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Around 2.5 million people in Europe are living with HIV.1 The overall prevalence is 0.3% compared to 5% in Sub-Saharan Africa.2 Most European countries have been working to combat the HIV epidemic since the early 1980s. As a result, mortality from AIDS in Europe has steadily decreased since 2001.3 But does this mean that the crisis is really over? And what does this imply for the insurance industry? Do lower case numbers in most countries of Europe suggest insurers can be more relaxed about the risk and make it simpler for people with HIV to obtain life insurance cover?
Most countries of Europe have been both very active and successful in fighting the HIV and AIDS epidemic since the early 1980s, when AIDS was first established as a disease and the HIV virus was identified as causing AIDS. Consequently, numbers of new infections were going down for years, while treatment became more effective and more widely available. But recent trends are worrying. Firstly, the HIV virus is detected late in around half of all new cases. When the virus is detected after being present for a long time, the prognosis is poor. People suffering from late-stage HIV do not benefit as much from improvements in treatment as those who are diagnosed early. Although accessibility and quality of treatment is comparably good in Europe, many people suffer and die due to late diagnosis. Secondly, the prevalence of HIV cases is increasing. This might sound like good news if it were suspected it could be attributed to a decrease in mortality alone but this is not the case. Another reason for the increased prevalence is the steep climb in incidence rates – the number of new infections detected rose by 80 % from 2004 to 2013 (WHO, 2014).4
The number of new diagnoses varies greatly between the different countries in Europe. In Eastern regions the rate is 0.4‰, in the West it is 0.06 ‰ and in Central Europe 0.02‰. Some of these numbers are increasing rapidly. Currently Estonia has the highest rate of HIV, followed by Ukraine, Russia, Latvia and Portugal. The official numbers should be interpreted with care, however. Some infections go undetected because people have no access to testing or cannot afford it. People might avoid having a test for fear of stigmatism if they are found to be HIV-positive. In addition, reporting varies from country to country. In some countries all new and existing HIV infections must be reported, in others there is no such obligation or the obligation is limited to reporting only cases of full-blown AIDS. So, however small the numbers may appear, the all-clear is not in sight for Europe.5
In the early days of HIV, when infection resulted in a very limited life expectancy, few would have anticipated that insurers would consider insuring HIV-positive lives just a few years later. Some of the emerging population groups affected, intravenous drug users for example, were not traditional prospects for life insurers. With the passage of time, the growth in the number of people with HIV and the shift in the affected population, the need for insurance has become more acute and companies have begun to consider the options.
Advances in testing protocols and treatment methods have proven to be so effective that people who are HIV-positive today can enjoy, under optimal circumstances, near-normal life expectancy. Some European insurers, for example in Italy, automatically excluded HIV for five to seven years in lieu of underwriting, only to find this approach became ineffective once insured people with HIV began to outlive these time limits.
From a legal point of view, both EU and national laws have become clearer and stricter regarding discrimination of people on grounds of disability or sexual orientation, both of which are relevant criteria when looking at HIV. As an example, application form questions asking for sexual orientation that were common decades ago are prohibited in much of Europe today. The same applies to stereotype underwriting guidelines, such as mandatory HIV testing exclusively of homosexual males.
But it is not only the surrounding conditions that have changed dramatically since the early 1980s when the first HIV cases were diagnosed. Today, many insurance companies in Europe will consider insuring an HIV-positive life, and offers will be available to “favourable” HIV risks. These offers will still be restricted in terms of the kind of benefit offered, the duration of the policy, and a loading for elevated risk will typically be applied. At the same time, many European insurers are hesitant to consider insuring HIV-positive risks – many referring cases directly to a reinsurer for assessment. It is also the case that the number of people with HIV who apply for life insurance is rather low in most countries. This corresponds to some degree with the very small numbers infected, but it may also be because they anticipate being refused, fear it will be unaffordable, lack a need for insurance cover or are reluctant to be open about HIV infection.
