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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
2
FACE OF A KILLER
Source: CDC image library3
INFECTIOUS PATHWAY
• Men having sex with men• Heterosexual• Intravenous drug user• Blood product (transfusion, hemophilia)• Occupational
4
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
5
Other and not reported
39%
IDU14%
Hemophilia0%
Blood transfusion
0%
High risk sex47%
INFECTIOUS PATHWAY -WOMEN
Source: HIV AIDS Surveillance vol 19 CDC
6
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
7
“Mortality Rates Among People With HIV, Long on the Wane, Continue to Drop”HIV Medicine Feb 2013
8
HIV TODAY
MAGIC JOHNSON diagnosed 1991, alive today
9
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
10
WHAT IS UNDERWRITING
ABOUT?
Select
Offer
11
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
12
Source: Pallella et al, J Acq Immune Def Syndr 2006
ADVANCES IN TREATMENT
13
VIDEO- INFECTION
https://www.youtube.com/watch?v=RO8MP3wMvqg
4’08”
14
ACTION PATH OF TREATMENT
15
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
16
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
20
HIV DISEASE ET ALSource :
SG Deekset al Lancet 2 nov 2013: 382:1525-
1533The end ofAIDS: HIV as a chronic disease
21
HIV CONTINUUMSource :
SG Deekset al Lancet
2 Nov 2013:
382:1525-1533
The end ofAIDS: HIV as a chronic disease
22
• Mortality from HIV• AIDS defining diseases
~50% • Liver disease (hepatitis co-
infection)• Infection (non AIDS
defining)• Cancer (non AIDS defining)
THE RISKS
23
• Mortality from treatment• Cardiovascular
• Mortality from behavior• Drug overdose, accident,
suicide
THE RISKS
24
• Not too young at infection
• Not too young when buying the policy
NOT TOO YOUNG
25
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
27
THE GRITTY REALITY
CASE STUDIES
28
QUESTIONS
Jean-Marc Fix, FSA, MAAA
VP, R&DOptimum Re Insurance Co.
29