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 co-infection.
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 successful ART.”
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”.
Kaulich-Bartz J et al. Insurability of HIV positive people treated with antiretroviral therapy in Europe: collaborative analysis of HIV cohort studies. AIDS 27, online edition: DOI: 10.1097/QAD.0b013e3283601199, 2013.