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How Insurable Is HIV Disease?

Robert Kneepkens, MD, RGA

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Potential conflicts

• Chief medical officer ACHMEA, division Pension & Life• Working Group HIV (1996-2011) and Committee

Medical Ethical Affairs (2010-present) of the Association of Insurers

• Risk calculations performed by the independent HIV Monitoring Foundation for the Working Group HIV • You’re allowed to use the risk models in your

company• CLIMOA/ACDMAV is allowed to distribute this

presentation among members and praticipants

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Learning Objectives

• The importance and the impact of the Dutch HIV-insurance models in the Netherlands

• The basic principle, assumptions, and restrictions of the models

• The limitations of the results

• The internal and external validity of the models:What should be done before you can use these models in Canada?

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$ 1,000,000,000A short history 1987 : introduction HIV test: > 200,000 guilders and when indicated

1992 : legislative proposal: total ban on testing

1993 : Code of Conduct: testing allowed in case of…

-blood transfusions in certain countries,-needle sharing, -anal gonorrhoea,-high sums insured.

1996 : Working Group HIVto study insurability

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Working Group HIV 1996 - 2011

1998 : ATHENA-project

1999 : Report#1 - Possibilities?

2001 : HIV Monitoring Foundation

2004-2005 : Report#2 - Risk model for ART+

2008-2009 : Report#3 - Risk models for ART+ and for ART-naive

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In- & exclusion criteria 1

Mode of transmission RH OR

Overall 3.42 3.44

MSM 2.28 2.28

Heterosexual 3.86 3.88

Injection drug use 20.00 20.64

Life expectancy of recently diagnosed asymptomatic HIV-infected patients approaches that of uninfected individuals. Van Sighem A, Gras L, Reiss P, BrinkmanK, De Wolf F, on behalf of the ATHENA national observational cohort study. AIDS, 2010.

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In- & exclusion criteria 2

Disease stage RH OR

Overall 3.42 3.44

CDC-A 2.94 2.95

CDC-B 5.00 5.06

CDC-C (AIDS) 11.54 11.74

Life expectancy of recently diagnosed asymptomatic HIV-infected patients approaches that of uninfected individuals. Van Sighem A, Gras L, Reiss P, BrinkmanK, De Wolf F, on behalf of the ATHENA national observational cohort study. AIDS, 2010.

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• Prevalence:

•IVDU 3-8%; HBV 7-11%; HCV 10-19%

•Most IVDU have HBV and HCV

•Mortality probably lower in non-IVDU

In- & exclusion criteria 3

Hepatitis B/C infection RH OR

HBV status unknown 6.11 6.18

HBV positive 3.33 3.35

HCV status unknown 5.86 5.92

HCV positive 6.45 6.51

Life expectancy of recently diagnosed asymptomatic HIV-infected patients approaches that of uninfected individuals. Van Sighem A, Gras L, Reiss P, BrinkmanK, De Wolf F, on behalf of the ATHENA national observational cohort study. AIDS, 2010.

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In- & exclusion criteria 4

Comparable criteria for both risk models (ART+ and ART-naive)

• No IVDU• At 24 weeks after start ART (ART+): CD4 >50• At 24 weeks after diagnosis (ART-naive): CD4 >50, no AIDS• At application: CD4 > 200, no AIDS

CD4 count at 24 weeks RH OR

Overall 3.42 3.44

< 50 cells/ml 16.67 17.05

50 – 200 cells/ml 4.12 4.15

200 – 350 cells/ml 2.86 2.87

Life expectancy of recently diagnosed asymptomatic HIV-infected patients approaches that of uninfected individuals. Van Sighem A, Gras L, Reiss P, BrinkmanK, De Wolf F, on behalf of the ATHENA national observational cohort study. AIDS, 2010.

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New business Life : Adults 18-65

• New business : 700.000 of 7 mi. = 1 in 10 prospects

• Chronically diseased : estimated 1 in 25

• ART+ : estimated 1 in 100

• ART-naive : estimated 1 in 200

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Clients & Insurances: all insurers (2005-2012)

400 clients400 clients

14% declined(OR 4.6)

14% declined(OR 4.6)

4% rejected(OR 1.4)

4% rejected(OR 1.4)

81% insured(OR 0.3)

81% insured(OR 0.3)

1% ended(OR 0.3)

1% ended(OR 0.3)

80% active(OR 0.5)

80% active(OR 0.5)

nobodydied

nobodydied

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Characteristics at application 1

