% IDU 8% Male to male(msm) 61% Source: HIV AIDS Surveillance vol 19 CDC 5
INFECTIOUS PATHWAY -WOMEN IDU 14% Other and not reported 39% Hemophilia 0% Blood transfusion 0% High risk sex 47% Source: HIV AIDS Surveillance vol 19 CDC 6
WHAT WE REMEMBER AIDS Is Top Cause of Death for Young Adults in U.S. Disturbing report by federal agency San Francisco Chronicle 2/1/95 Hunting for the Hidden Killers: AIDS Time Magazine 7/4/83 Together in Life and Death San Ramon pair die of AIDS 2 days apart Ray, 58, and Peggy, 54, of San Ramon, died earlier this month after battling the disease for five years. They were buried Monday in the same grave. SFC 2/1/95 7
Mortality Rates Among People With HIV, Long on the Wane, Continue to Drop HIV Medicine Feb 2013 8
HIV TODAY MAGIC JOHNSON diagnosed 1991, alive today 9
HIV INFECTION AIDS HIV= Infection with virus AIDS=Infection + CD4 count<200 OR AIDS defining condition regardless of CD4. Thrush; Coccidioidomycosis; Cryptococcosis; Cryptosporidiosis; CMV; HIV encephalopathy; HSV chronic ulceration; Histoplasmosis; Isosporiasis; Kaposi s + others Opportunistic infections or unusual neoplasms known to result from immune suppression 10
WHAT IS UNDERWRITING ABOUT? Select Offer 11
DEATH RATES TRENDS 12 Note: For comparison with data for 1999 and later years, data for 1987 1998 were modified to account for ICD-10 rules instead of ICD-9 rules. *Standard: age distribution of 2000 US population Death rates are age adjusted
ADVANCES IN TREATMENT 13 Source: Pallella et al, J Acq Immune Def Syndr 2006
VIDEO- INFECTION https://www.youtube.com/watch?v=ro8mp3 wmvqg 4 08 14
15 ACTION PATH OF TREATMENT
HAART Highly Active Antiretroviral Treatment Latest is triple cocktail, for ART naïve patients: 1. NNRTI + 2 NRTI: Atripla, Complera, Odefsey 2. Ritonavir boosted PI + 2 NRTI 3. INSTI + 2 NRTI: Stribild, Genvoya, Triumeq NRTI = nucleos(t)ide reverse transcriptase inhibitor NNRTI = non-nucleoside reverse trans. inhib. PI = protease inhib. INSTI = integrase strand transfer inhib. Source: Antiretroviral drugs for treatment and prevention of HIV infection in adults JAMA 2016 16
17 HIV DRUGS 2016 Single-Tablet Regimens NRTI NNRTI Protease Inhibitors Entry Inhibitors Atripla Combivir Edurant Aptivus Fuzeon Complera Descovy Intelence Crixivan Selzentry Genvoya Emtriva Rescriptor Evotaz Odefsey Epivir Sustiva Invirase Integrase Inhibitors Stribild Epzicom Viramune Kaletra Isentress Triumeq Retrovir Lexiva Tivicay Trizivir Norvir Vitekta Truvada Prezcobix Videx EC Prezista Pharma Enh. Viread Reyataz Tybost Zerit Ziagen Viracept
OTHER HIV THERAPEUTIC CLASSES Antifibrotics: Losartan Biological response modifiers: rintatolimod Gene Therapy Products: antisense gene, CCR5 modification Immune Modulators: activators and suppressants Latency-Reversing Agents Maturation Inhibitors Microbicides Nucleoside Reverse Transcriptase Inhibitors (Viral Decay Accelerators) 18 (ource; https://aidsinfo.nih.gov
HIV RESERVOIRS CD4+ memory T-cell Can stay inactive and virus dormant for many years Under current therapy: 60+ years to clear the virus (1) 19 (1): Marsden and Zack J Antimicrob Chemo 2009
THE MECHANISM Depletion of CD4+ T helper Cells Loss of immune protection Opportunistic infection 20
HIV DISEASE ET AL Source : SG Deeks et al Lancet 2 nov 2013: 382:1525-1533 The end ofaids: HIV as a chronic disease 21
HIV CONTINUUM Source : SG Deeks et al Lancet 2 Nov 2013: 382:1525-1533 The end ofaids: HIV as a chronic disease 22
Mortality from HIV THE RISKS AIDS defining diseases ~50% Liver disease (hepatitis coinfection) Infection (non AIDS defining) Cancer (non AIDS defining) 23
THE RISKS Mortality from treatment Cardiovascular Mortality from behavior Drug overdose, accident, suicide 24
NOT TOO YOUNG Not too young at infection Not too young when buying the policy 25
THE IDEAL CASE Values Treatment Compliance Follow-up 26
WHAT TO LOOK OUT FOR Lack of compliance Bad test trends Behavior red flags Additional health issues: STD Cardiac Kidney/liver 27
THE GRITTY REALITY CASE STUDIES 28
QUESTIONS Jean-Marc Fix, FSA, MAAA VP, R&D Optimum Re Insurance Co. 29