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Towards a better understanding of HIV and AIDS

06 February 2014 Dr Phillipa Peil, Medical Officer at Liberty
Dr Phillipa Peil

Dr Phillipa Peil

Little did the physicians who first described a cluster of symptoms in 1981 (which later became known as Acquired Immune Deficiency Syndrome (AIDS)), realise the devastation it would cause across the world. In 2011, it was estimated that there were 34 million people living with Human Immunodeficiency Virus (HIV), 23.5 million of those in Africa. Since the first case of HIV was diagnosed, it is estimated that more than 60 million people have contracted HIV and nearly 30 million have died of HIV-related causes.

Of big concern is the fact that only 50% of HIV-positive people in Africa know that they are HIV positive. This means that the disease continues to spread, mainly because of unprotected sex amongst untested partners.

 

The overall HIV prevalence rate for South Africa, as estimated by Stats SA and shown in the graph below, is approximately 10%. That is, 1 in 10 South Africans is HIV positive.

 

 

From: http://www.statssa.gov.za/publications/P0302/P03022013.pdf

 

Stats SA estimates that 5.26 million South Africans will be living with HIV in 2013. It also estimates that 200 000 South Africans will die from AIDS-related complications in 2013.The number of HIV-positive South African’s receiving treatment is estimated to be between 1,9 million to 2,1 million, depending on the statistical source.

HIV is a retrovirus which, if not treated, causes AIDS. The virus causes severe damage to the body’s immune system by killing the body’s defence cells, thereby weakening the person’s ability to fight off infections and diseases. AIDS, the late stage of HIV infection, is when the body can no longer defend itself against infections and cancer.

There are two types of HIV, namely HIV 1 (which has various subtypes) and HIV 2. HIV 1 is the most common type found in South Africa. Both HIV 1 and HIV 2 produce the same patterns of illness, although HIV 2 causes a disease that progress more slowly than HIV 1.

 

There is at present no cure for someone infected with HIV, but since the development of highly active antiretroviral therapy (HAART) in 1996, this treatment has given people with HIV hope to live long, active and healthy lives.

 

Testing for HIV

 

The first test for HIV was produced in 1985 and could only detect HIV 1. Today there are several generations of laboratory tests performed on venous blood, as well as rapid HIV test kits. It is very important that the type of test being used is able to detect the HIV subtypes that are present in South Africa. Otherwise, testing may lead to the disease not being picked up in individuals who have been infected with HIV. This is called a false negative result. That is the disease has not been detected, incorrectly. False negative tests can also occur, for example if the test is done too soon after exposure to the virus.

 

False positive test results are results that show a reactive HIV test result in someone who does not actually have HIV. That is, healthy people being identified incorrectly as having HIV. This may occur due to a cross-reaction of the test with other viruses.

 

Traditionally the insurance industry has done venous HIV blood tests when people apply for insurance policies. However, with the intention of making insurance medicals more convenient and less invasive for clients, certain companies have recently introduced rapid HIV testing as part of their underwriting process.

 

Diagnosis of HIV infection is different to screening for HIV (see the table below).The WHO (World Health Organisation) has set out a protocol which needs to be followed when screening and making a diagnosis of HIV. The insurance industry uses screening tests for HIV rather than diagnostic tests to confirm the diagnosis.

 

 

 

Differences between diagnostic tests and screening tests

 

Diagnostic test

Screening test

Result

The cut off is set towards high specificity, with more weight given to diagnostic precision and accuracy than to the acceptability of the test to patients.

The cut off is set towards high sensitivity. As a result, many of the positive results are false positives. This is acceptable, particularlyifthe screening test is neither harmful nor expensive.

Cost

Patients have symptoms that require accurate diagnosis and therefore higher costs are justified.

Since large numbers of people will be screened to identify a very small number of cases, the financial resources needed must be justified carefully.

Result of the test

The test provides a definitive diagnosis, e.g. a definite diagnosis of Meningitis through blood test or lumbar puncture.

