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The initial concerns of insurance and reinsurance companies withregards to the human immunodeficiency virus (HIV) epidemic date backto the 1980s. The main problem was the protection of their business fromthe consequences of a new and worrying disease that epidemiologicaldata showed to be transmitted by sexual intercourse and contact withcontaminated blood.
Medical selection for individual life insurance cover was rapidly adaptedto include a specific serological test for HIV detection. In France, forexample, this test, by consensus, became a requirement for cover of allamounts over 1 million francs (152 672 Euros).
Since the 1980s, insurance proposals from HIV-positive applicants werevery carefully considered and accepted, in France, only for coveringloans according to the conditions of the 1991 convention.
The recent introduction of drug therapy capable of slowing down theprogression of the disease has prompted the insurance community toreview its attitude towards HIV-positive applications.
HIV infection has become pandemic since the 1980s and it can be confidently stated that the available and the natural history of the dis- ease with progression to death was totallyunaffected by medical intervention. In 1986, At the end of the year 2000, a United Nations Zidovudine (Retrovir®) was introduced but its effects were too transient to influence the drome) report estimated that about 36 million life expectancy of HIV-positive patients.
Between 1989 and 1994, antiretroviral mole- throughout the world, with 540 000 cases in Western Europe (and about 30 000 new cases slightly improved the prognosis but there was America and nearly 6 million in South andSouth East Asia.
The breakthrough came in 1995 with the firstlarge scale trials of antiprotease drugs. Deaths In Europe, the highest incidence (though not from AIDS and the number of newly notified the largest number of cases) is observed in cases of AIDS dropped precipitously in 1996: Spain, followed by Portugal and France. By only 700 deaths compared with 4500 in 1995.
extrapolation from the number of notifiedcases of AIDS, it is estimated that about This tendency was confirmed in the years that 110 000 people living in France in 2000 were followed. Irrespective of the stage of the dis- suffering from HIV infection. A more precise estimation is very difficult because the date of transformed and life expectancy considerably primary infection is hardly ever known and only cases of full-blown AIDS have to be noti- stage have benefited from triple anti-retroviral therapy over the past 5 years with some ofthem even returning to work.
At the beginning of the 21st century, HIV-relateddisease in France entered a new era char-acterised by lower mortality. How did thiscome about? AIDS: three dates
AIDS : three key figures
Of the 110 000 HIV-positive patients living in France, approximately 90 000 receive regular nisms of HIV resistance and by the polymed- medical attention; about 80 000 are treated and 70 000 receive triple anti-retroviral therapy.
treatment more difficult. Nevertheless, it is Nearly one fifth of these cases are at the stage of AIDS. By deduction, there are about chemotherapy will become available in the 20 000 people living in France who are not under medical supervision, most of whom are patients with HIV infection will continue to probably unaware of their condition.
improve. The condition should become achronic disease with a smaller impact on mor- Before the advent of current treatment protocols, the median survival time of a HIV-positivepatient used to be 5 to 7 years. Recent results In fact, at the present time, SCOR reinsures very have shown a significant increase in life substandard risks with comparable mortalities expectancy, confirmed by data from the World to that of early stage HIV infection under medical treatment. Therefore, HIV infection has been studies, especially one carried out by the Clinical Epidemiological Working Group on ments without creating a special insurance New, more effective and better tolerated anti-retroviral molecules under developmentshould reinforce this tendency. On the other Patients with HIV infection have benefited At SCOR, we consider HIV infection to be a
considerably from therapeutic advances over substandard risk, which can be assessed
the past 6 years. Our regular review of med- and rated like many other diseases.
ical progress in this field has led to a re-exam-ination of the possibilities of life insurance for The medical requirements are listed in the insert on page 4. This procedure will beapplied initially for the cover of loans but With appropriate extramortality ratings, a sig- could rapidly be extended to other insurance nificant number of HIV-positive applicants may now be underwritten providing certainessential medical information is obtained.
I Dr Patrick Malamud, Associate Medical
I Michel Dufour, Head of Underwriting R&D
I Laure Olié, Head of CERDALM (Longevity-
Mortality R&D Center) — [email protected]
In addition, mortality increases with the dura- This very much depends on the applicant’s tion of HIV infection. The first positive HIV test medical profile. The quality of medical care of is therefore the most objective reference for HIV-positive patients is an essential factor of assessing the progress of the disease. In survival. It requires a responsible attitude by practice, it is impossible to go back further the patient to the necessity of regular follow- because the date of primary infection is usu- up. At the present time, the best markers of immune status are the CD4 count and its ratioto total lymphocyte count and the CD4/CD8 Our rating schedule is based on the duration lymphocyte ratio; measuring the viral RNA of cover and the time elapsed between the load by PCR provides a means of evaluating first positive HIV test and the insurance pro- the progression of the viral infection during posal. The extramortality rating applied is constant throughout the policy and higher withthe duration of cover and time elapsed since Insurance cover will be limited to appli-
cants with:
Medical Decision
The final medical decision is the result of
individual adaptation of the basic table,
case by case. Several prognostic factors
slow progression of the disease i.e. a low are taken into consideration:
The individual’s resistance to the infection At SCOR, we have determined rating sched- based on the viral load and CD4 count.
ules based on the time elapsed since the firstpositive HIV test. The date of diagnosis must therefore be obtained with the medical file.
ance, complementary prognostic factors.
A past history of opportunist infection, the The following conditions are recommended
last but not least factor of evaluation.
The medical questionnaire and medical report in all cases, limitation of cover to a maxi- required for life insurance cover are essential.
In addition, a specific complementary ques-tionnaire needs to be completed by the Extramortality ratings are the most appropri-ate method of loading the premiums of HIV-positive insureds as the risk of death increas-es with age.
Editing committee
Division Vie
Sub-editors

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