A matter of fairness – Increasing the insurability of HIV
22 May 2012
Life insurance thrives on data. In countries with abundant HIV data – typically those with higher HIV rates – insurance has been available to HIV sufferers for some time. As more data is collected, with re/insurers often at the forefront of studies, coverage for those with HIV is being extended across the world.
In 2003, the landmark study, Mortality in the Swiss HIV Cohort Study (SHCS) and the Swiss general population, was published in respected medical journal The Lancet . Christian Jaggy, now Head of Sales with Elips Life AG, was one of the lead authors of the report. At that time he was with Swiss Re as a project manager for portfolio analyses in its Life & Health Division (L&H). That study has now being updated using an expanded subject population tracking longer follow-up periods. Wayne Dam, Senior Products Actuary at Swiss Re, leads the team undertaking the current study.
The two study authors have very different perspectives on HIV. Wayne Dam is South African, where HIV has been part of a life insurance company’s daily business for many years. This has not been the case in most other insurance markets, as Christian Jaggy makes clear. In recent interviews, both experts provide insight into Swiss Re’s efforts to extend the boundaries of insurance and provide life insurance for persons with HIV.
Interview with Christian Jaggy (CJ)
Could an HIV-positive person get life insurance in 2002?
CJ: HIV was an emotional topic in the re/insurance world as it was in society. We were missing a rational, evidence-based approach to the impairment. In the late 1990s, it was clear from a medical point of view that considerable treatment improvements had been made, with fewer side effects that had been a problem with earlier drugs used to treat HIV. We needed to analyse the extra mortality data for HIV-positive persons receiving Highly Active Anti-Retroviral Therapy (HAART) to establish that the extra mortality associated with HIV had fallen. Swiss Re was regularly receiving requests at that time as to whether individual HIV-positive persons could be insured, but as there were no up-to-date analyses available, these requests were generally denied. Only a very few HIV-positive individuals could obtain life or health insurance.
Even in 2002 there were some progressive reinsurers who believed that due to the improvements in therapy, well-treated HIV-positive persons could be insured for mortality at least for a short term period. The maximum duration of the cover offered was from 10 to 15 years and age limitations were applied. Interestingly, at that point in time it was less of a concern whether or not there was a co-infection with hepatitis C, although CD4  counts were already being used as a factor. I do not know whether any policies were actually being written or if these insurers were merely using it as a marketing tool.
What had been the impact of HIV on the life insurance industry up to that point?
CJ: A Joint Special Report  released in 1987 by the US Society of Actuaries provides interesting reading. It indicated that HIV could have a major impact on the life insurance industry. The cumulative AIDS mortality rate was very high, with 80-90% of HIV infections progressing to full-blown AIDS and death after 10 years. At that time the life expectancy for a person diagnosed with fully developed AIDS was about 2.1 years. The HIV virus was only identified in 1981 and it took some time to gather the data and analyse the potential implications for the life insurance industry. This was a very interesting document.
How did this lead to the study?
CJ: The collaboration was the result of contacts between with the Swiss Re Medical Services Team and the SHCS, together with Professor Bernard Hirschel at the University Hospitals of Geneva. He was very interested in analysing the extra mortality of HIV-positive individuals. It was a pioneering approach to analyse it on behalf of the life insurance industry and not only from a medical point of view. We were invited to participate in the study and I was very interested to do so. I was by no means an HIV specialist, although there had been HIV cases in the hospitals in which I had worked. For me, it was basically a matter of fairness based on medical progress.
The study covered the observation period from 1997 to 2001. In early 2002 we received the data from the SHCS to start work. At about that time, I participated in a medical officers' workshop where I learned that other reinsurers were discussing the HIV impairment and whether it could be reinsured. This workshop very much motivated me to do the analysis to determine whether the HIV impairment could be insured for at least certain subclasses of HIV-positive individuals.
How did the collaboration work?
CJ: I was in constant contact with Bruno Ledergerber at the University Hospital of Zurich. We did the hard statistical work and data cleansing with him. It was mostly follow up work on some of the participants to see if they had actually died within the study period. There is always a delay in receiving this kind of information. The overall quality of the data was excellent and that is why the SHCS data base is still used today for other studies related to HIV. We wrote the article with Prof. Hirschel and Swiss Re’s Medical Services Team led by Jan von Overbeck.
What challenges did you face?
CJ: The goal of the study was to find out which sub-class of HIV-positive individuals might be insurable. We faced the challenges of how to measure the extra mortality associated with this impairment and on which sub-classes of HIV-positive persons we should focus. The SHCS data is heterogeneous and contained, for example, many people from North Africa with the disease living in Switzerland. We had to decide whether to look at all of the data or just sub-groups. Ultimately we looked only at Swiss citizens. Therefore we did not have to adjust for ethnicity, although we did for age and gender.
We looked at roughly 4,000 people for five years from 1997 through 2001. Not all of them were analysed for the full five years, so we ultimately analysed approximately 12,900 life years. The successfully-treated sub group (defined by high CD4 count and low viral load) consisted of 550 individuals with total life years of 1,500.
We faced no opposition within Swiss Re to our work, apart from the general attitude of the re/insurance industry in general which we have already discussed. It is difficult to overcome this conservative approach and be a leader. Swiss Re had been a pioneer in experimental underwriting in the past, specifically for successfully treated cancer patients and organ transplants. With HIV, we needed to overcome the hurdle and find a basis from which we could start to insure these people. Ultimately, the rationale behind the study convinced everyone to proceed.