The result of the test is an estimate of the level of risk and determines whether a diagnostic test is justified.

Invasiveness

May be invasive (lumbar puncture).

Often non-invasive.

Population offered the test

Those with symptoms or whom are under investigation following a positive screening test.

Those at some risk but without symptoms of disease.

 

https://wiki.ecdc.europa.eu/fem/w/fem/diagnostic-tests-versus-screening-tests.aspx

What is a "reactive" HIV test result?

A ‘reactive’ HIV test result from an insurance screening HIV test means that a possibility exists that the person may have been exposed to HIV. It may also mean that there has been a cross-reaction with other viruses, as described above. A person who receives a reactive screening test result needs further diagnostic blood tests to determine his or her precise HIV status.

What is the window period?

The window period of a test is the time between being infected with HIV and when a test can reliably detect that infection. The length of the window period for HIV tests depends mainly on the type of HIV test being used and can vary anywhere between 9 days and 6 months.

What is ‘Informed consent’ for HIV testing?

No insurance applicant can be tested for HIV without being informed of their rights (shown below). Most insurance companies in South Africa will pay for a post-test counselling session with an applicant’s choice of doctor at the time the person receives their test results and provide an explanation as to what the screening test result means.

 

Informed consent for HIV testing

HIV testing- you have the right

 

1. To not be tested for HIV without your free and informed consent.

2. To be given all relevant information on the harms, risks and benefits of being tested for HIV.

3. To refuse the HIV test.

4. To receive or waive pre-test counselling.

5. To have the test results treated confidentially.

6. To counselling after the test if the result is reactive, with the doctor selected on the HIV consent form.

 

 

How Is HIV transmitted?

 

Anyone who is infected with HIV can transmit it, whether or not they appear sick or have a diagnosis of AIDS. The most common way that HIV is transmitted is during unprotected sexual intercourse with an infected partner. The virus can also be transmitted by contact with infected blood, such as amongst illegal drug users via sharing of needles and syringes.

 

HIV can be transmitted from a mother to her child before and during birth. The virus may also pass to the baby during breastfeeding, especially if the mother is not treated effectively.

 

More rarely, HIV can be transmitted via blood transfusions and organ transplants. There is a very small risk of health care workers (doctors, nurses, etc.) being infected with HIV from infected patients, as well as patients getting HIV from health care workers.

What are the risk factors for contracting HIV?

 

The sexual activity index for South Africa looks significantly different to corresponding indices of developed countries. In particular, the average age of male partners for younger females is significantly higher in South Africa. In addition this sexual contact is frequently unprotected, leading to high incidence and prevalence rates for younger females.

 

Another contributor to high prevalence rates is the pattern of having multiple sexual partners, especially in the Free State. The issue of high partner turnover observed in South Africa increases the risk of contracting HIV.

 

Other factors that increase risk are the presence of sexually transmitted diseases, lack of circumcision and genetic predisposition in certain population groups in South Africa.

 

 

HIV prevalence in South Africa 2012, by age and sex

 

http://www.hsrc.ac.za/en/media-briefs/hiv-aids-stis-and-tb/plenary-session-3-20-june-2013-hiv-aids-in-south-africa-at-last-the-glass-is-half-full

 

How Is HIV infection treated?

HIV is now regarded as a treatable, chronic infection. People adhering to their treatment and check-up schedules can look forward to a near-normal lifespan compared to HIV negative people. Treatment options are also now far easier to follow, with less toxic side effects.

 

In South Africa, the increase in access to HIV treatment is enabling a larger portion of the HIV-positive population to live successful and near-normal lives. By 2015, there are hopes that there will be more than 3 million HIV-positive people on antiretroviral therapies (ARTs).

HIV infection is treated with a combination of antiviral drugs. These drugs cure neither HIV infection nor AIDS. The treatment is able to suppress the virus and reduce the damage to the immune system. There are many studies which show that treatment with ARTs reduces both AIDS and Non-AIDS mortality as well as morbidity in HIV-positive individuals. Owing to the benefit of antiviral drugs, people with HIV infection may remain healthy for many years.

