We publish the first of a two part series by Dr Pamela Chetty, Life Business Unit, MRoA, on compliance in HIV products which assists life companies in underwriting HIV positive individuals. Part II will follow in our April issue.
The Life Assurance Industry in South Africa (SA) has made progress in leaps and bounds since a decade ago, when a diagnosis of Human Immunodeficiency Virus (HIV) meant being subjected to various types of exclusions. However, with approximately 12% of its 47 million people in SA being HIV positive( HIV+), the Life Assurance Industry has over a period of time, taken a closer look at what can be offered to these people.
SA is one of the first countries in the world to introduce life assurance for HIV+ individual. The usual practice for life companies throughout the world, and in SA, is to test for HIV at inception. If the person is HIV negative, then cover would be offered (provided all other factors are satisfactory). If the person later contracts HIV and dies as a result of the disease, a claim would be valid. Thus, the advancement in the arena of HIV management has meant that the decision does not have to be one of ‘declined’ at inception if the person is HIV +.
For the condition of HIV being an insurable risk, it is obvious that the life span of these individuals is a vital consideration. Highly Active Antiretroviral Therapy (HAART) has reduced AIDS-related death rates by more than 80% and increased life expectancy for HIV+ people taking the drugs to more than 10 years, according to a study published in the 18 October 2003, issue of The Lancet.
World-wide, ARV’s are credited with drastically reducing Aids deaths, improving life span and guarding against opportunistic infections by decreasing viral loads and improving CD4 counts. It is now widely accepted as the frontline treatment for HIV/Aids.
Two small companies and at least three large companies have introduced Life Cover for HIV + people. These recent changes in the Life Insurance Industry can be attributed to the recognition that there is improved life expectancy of HIV+ persons who are on Anti- ARVs. “In most generalised cases, there is an average of 10 years between infection and death-it takes roughly five years from infection to the first showing of opportunistic infection and then another five years to full blown AIDS and finally death. Once on effective ARV treatment, a person’s life span can be doubled from what it would be without ARV’s.
The result being that, although these policies were initially extremely expensive, the life assurance industry has opened itself now to a greater understanding of this disease, in terms of treatment and prognosis. The current trend being that HIV is more and more being perceived as a chronic, treatable disease, not unlike Diabetes Mellitus.
ARV Treatment in South Africa
“The statistics are heartening in terms of where SA stands in terms of ARV therapy. More than 370 000 people had been initiated on antiretroviral therapy by September 2007.” These figures represent the Government ARV Programmes and certainly would be higher if one considers the self-funded, Medical Aid and Work-Place Programmes.
When considering the total number of patients receiving ARV treatment, SA leads all of Africa and is ranked second only to Brazil, the 10th largest economy in the world. These figures certainly represent a sizeable chunk of the population previously considered uninsurable as now being insurable. However, one of the greatest challenges facing the HIV+ individual is compliance to the ARV’s. The issue of compliance has a direct impact on the development of a product for the HIV+ person.
Poor Compliance to ARV’s- Implications on Life Cover for the HIV+ Client
Compliancy is essential once a person is diagnosed HIV+. It necessitates lifestyle changes, taking of daily multi-vitamins, regular blood tests and a commitment to regular follow-ups. This should continue prior to the commencement of ARVs and continued after ARVs are commenced. The decision to commence ARVs will be based on CD4 count, Viral Load and/or WHO staging of the illness. If the HIV+ individual maintains his/her health, ARV’s may be deferred. Once ARV treatment has commenced, compliance becomes of critical importance.
Poor compliance on ARV’s must be viewed in an extremely serious light, the ramifications of which extend from the medical complications to the economic impact. Individuals on ARV’s who are non-compliant may contribute to the emergence of drug resistant HIV strains, which are more difficult to treat. This may necessitate second or third line drugs which are usually more expensive. Therefore, it is of the utmost importance that HIV+ individuals have compliance impressed upon them.
Another economic implication is the success of the life product. Poor compliance has negative outcomes in terms of life span, which would make the product more expensive.
The HIV+ person with poor compliance will be less insurable and therein lies the challenge for the Life Industry. Strategies need to be developed to build incentives within their products to enhance compliancy, e.g., a reward system for HIV+ Clients who exhibit good compliance. Similarly, those Clients with records of poor compliance may be subjected to higher premiums or lower sums assured. To summarise, excellent record keeping, with intense case management of clients is imperative for the success of products for the HIV+ person.
Factors which Compromise Compliancy to ARV’s
1. Lack of initial Education and targeted Literacy Programmes prior to commencing on ARV’s: The importance of regular follow-ups, CD4 Counts, Viral Loads, and early and appropriate treating of opportunistic infections should be impressed upon in the initial literacy Programmes. Reinforcement Classes/Compliancy Programmes should be ongoing for compliancy issues to be adequately addressed.
2. Poly-pharmacy: This term refers to the use of multiple drugs, or too many forms of the drug are used, or more drugs are prescribed than clinically warranted, or even when all prescribed medications are clinically indicated but there are too many pills to take (pill burden). This is often the case with ARV’s which result in confusion and poor compliancy.
3. Social Issues: Stigma of waiting for ARV’s at designated sites. This can be avoided if HIV+ persons have the option of having their drugs couriered to a location of their choice.
4. Side effects: Ranging from the minor for example skin-rashes to the more serious like hepatitis and lactic- acidosis. These side effects are often unexpected and frightening. This results in defaulting of the drugs prior to consulting with their healthcare practitioner. Pamphlets highlighting the side-effects and how to deal with them, support Programmes and toll-free help lines may be helpful in this regard.
5. Work commitments: Compliance necessitates regular follow ups. This may impinge upon work commitments. There are a few big companies in SA that recognize the impact of the HIV/Aids pandemic on the well being of their employees and business, and offer treatment Programmes at the workplace. However, if HIV/Aids Programmes are implemented at the workplace more extensively, it would obviate the need to take leave from work to fetch medication.
6. Forgetfulness This may be alleviated by a system similar to the treatment of Tuberculosis (TB) as recommended by WHO, namely the Directly-Observed-Treatment-Short –Course (DOTS). Put simply this would necessitate a treatment Buddy who would oversee that the patient actually swallows his/her pills, daily. The treatment Buddy is usually is a work colleague, relative or neighbour.