What were the findings of the 2002 study?
CJ: We identified that intravenous (IV) drug users had a higher mortality level, due to the high number of co-infections with hepatitis C and also high risk behaviour. Their mortality rate was too high to be covered by insurance. However, for those who became HIV positive through other infection paths the findings were clear. HIV-positive and hepatitis C negative persons successfully being treated had an extra mortality of 3 to 4 per mille compared to the general Swiss population. Even though it is a substantial extra mortality, it was comparable to the rating of people being successfully treated for cancer which at that time was 5 to 10 per mille. Successfully-treated cancer patients were able to obtain life insurance being rated for the extra mortality. Ultimately, we indentified a sub-group of HIV positive persons that were insurable.
Did its publication have any impact?
CJ: After the study was published in The Lancet, it had an impact in the press and the HIV community. The press reaction was positive in the sense that the issue was being addressed. The study was criticised for being too small to transfer the results into an overall rating strategy. We ourselves, however, had acknowledged this and recommended that the study needed to be expanded to a European scale. HIV support groups seized upon the findings to argue that HIV-positive persons receiving treatment should not be discriminated against for life insurance purposes. However, for the life insurance industry you have to be careful that you do not promise too much and then fail to keep the promises. Certain subgroups of HIV positive individuals cannot be covered for economic reasons. For me personally, this was very rewarding work and I am very thankful for the opportunity that the SHCS board and Swiss Re provided for me and the team.
Interview with Wayne Dam (WD)
How did you come to work on HIV as an actuary in the re/insurance industry?
WD: South Africa has the highest number of HIV cases in the world. India may rival it a bit these days, but certainly historically it has been the country with the most. It is also a fairly large insurance market. The combination of these two factors means that HIV is almost a compulsory part of the curriculum for an actuary working in life insurance in South Africa. In that general context, I was introduced to HIV. HIV is an area where reinsurers in particular like to give their clients advice. Swiss Re was one of the leaders in that field. I was also a member of the AIDS committee of the Actuarial Society of South Africa. Within the committee and also at Swiss Re, we would work on various AIDS models and advise our clients.
Why is HIV still a topic for the life insurance industry in 2012?
WD: Until people are no longer becoming HIV positive or dying from AIDS, this will probably remain a topic. The fact is that there are still many people in many countries dying due to HIV and in several markets it is one of the leading causes of death and therefore it is very relevant to life insurers.
Why is Swiss Re updating the 2002 study?
WD: We wanted to extend the scope of the study beyond just the Swiss market; and to reflect the medical progress achieved against HIV since the Swiss study. We were fortunate to be able to collaborate with Antiretroviral Therapy Cohort Collaboration (ARTCC) who provided us with a lot more data. So we expanded the study both in terms of the countries covered as well as the level of detail captured. As a result we can draw a lot more meaningful conclusions from it.
What is the scope of the new study?
WD: The study is being done in collaboration with the ARTCC, which is being coordinated by a team at the University of Bristol in England. ARTCC is an international collaboration of HIV observational cohorts whose research is focussed on patients who are receiving antiretroviral therapy. We are using their data from six countries in Western Europe - the Netherlands, France, Italy, Spain, Switzerland and the United Kingdom.
What are the preliminary findings of the updated study?
WD: The study is quite rich in results, but the high-level conclusion that we have drawn is that roughly half of the lives covered by the study fall within the realm of insurability. This compares favourably to the previous Swiss study. Insurability is defined differently by different re/insurers, but it basically means that the loadings to the normal insurance premiums are not too excessive. This reflects the ability of the insured to pay the premium, which will differ between countries.
What will Swiss Re do as a result of the findings of the updated study?
WD: We have updated our internal underwriting guidelines, so that if clients refer any HIV-positive lives to us we are now considerably more likely to be able to give a rating, or in other words reinsure those lives. Swiss Re will also be in the position to advise our clients on how they can insure HIV-positive lives in their markets.
Where do insurers stand today in insuring HIV-positive lives?
WD: This varies quite a bit from country to country. Some countries are still pretty much in the dark ages and exclude everything. You need to unpack a few issues. For example if a HIV-negative person takes out an individual life insurance policy, will the company pay if the person becomes HIV positive later and then dies? Most markets will not exclude in those circumstances, but there are still a few that would exclude. Best practice is to eliminate as many exclusions as possible, ie once the underwriting is done subsequent events which may increase the risk of the insured do not result in the insured losing cover. Best practice in a group environment is that HIV-positive lives are included in the group cover or at least treated in a similar fashion to other serious conditions.
The one area where HIV is different from other diseases is where HIV-positive lives apply for insurance. That is currently where the industry is breaking ground. Life insurance is being offered to HIV-positive persons in a few markets, examples of which are France, the Netherlands, South Africa and the United Kingdom. And this is the area, individual life insurance for HIV-positive persons, where the study can hopefully expand the market. The goal being that HIV will eventually be treated by life insurers like any other disease.
Interview undertaken by Rick Perdian
 Mortality in the Swiss HIV Cohort Study (SHCS) and the Swiss general population. Jaggy C. et al. Lancet. 2003 Sep 13; 362 (9387): 877-8.
 CD4 cells are a type of white blood cell that fights infection (also called T-helper cells). Their presence is a good indicator as to the stage of HIV.
 Cowell MJ, Hoskins WH. AIDS, HIV mortality and life insurance: A joint special report Society of Actuaries, USA 1987.
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