Test & Treat : Changing the face of insurance for persons living with HIV? Kadene Gibbs FSA, MSc Dr Matthew Procter
Agenda 1. Background 2. Understanding HIV and Factors affecting Prognosis 3. History of Test & Treat 4. Opportunities for Life Insurance 5. Further Refinements 6. Questions and Discussion
Background Global Prevalence Global estimates by WHO region 36.7 million South-East Asia Americas Europe Eastern Mediterranean Western Pacific living with HIV globally Africa
ART Coverage % Background Global ART coverage percentage 60% 50% 40% 30% 20% 10% 0% 2000 2010 2016 Calendar year African Region South East Asia Region Global net of African Region *UNAIDS/WHO, 2016
Background National Prevalence No. of persons with HIV No. of old diagnosis No. of new infections *UNAIDS/WHO, 2016
ART Coverage % Background National ART Coverage Percentage 60% 56% 50% 40% 34% 40% 45% 49% 30% 20% 10% 0% 27% 20% 15% 10% 7% 4% 1% 2% 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Calendar Year *UNAIDS/WHO, 2016
Background Hannover Re Prevalence Study Hannover Re partnered with Lancet All HIV tests done between 2009 to 2016 Data anonymized to Hannover Re researchers 2.2 million tests on unique individuals 275,000 positive tests observed
HIV Prevalence (%) Background Hannover Re Prevalence Study 25% 20% 15% 10% 5% 0% 2009 2010 2011 2012 2013 2014 2015 2016 Calendar year Insurance Out-patient
HIV prevalence (%) Background Hannover Re Prevalence Study 25% 20% 15% 10% 5% 0% 20-25 25-30 30-35 35-40 40-45 Age group Insurance Out-patient
HIV Prevalence (%) Background Hannover Re Prevalence Study 5.0% 4.5% 4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% 20-25 25-30 30-35 35-40 40-45 45-50 50-55 55-60 60-65 Age group Males Females
Understanding HIV
Factors affecting HIV prognosis ART ADI and Co-morbidities Infection Route CD4 and Viral Load SEC
Test & Treat History 2000 2012 2014 CD4 < 200 WHO Stage 3 and 4 Illness Significant Symptoms CD4 < 350 WHO Stage 3 and 4 Illness HIV and Non- HIV related illness CD4 < 500 WHO Stage 3 and 4 Illness HIV and Non-HIV related illness
Test & Treat Current In treatment, strong evidence has emerged In treatment, strong to evidence show that using ART has emerged to show earlier that results in better using ART earlier results clinical better outcomes for clinical outcomes for people people living with HIV living with HIV compared compared with with delayed delayed treatment. treatment. - World Health Organization, 2015 - World Health Organization, 2015 11
Test & Treat History 2000 2012 2014 2015 - current CD4 < 200 WHO Stage 3 and 4 Illness Significant Symptoms CD4 < 350 WHO Stage 3 and 4 Illness HIV and Non- HIV related illness CD4 < 500 WHO Stage 3 and 4 Illness HIV and Non-HIV related illness CD4 at diagnosis Treatment recognised as prevention
Test & Treat History 2000 2004 2012 2014 2015 - current 34% 45% 56% CD4 < 200 WHO Stage 3 and 4 Illness Significant Symptoms CD4 < 350 WHO Stage 3 and 4 Illness HIV and Non- HIV related illness CD4 < 500 WHO Stage 3 and 4 Illness HIV and Non-HIV related illness CD4 at diagnosis Treatment recognised as prevention Uninsurable risks ART programme Mortality and limited Morbidity risks Cover similar to standard life
Opportunities for Life Insurance Industry Mortality - Pricing Relative mortality risk (%) 1800% 1600% 1400% 15 X 1200% 1000% 800% 600% 400% 200% 0% <50 50-99 100-199 200-349 350-499 >=500 CD 4 count at diagnosis 3 X
