Living with, Rather than Dying from, HIV:

The course of HIV infection was dramatically improved by the introduction of combination antiretroviral therapy in 1996. Earlier and more effective treatment has substantially reduced both mortality and morbidity. Although a cure remains elusive, many individuals with HIV infection can now anticipate a lifespan similar to that of the general population.

In people living with HIV (PLHIV) who are responding well to treatment and have no significant comorbidities, we now find standardized mortality ratios that are in insurable ranges, for most ages. Moreover, in this same group we have found rates of potentially disabling conditions to be only modestly increased. Thus, in addition to being eligible for life coverage, some of those living with HIV can now qualify for disability coverage.

Human Immunodeficiency Virus (HIV) is a retrovirus that infects and destroys CD4+ T lymphocytes, one of the body’s key immune defenses. It is spread through exposure to body fluids, most frequently through sexual activity, shared needles, or during childbirth.

Once an individual is infected with HIV, viral replication begins, but the rate of progression depends on a complex interplay of immune functions. Given the ability of HIV to quickly incorporate its genetic material into the DNA of the T lymphocyte, eradication of the infection is not currently feasible. Left untreated, more than 90% of infections will progress to acquired immune deficiency syndrome (AIDS). Fewer than 7% will remain asymptomatic and about 1 in 300 will become non-viremic "elite controllers” and have a favorable course, without any treatment.

Following the confirmation of a positive HIV result, viral levels and CD4 cell counts are measured and treatment with combination anti-retroviral therapy (ART) is started. ART successfully suppresses the virus level – in many cases converting HIV infection into a chronic, treatable disease. This is possible if effective treatment is maintained, and close follow-up care is provided.

Since the introduction of ART in 1996, life expectancy for PLHIV has increased markedly. As treatment regimens have evolved from multiple pills taken multiple times per day to a single pill per day compliance has also improved, further improving outcomes.

Recent studies consistently show improved mortality. These studies are, of course, limited by shorter duration of follow-up. However, the reduced mortality is consistent with the overall decline in AIDS diagnoses. It is also consistent with the current practice of initiating ART at the time of HIV diagnosis, rather than when CD4 counts fall below 500, as was the previous practice.

HIV positive individuals have a higher prevalence of significant comorbidities (such as smoking, drug and alcohol use, cardiovascular and psychiatric disorders). These make mortality comparisons more difficult. However, following adjustment for these comorbidities it becomes evident that mortality rates are much lower, although still higher than in a similar group without HIV infection.

Despite effective treatment, complications from chronic HIV infection – or from the treatment itself – can occur, contributing to higher rates of morbidity.

Studies have found that PLHIV have fewer quality-adjusted years of life and develop complications more frequently and at younger ages, than those without HIV.   These include cardiovascular disease, osteoporosis, cognitive dysfunction, and certain malignancies. Much of this added risk can be explained by a higher prevalence of comorbid conditions and behaviours, although additional risk can also be due to long-term ART use. Lastly, sustained HIV-induced immune activation and its resultant chronic inflammation can lead to accelerated aging, and an increased risk of multiple comorbidities over time.

Similarly to the mortality risk, the morbidity risk, while higher among PLHIV at all ages, appears to be relatively low in those with well-controlled HIV infection and without important comorbid risks. 

Today’s HIV-positive population is considerably different than it was in the past. Earlier and more effective treatments, with better compliance, have dramatically improved both mortality and morbidity for PLHIV. If effective treatment is maintained, and careful follow-up is provided, acute HIV infection can now be converted into a chronic, manageable disease.

Our analysis concludes that mortality rates for PLHIV, although remaining higher than expected, are now definitely priceable for an insurance portfolio. In addition, we find that those with well-controlled HIV infection and no significant comorbidities can now qualify for disability coverage.

For more information regarding Munich Re Life US’s medical research supporting mortality and morbidity improvements for PLHIV, contact Dr. Gina Guzman and Dr. Brad Heltemes.