Disease of the Month: HIV/AIDS

HIV/AIDS is still a major global killer. But, with medical advances in the west, what are the insurance implications? Fergus Bescoby investigates

HIV first emerged as a threat to humanity in the early 1980s. It spread so fast that initially there were fears that it might wipe us all out. Happily, there now seems no danger of that.

Genetic research indicates that HIV originated in west-central Africa during the late nineteenth or early twentieth century. AIDS was first recognised by the US Centers for Disease Control and Prevention in 1981 and its cause, HIV, identified in the early 1980s.

Over the past 27 years, nearly 25 million people have died from AIDS. HIV/AIDS causes debilitating illness and premature death in people during their prime years of life and has devastated families and communities.

In some countries, particularly those located in Sub-Saharan Africa, HIV rates are extremely high. For instance, in the Republic of South Africa it is estimated that about 11% of the population is HIV-positive.

Through unprecedented global attention and intervention, the rate of new HIV infections has slowed and prevalence rates have levelled off. However, despite the progress seen in some countries and regions, the total number of people living with HIV continues to rise.

As yet there is no cure for HIV/AIDS. Neither is there a vaccine to prevent HIV infection, however new medications are now available which slow the progression of the infection and consequently allow infected individuals the chance to lead a more normal life.

What are HIV and AIDS?

HIV stands for Human Immunodeficiency Virus and is a virus that takes over certain immune system cells to make many copies of itself. HIV causes slow but constant damage to the immune system.

Normally, the human immune system is the body’s protection against bacteria and viruses and can be likened to a coat of armour. When HIV enters the body, it starts poking holes in the armour and eventually weakens it to such an extent that it is unable to protect the body. Once the immune system or armour is very weak or is gone, the person is said to have AIDS.

AIDS stands for Acquired Immune Deficiency Syndrome and is the condition diagnosed when there are a group of related symptoms that are caused by advanced HIV infection or when someone has a CD4 (immune cells) count of less than 200. AIDS makes the body vulnerable to life-threatening illnesses called opportunistic infections.

The term AIDS was first used by doctors when the exact nature of the HIV virus was not fully understood. However, the term is no longer widely used because it is too general to describe the many different conditions that can affect somebody with HIV. Specialists now prefer to use the terms advanced or late-stage HIV infection.

An opportunistic infection is an infection that would not be life-threatening to an otherwise healthy person. Often it is these infections that are the cause of illness or death in HIV-positive individuals, not the virus itself.

In the absence of antiretroviral therapy, the median time of progression from HIV infection to AIDS is nine to ten years, and the median survival time after developing AIDS is only 9.2 months. However, the rate of clinical disease progression varies widely between individuals, from two weeks up to 20 years.

The rate of progression depends on certain factors that influence the body’s ability to defend against HIV such as the infected person’s general immune function. Older people have weaker immune systems, and therefore have a greater risk of rapid disease progression than younger people.

Poor access to health care and the existence of coexisting infections such as tuberculosis also may predispose people to faster disease progression.

The infected person’s genetic inheritance plays an important role and some people are resistant to certain strains of HIV. HIV is genetically variable and exists as different strains, which cause different rates of clinical disease progression.

How does HIV affect the body?

As mentioned above, the symptoms of AIDS are primarily the result of conditions that do not normally develop in individuals with healthy immune systems. Most of these conditions are infections caused by bacteria, viruses or parasites that are normally controlled by the elements of the immune system that HIV damages. Opportunistic infections are common in people with AIDS and can affect nearly every organ system.

People with AIDS also have an increased risk of developing various cancers such as Kaposi’s sarcoma, cervical cancer and cancers of the immune system known as lymphomas.

Additionally, people with AIDS often have systemic symptoms of infection like fevers, sweats (particularly at night), swollen glands, chills, weakness, and weight loss. The specific opportunistic infections that AIDS patients develop depend in part on the prevalence of these infections in the geographic area in which the patient live. More mention is made of associated medical conditions later in the box above.

Diagnosis of HIV infection

Screening for HIV infection is most commonly done by testing blood for HIV antibodies, however more recently other methods have been introduced. These include collecting secretions from between the cheek and gum for evaluation and also urine testing. The latter two methods are often favoured as they eliminate the need for a needle stick, although a blood test may still be required in the event of a positive test.

How is HIV Transmitted?

HIV is transmitted through four body fluids:  blood, semen, vaginal fluid, and breast milk. In order to pass HIV from one person to another, HIV-infected fluid from one person needs to get into the bloodstream of another person. HIV is usually transmitted through sharing needles, unprotected anal, vaginal, and sometimes oral sex, and from mother to infant before or during delivery or while breastfeeding.