Opportunities for Life Insurance Industry Mortality - Pricing Relative mortality risk (%) 900% 750% 600% 450% 300% 150% 0% < 25 25-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66+ Age group SEC 4 SEC 3 SEC 2 SEC 1 *Illustration
Opportunities for Life Insurance Industry Critical Illness and Disability - Pricing Weighted average probability of condition-specific rates Weights = Expected claims distribution
Opportunities for Life Insurance Industry Critical Illness - Pricing Relative morbidity risk (%) Deriving relative risk rates for HIV+ lives Cancer Cardiovascular Neurological Other natural Non-natural 15 Standard Insured Life HIV+ Life
Opportunities for Life Insurance Industry Critical Illness - Pricing CI Claims Distribution 6% 14% Cancer Cardiovascular 6% 7% 4% 11% 52% Neurological Other Natural 29% 54% 17% Non-natural 30 to 40 50 to 60 *Hannover Re Experience
Opportunities for Life Insurance Industry Critical Illness - Pricing Relative morbidity risk (%) Estimate of cost for HIV + lives Standard Insured Life HIV+ Life 30 40 YEARS Standard Insured Life HIV+ Life 50 60 YEARS Cancer Cardiovascular Neurological Other natural Non-natural
Opportunities for Life Insurance Industry Disability - Pricing Relative morbidity risk (%) 140% 120% 100% 80% 60% 40% 20% 0% Estimate of lump sum disability cost for HIV+ lives Standard Insured Life HIV+ Life 30 40 YEARS Standard Insured Life HIV+ Life 50 60 YEARS Musculoskeletal Neurological Other natural Cancer Mental and behavioural Non-natural Cardiovascular
Opportunities for Life Insurance Industry Underwriting vs. Pricing UNDERWRITING PRICING ADDITIONAL FACTORS Undetectable Viral Load? Age Not frequently used in Life insurance Gender No AIDS defining illnesses Socio-economic class Smoking status Duration on ART Infection route Good ART compliance CD4 at diagnosis vs current CD4 at treatment inception
Considerations EM loadings Relative Mortality Risk (%) 700% 600% 500% 400% 300% 200% 100% 0% 30-40 40-50 50-60 60-70 70-80 80-90 90-100 Age Group Standard Life Flat RR of 300% Age Dependent Loading +5.75 Per Mille *Illustration
Considerations ART Duration????? 0 Years 10 Years
Considerations Compliance
Summary Decline in mortality + morbidity over the years Better classify risks Test and Treat
Summary Opportunities
Questions & Discussion
References 1. Product Development in an HIV/AIDS Environment Stuart Land 2. Antiretroviral therapy and early mortality in South Africa Andrew Boulle et al 3. Mortality and causes of death in people diagnosed with HIV - Sara Croxford et al 4. Mortality According to CD4 Count at Start of CART Among HIV-infected Patients followed for up to 15 Years after Start of Treatment - Margaret May et al. 5. Incidence of Types of Cancer among HIV-Infected Persons Compared with the General Population in the United States, 1992 2003 Patel et al 6. Risk of Cancer among Commercially Insured HIV-Infected Adults on Antiretroviral Therapy Lee et al 7. Increased Acute Myocardial Infarction Rates and Cardiovascular Risk Factors among Patients with Human Immunodeficiency Virus Disease Triant et al 8. Risk of coronary heart disease in patients with HIV infection Zanni et al 9. Comparison of Ischemic Stroke Incidence in HIV-Infected and Non-HIV-Infected Patients in a U.S. Health Care System Chow et al 10. Chronic Liver Disease in the Human Immunodeficiency Virus Patient Achara et al 11. Autoimmune diseases and HIV infection Virot et al 12. Update on HIV Dementia and HIV-Associated Neurocognitive Disorders Brew et al 13. Mid-year population estimates 2016 Statistics South Africa 14. http://www.who.int/hiv/topics/drugresistance/en/