The long-term effectiveness of
antiretroviral therapy means that many HIV-positive people should be eligible
for affordable life insurance, European investigators write in the online
edition of AIDS. Even though
HIV-positive people doing well on treatment had a higher mortality risk
compared to insured HIV-negative individuals, this excess was within acceptable
limits for life insurance cover.
“Our study provides evidence that could
allow life insurance up to 20 years term to be offered to lower risk HIV positive
individuals at affordable premiums,” write the authors. “Whole life insurance
at guaranteed rates may become feasible when data on mortality with longer
duration of ART [antiretroviral therapy] become available.”
Improvements in HIV treatment and care mean
that the life expectancy of many HIV-positive people is now approaching the average. A small number of life insurance products offering limited cover are
now available to people deemed to be 'low risk' – those doing well on
treatment with no history of injecting drug use or hepatitis C co-infection.
Despite this, access to life insurance
still remains limited.
Investigators from European Antiretroviral
ART Cohort Collaboration (ART-CC) were concerned that fair access to life
insurance was being denied to people doing well on HIV therapy.
They therefore estimated the relative
mortality risk for HIV-positive people from six months after starting antiretroviral
therapy compared with the insured population in France, the Netherlands and UK,
and with adjusted mortality rates for Italy, Spain and Switzerland.
The analysis was based on data provided by approximately
35,000 people who started HIV therapy between 1996 and 2008. Most (70%) were
male and aged between 30 and 49 years (65%). Three-quarters had a CD4 cell count
below 350 cells/mm3 when they initiated treatment. None were
infected with HIV via injecting drug use or had baseline hepatitis C
There were 1236 deaths during 174,906
person-years of follow-up, a mortality rate of 0.71 per 100 person-years of
follow-up. Mortality rates fell with age (p < 0.005) and duration of
antiretroviral therapy (p < 0.005) and were lower for people who started
treatment after 2001 (p < 0.005).
The investigators compared mortality risk
between the insured HIV-negative population and the subset of the lowest-risk
HIV-positive people – individuals with an undetectable viral load and CD4
cell count above 350 cells/mm3 six months after starting treatment
and no history of AIDS-defining illness.
People with these characteristics aged
between 30 and 39 years had a relative mortality risk of 459% compared to
insured HIV-negative individuals.
The investigators emphasise that this risk was
well within the 500% limit normally used as the threshold for insurability.
Mortality risk fell with increasing age and
duration of therapy. Individuals in their 40s who had been taking treatment for
over seven years and who had a CD4 cell count between 200 and 349 cells/mm3
had a relative mortality risk of 238%.
“Relative mortality compared with insured
HIV negative lives declined with increasing duration of ART, and decreased with
age despite increases in mortality rates with age, a phenomenon that has been
observed in other studies of HIV populations,” note the authors. “The lives of
people with HIV tend to become more insurable with increasing duration of
Overall, 61% of people taking treatment
had a mortality risk below the 500% threshold and 28% had a risk below 300%.
“Our results imply that more than 50% of
patients – those with lower relative mortality – in an HIV positive population
with similar risk profile to that analysed in this study cold be insurable,”
comment the investigators. They believe their estimates are likely to be
conservative as modern HIV therapy is much more tolerable and effective than
that taken in the late 1990sand early 2000s. “People newly
diagnosed with HIV can be expected to survive longer than those recruited to
cohorts between 1996 and 2010: studies such as ours necessarily provide
trailing indicators of mortality rates.”
The investigators conclude that the lack of
insurance products for people doing well on HIV treatment can no longer be
justified, “since the excess mortality of those with HIV is comparable to many
other groups with morbidities that are insured…our study provides data that
will allow the insurance market to open up to people living with HIV.” The
authors intend to communicate their findings directly to insurance companies so
that they can amend their policies, “with consequent improvements in the
quality of life for HIV positive people”.