When to initiate treatment in HIV positive individuals is the subject of many trials, debates and discussions. The potential risks of ART need to be balanced with the potential benefits of starting treatment early in the course of the disease.

 

 

Underwriting of HIV

A brief history of the treatment of HIV in the insurance industry

1980s – Pre-HIV, products and underwriting practices made no allowance for detection of the disease.

Late 1980s – HIV becomes better known in rest of the world, with South African insurers doing significant amounts of research to determine the best way of dealing with the disease.

Early 1990s – South African insurers continue offering the same cover, but add an AIDS exclusion clause on all policies and start testing applicants for HIV at the inception of the policy. Any person who becomes HIV positive during the term of their policy is disqualified from cover and nobody who is HIV positive at policy application stage qualifies for cover.

Mid 1990s – Re-testing policies are introduced. The insured is expected to undergo an HIV test every 5 years. If they don’t undergo the repeat test or they test positive, the sum insured would fall to 10% or 20% of the original sum insured with no change in premiums. HIV exclusion clauses do not however apply to these policies.

Late 1990s – Some insurers start offering term cover to HIV positive lives, generally with short term period options of 5 to 10 year only. Only very healthy HIV positive lives would qualify for cover under these contracts and premiums are generally high relative to other products.

Late 1990s to early 2000s – AIDS exclusion clauses start falling away, with life insurers only requiring a test at inception. The probability of contracting HIV and subsequently passing away from AIDS after policy inception is priced for with the help of the ASSA AIDS models.

Mid 2000s – Niche insurers start offering HIV positive lives cover subject to adherence to a stated treatment regime or protocol. Tests are required on a 4 to 6-monthly basis and, if deemed non-adherent, cover would fall to 10% of original sum insured. Term and whole of life cover is made available.

2013 – Major insurers start offering HIV positive lives life cover as part of a normal product, subject to extra mortality loadings only. Qualifying criteria vary from insurer to insurer.

 

For many years consumer groups have put pressure on South African insurers to provide HIV positive lives with access to insurance cover. In most instances insurers’ decisions not to provide cover were considered discriminatory and unfair.

Insurance companies on the other hand considered their decision to decline these lives insurance cover a matter of "fair” discrimination, i.e. they simply did not have enough data and evidence to determine whether cover could actually be provided, and if so, at what price it would be provided.

With a growing understanding of HIV’s natural disease progression and the dramatic change in life expectancy associated with improved access to treatment, the insurance industry has been placed in a position where it could gradually start to offer cover to certain HIV-positive applicants.

Life insurance products for HIV-positive individuals will be underwritten and priced according to the individual risk appetites of the companies offering the products. Factors which may be taken into account could include the time since diagnosis, age at diagnosis, adherence to treatment, CD4 count (state of immune system) and viral load (how much virus is present in the body), stage of the disease, including whether the applicant has advanced AIDS, to name but a few.

 

Companies will probably initially be conservative with the underwriting of HIV-positive cases until they have built up some experience on which to base their risk management. But even so, the benefits of this offering to HIV-positive individuals will be of tremendous value to infected people.

 

References

 

http://www.statssa.gov.za/publications/P0302/P03022013.pdf

 

http://www.hsrc.ac.za/en/media-briefs/hiv-aids-stis-and-tb/plenary-session-3-20-june-2013-hiv-aids-in-south-africa-at-last-the-glass-is-half-full

 

http://www.statssa.gov.za/publications/P03093/P030932008.pdf

 

http://www.health24.com/Medical/HIV-AIDS/News/One-in-10-in-SA-HIV-positive-20130514

 

http://www.uptodate.com/contents/the-stages-and-natural-history-of-hiv-infection?detectedLanguage=en&source=search_result&search=HIV&selectedTitle=2%7E150&provider=noProvider

 

http://www.uptodate.com/contents/search?search=HIV

 

http://www.who.int/hiv/

 

 

 

 

 

 

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