A tiny number of cases occur for other reasons, for instance as a result of blood transfusion and organ donation or sperm donation from a person who is HIV-positive. HIV cannot be transmitted by touching someone or sharing items, such as cups or pencils or through coughing and sneezing. Additionally it cannot be spread through routine contact in restaurants, the workplace or schools.

Treatment

Although treatments for AIDS and HIV can slow the course of the disease, there is currently no vaccine or cure. Antiretroviral treatment reduces both the mortality and the morbidity of HIV infection, but these drugs are expensive and routine access to antiretroviral medication is not available in all countries. Due to the difficulty in treating HIV infection, preventing infection is a key aim in controlling the AIDS pandemic.

Anti-HIV (also called antiretroviral) medications are used to control the reproduction of the virus and to slow or halt the progression of HIV-related disease. When used in combinations, these medications are termed Highly Active Antiretroviral Therapy (HAART). HAART combines three or more anti-HIV medications in a daily regimen, sometimes referred to as a ‘cocktail’.

Anti-HIV medications do not cure HIV infection and individuals taking these medications can still transmit HIV to others. They also have side effects which can vary in severity and include decreased levels of red or white blood cells, inflammation of the pancreas, liver toxicity, rash, gastrointestinal problems, elevated cholesterol level, diabetes, abnormal body-fat distribution and painful nerve damage.

Underwriting Implications

An HIV test is requested as part of the standard non-medical limit within most companies. The actual amount varies but is generally requested at around the £1m level.

Due to the nature of the disease the majority of insurance companies do not offer straightforward life insurance cover to individuals who are HIV positive, although PruProtect currently offer a maximum of £250,000 life cover to clients who meet certain criteria. This is deemed a step in the right direction and has been welcomed by the industry.

Fergus Bescoby is underwriting development manager at PruProtect

Associated medical conditions

• Pneumocystis pneumonia is relatively rare in healthy, immunocompetent people, but common among HIV-infected individuals. Before the advent of effective diagnosis, treatment and routine prophylaxis in Western countries, it was a common immediate cause of death. In developing countries, it is still one of the first indications of AIDS in untested individuals, although it does not generally occur unless the CD4 count is less than 200 cells per µL of blood.
  
• Tuberculosis (TB) is unique among infections associated with HIV because it is transmissible to immunocompetent people via the respiratory route, is not easily treatable once identified, multidrug resistance is a serious problem. Tuberculosis with HIV co-infection (TB/HIV) is a major world health problem and according to the World Health Organisation: in 2007, 456,000 deaths among incident TB cases were HIV-positive, a third of all TB deaths and nearly a quarter of the estimated 2 million HIV deaths in that year.
  
• Eosophagitis is an inflammation of the lining of the lower end of the esophagus. In HIV infected individuals, this is normally due to fungal or viral infections. In rare cases, it could be due to micobacteria.
  
• Unexplained chronic diarrhoea in HIV infection is due to many possible causes, including common bacterial and parasitic infections and uncommon opportunistic infections. In some cases, diarrhoea may be a side effect of several drugs used to treat HIV, or it may simply accompany HIV infection, particularly during primary HIV infection. It may also be a side effect of antibiotics used to treat bacterial causes of diarrhoea. In the later stages of HIV infection, diarrhoea is thought to be a reflection of changes in the way the intestinal tract absorbs nutrients, and may be an important component of HIV-related wasting.
  
• HIV infection may lead to a variety of neuropsychiatric symptoms, either by infection of the now susceptible nervous system by organisms, or as a direct consequence of the illness itself.
  
• Toxoplasmosis is a disease caused by the single-celled parasite which usually infects the brain, causing toxoplasma encephalitis, but it can also infect and cause disease in the eyes and lungs. Cryptococcal meningitis is an infection of the meninx (the membrane covering the brain and spinal cord) by the fungus Cryptococcus neoformans. It can cause fevers, headache, fatigue, nausea, and vomiting. Patients may also develop seizures and confusion; left untreated, it can be lethal.
  
• AIDS dementia complex (ADC) is a metabolic encephalopathy induced by HIV infection and fuelled by immune activation of HIV infected brain macrophages and microglia. These cells are productively infected by HIV and secrete neurotoxins of both host and viral origin. Specific neurological impairments are manifested by cognitive, behavioural, and motor abnormalities that occur after years of HIV infection and are associated with low CD4+ T cell levels and high plasma viral loads.
  
• Patients with HIV infection have substantially increased incidence of several cancers. This is primarily due to co-infection with an oncogenic DNA virus, especially Epstein-Barr virus (EBV), Kaposi’s sarcoma-associated herpes virus (KSHV) and human papilloma virus (HPV). Invasive cervical cancer in HIV-infected women is also considered AIDS-defining and is caused by human papilloma virus (HPV).
  
• AIDS patients often develop opportunistic infections that present with non-specific symptoms, especially low-grade fevers and weight loss.