UNDERWRITING HIV:

THE FAIRY TALE HAS BECOME REALITY

Midwestern Underwriting Conference 2016

Jean-Marc Fix, FSA, MAAAVP, R&D, Optimum Re Insurance Co.

• Where are we with HIV?• The risk• The ideal case• What to look out for?• Reality: case studies

AGENDA

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FACE OF A KILLER

Source: CDC image library3

INFECTIOUS PATHWAY

• Men having sex with men• Heterosexual• Intravenous drug user• Blood product (transfusion, hemophilia)• Occupational

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Male to male(MSM)

61%IDU8%

Hemophilia0%

High risk sex7%

not reported

19%

MSM+IDU5%

Blood transfusion

0%

INFECTIOUS PATHWAY -MEN

Source: HIV AIDS Surveillance vol 19 CDC

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Other and not reported

39%

IDU14%

Hemophilia0%

Blood transfusion

0%

High risk sex47%

INFECTIOUS PATHWAY -WOMEN

Source: HIV AIDS Surveillance vol 19 CDC

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WHAT WE REMEMBER

AIDS Is Top Cause of Death for Young Adults in U.S. Disturbing report by federal agency

San Francisco Chronicle 2/1/95 Together in Life and Death

San Ramon pair die of AIDS 2 days apart… Ray, 58, and Peggy, 54, of San Ramon, died earlier this month after battling the disease for five years. They were buried Monday in the same grave. SFC 2/1/95

Hunting for the Hidden Killers: AIDS

Time Magazine 7/4/83

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“Mortality Rates Among People With HIV, Long on the Wane, Continue to Drop”HIV Medicine Feb 2013

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HIV TODAY

MAGIC JOHNSON diagnosed 1991, alive today

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HIV INFECTION ≠ AIDS

• HIV= Infection with virus• AIDS=Infection + CD4 count<200 OR AIDS defining

condition regardless of CD4.• Thrush; Coccidioidomycosis; Cryptococcosis;

Cryptosporidiosis; CMV; HIV encephalopathy; HSV chronic ulceration; Histoplasmosis; Isosporiasis; Kaposi’s + others

• Opportunistic infections or unusual neoplasms known to result from immune suppression

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WHAT IS UNDERWRITING

ABOUT?

Select

Offer

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DEATH RATES TRENDS

Note: For comparison with data for 1999 and later years, data for 1987−1998 were modified to account for ICD-10 rules instead of ICD-9 rules.

*Standard: age distribution of 2000 US populationDeath rates are age adjusted

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Source: Pallella et al, J Acq Immune Def Syndr 2006

ADVANCES IN TREATMENT

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VIDEO- INFECTION

https://www.youtube.com/watch?v=RO8MP3wMvqg

4’08”

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ACTION PATH OF TREATMENT

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HAART

• Highly Active Antiretroviral Treatment• Latest is triple cocktail, for ART naïve patients:1. NNRTI + 2 NRTI: Atripla, Complera, Odefsey2. Ritonavir boosted PI + 2 NRTI3. INSTI + 2 NRTI: Stribild, Genvoya, Triumeq

NRTI = nucleos(t)ide reverse transcriptase inhibitor

NNRTI = non-nucleoside reverse trans. inhib.

PI = protease inhib.

INSTI = integrase strand transfer inhib.

Source: Antiretroviral drugs for treatment and prevention of HIV infection in adults JAMA 2016

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HIV DRUGS 2016

Single-Tablet Regimens NRTI NNRTI

ProteaseInhibitors

Entry Inhibitors

Atripla Combivir Edurant Aptivus Fuzeon

Complera Descovy Intelence Crixivan Selzentry

Genvoya Emtriva Rescriptor Evotaz

Odefsey Epivir Sustiva Invirase Integrase Inhibitors

Stribild Epzicom Viramune Kaletra Isentress

Triumeq Retrovir Lexiva Tivicay

Trizivir Norvir Vitekta

Truvada Prezcobix

Videx EC Prezista Pharma Enh.

Viread Reyataz Tybost

Zerit Viracept

Ziagen17

OTHER HIV THERAPEUTIC

CLASSES• Antifibrotics: Losartan• Biological response modifiers: rintatolimod• Gene Therapy Products: antisense gene, CCR5

modification • Immune Modulators: activators and suppressants • Latency-Reversing Agents • Maturation Inhibitors • Microbicides • Nucleoside Reverse Transcriptase Inhibitors (Viral

Decay Accelerators)

(ource; https://aidsinfo.nih.gov18

HIV RESERVOIRS

• CD4+ memory T-cell• Can stay inactive and virus dormant for

many years• Under current therapy: 60+ years to clear the

virus (1)

(1): Marsden and Zack J Antimicrob Chemo 200919

THE MECHANISM

• Depletion of CD4+ T helper Cells

• Loss of immune protection

• Opportunistic infection

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HIV DISEASE ET ALSource :

SG Deekset al Lancet 2 nov 2013: 382:1525-

1533The end ofAIDS: HIV as a chronic disease

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HIV CONTINUUMSource :

SG Deekset al Lancet

2 Nov 2013:

382:1525-1533

The end ofAIDS: HIV as a chronic disease

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• Mortality from HIV• AIDS defining diseases

~50% • Liver disease (hepatitis co-

infection)• Infection (non AIDS

defining)• Cancer (non AIDS defining)

THE RISKS

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• Mortality from treatment• Cardiovascular

• Mortality from behavior• Drug overdose, accident,

suicide

THE RISKS

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• Not too young at infection

• Not too young when buying the policy

NOT TOO YOUNG

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THE IDEAL CASE

Values

Compliance

Treatment

Follow-up26

• Lack of compliance• Bad test trends• Behavior red flags• Additional health issues:

• STD

• Cardiac

• Kidney/liver

WHAT TO LOOK OUT FOR

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THE GRITTY REALITY

CASE STUDIES

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QUESTIONS

Jean-Marc Fix, FSA, MAAA

VP, R&DOptimum Re Insurance Co.

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