%Male HIV+ Other risks

All clients 86% 55%

Declined 91% 64%

Rejected* 86% 53%

Ended 100% 47%

Died 69%

Active 84% 55%

* = Insurance offer rejected by applicant

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Characteristics at application 2

€ HIV+ Other risks

All clients 94,000 113,000

Declined 84,000 90,000

Rejected 126,000 111,000

Ended 52,000 113,000

Died 72,000

Active 95,000 114,000

Age HIV+ Other risks

All clients 41 40

Declined 41 43

Rejected 40 41

Ended 49 37

Died 48

Active 40 39

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Adults only: cells & years

Variables ART+ ART-naive

CD4 at diagnosis 341 593

CD4 at start ART 247 -

CD4 at 24 weeks ART: 438 Diag.: 882*

CD4 at application 587 567

Time to ART 2 years -

Time to application 7 years 4 years

Age at diagnosis 34 years 33 years

Age at start ART 36 years -

Age at application 41 years 37 years

* = Missing data in 1/3 of cases

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SMR = {1 – exp(-h)} / qx

• ART+ : h = exp(f0 + CDC-B*f1 + RNA*f2 + ln(CD4)*f3) – ln(1-qx)

• f0 = intercept

• CDC-B = 1 in case of event, 0 if no event first 24 weeks

• RNA = 1 if > 500, 0 if <= 500 at 24 weeks

• ln(CD4) minimum = 0.01 at 24 weeks

• 2008/2009-model: CD4 and diagnosis “before 1998”

• ART-NAIVE : h = exp(f0 + CDC-B*f1 + Age*f2 )

• f0 = intercept

• CDC-B = 1 in case of event, 0 if no event first 24 weeks

• Age in years at application

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Risk model for ART-naive

Calculates : Relative Hazard (Mortality Ratio)

f1CDC-B in first

24 weeks

2011, unpublished, same factors as in 2008/2009

f0Intercept

-8.5860 1.2888

f2AGE (per year)at application

0.0620

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Risk model for ART+

Calculates : Extra Hazard (per Mil)

f3Ln(CD4)

at 24 weeks

f1CDC-Bin first

24 weeks

2011, unpublished, new factors since 2008/2009

f0Intercept

-6.8898 0.7180 -0.6463

f2RNA >500

at 24 weeks

1.1665

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Mortality ratio: W2008, W2011, M2008, M2011

ART-naive: no CDC-B

180%

190%

200%

210%

220%

230%

240%

250%

Age: 45

W2008

W2011

M2008

M2011

ART-naive: CDC-B

0%

100%

200%

300%

400%

500%

600%

Age: 45

W2008

W2011

M2011

M2011

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Mortality ratio: W2008, W2011, M2008, M2011

ART+: CD4 400, no CDC-B

165%170%175%180%185%190%195%200%205%

Age: 45

W2008

W2011

M2008

M2011

ART+: CD4 400, CDC-B

0%

50%

100%

150%

200%

250%

300%

350%

Age: 45

W2008

W2011

M2008

M2011

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Mortality ratio depends on baseline risk

ART-naive: 45 year at application

0%

200%

400%

600%

800%

1000%

1200%

1400%

No CDC-B CDC-B

Population table

Premium table2011

Premium table2012

Insureds table

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$ 1,000,000,000ART-naive , no CDC-B, 45 yr. Male

Netherlands : q45•Our client : 0.00405•Population : 0.00168•Premium 2011 : 0.0014•Premium 2012 : 0.0011•Insured lifes : 0.00075

Canada :•Population : q45 = 0.00212

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Canada vs. Netherlands (q21 – q60, men 2007)

Human Mortality Database.  University of California, Berkeley (USA), and Max Planck Institute for Demographic Research (Germany). Available at www.mortality.org or www.humanmortality.de (data downloaded on June 1st 2012).

0.000

0.001

0.002

0.003

0.004

0.005

0.006

0.007

0.008

0.009

0.010

21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59

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Canada / Netherlands (q21 – q60, men 2007)

Human Mortality Database.  University of California, Berkeley (USA), and Max Planck Institute for Demographic Research (Germany). Available at www.mortality.org or www.humanmortality.de (data downloaded on June 1st 2012).

0.00

0.25

0.50

0.75

1.00

1.25

1.50

1.75

2.00

2.25

2.50

2.75

21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59

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Conclusions

WHY? Political pressure

WHO? Select real prospects only

HOW? Predictive models by independent scientists (HIV Monitoring Foundation)

Limitations Favourable reference population (underestimation of true risk); Dependent on type of adverse selection

Canada/US? Disease spectrum of applicants / adverse selection

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