Across Europe, claims experience linked to HIV cases is remarkably low despite the undoubted presence of relevant numbers of HIV-positive people in insurance portfolios; among these are people who contracted HIV or were diagnosed after applying for life insurance cover, as well as cases of non-disclosure. Despite all the similarities European countries share concerning the HIV situation, there are still some remarkable differences when it comes to the way HIV is dealt with in an insurance context as the following examples show.
For some time, Spain had the highest HIV prevalence in Europe but this has changed recently due to the steady rise in incidence in some Eastern European countries. The prevalence rate is, nevertheless, still high at 0.4%.6 With an incidence rate of 1.7 per 100,000, Spain remains among the top four countries measured by newly reported cases.
Much has been done to combat this situation. A national programme, the “Plan Multisectorial frente a la infección por VIH y el sida”, was initiated to ensure access to testing, early diagnosis and adequate treatment for those people found to be infected. In general, HIV testing can be performed confidentially and free of charge in Spain. But the plan suggests that to reach high risk groups, such as drug users, health facilities and services available to these groups should encourage HIV testing by offering it on an opt-out basis.7
Spanish scientists, who have been very active in seeking a cure for HIV, presented the “Barcelona Patient” in 2014. The patient, who received a blood transplant from the umbilical cord of a donor with a genetic resistance to HIV, appeared cured as the HIV virus was no longer detectable in his body.8
Spanish insurers are not completely open to the idea of extending cover to people with HIV. Application forms include a question about HIV diagnosis, past history of testing and about contact with other people who have HIV. Nevertheless, Spanish people with HIV are in a favourable position as they have access to at least one “HIV only” insurance product that was launched in 2014. The product meets their need for insurance while addressing any remaining hesitancy amongst insurers to provide cover.
To be considered for cover, an applicant must provide information about how his or her disease has developed since diagnosis, its progression, his or her treatment and its effectiveness and any co-infection with hepatitis B or C. If the applicant is considered to be insurable, a loading is applied that takes account of these factors, and the policy duration is typically limited. Despite these limitations, this offer might be attractive to people who may otherwise be ineligible for cover. As this product was launched only recently, it remains to be seen how much demand there is for a product of this type.
At a prevalence rate of 0.28%, one- quarter of which is deemed unaware of even carrying the disease, the UK is among the countries in Europe less affected by HIV. After a steep increase after 2000, incidence rates are now declining with around 6,000 new diagnoses in 2013. Also declining is the number of cases with late diagnosis that stood at 57 % in 2004 and has now dropped to 42 % – a level that shows some clear improvement, but is sadly still high.9 That the numbers are still this high is especially disappointing as the level of care and accessibility of treatment is remarkably good in the UK. Most people are linked to HIV care within three months of diagnosis, and a retention rate and treatment coverage of around 95 % is reported, with 90% of these patients receiving antiretroviral therapy.
While companies in the UK are not obliged to offer acceptance terms to people who have HIV, in practice many now do. General guidance comes from the “Statement of Best Practice for HIV and Insurance”10, an arrangement between the Association of British Insurers (ABI) and its members. The first such statement was issued in 1994. All ABI member companies must comply with its guidelines. The main objective of the statement is to ensure all applicants at risk are treated fairly and sensitively.
For this reason, insurers do not ask applicants to disclose counselling or testing for HIV but merely if they have ever tested positive or await the results of a test. All positive tests for hepatitis B or C and any sexually transmitted infection (in the past five years) must also be disclosed. Forms may include a question about exposure to HIV risk in the past five years but only ask if it was through unsafe sex, intravenous drug use or surgery performed outside the EU. In addition, HIV testing is obligatory for higher sums assured. The present statement dates from 2008 but is currently under review. Much of the language used in the statement itself seems rather redundant now as increasing numbers of UK companies offer terms for people with HIV. The outcome of the review and the associated consultation process cannot be predicted, but it is reasonable to assume that while UK insurers increasingly treat HIV like any other pre-existing medical condition, much of the current guidance will be relaxed or simply removed.
In Germany the good news is that the prevalence rate is the lowest in Europe. In 2013 the overall rate was 0.1 %.11 Less good news is that the number of new infections continues at the relatively high rate of around 3,200 per year.12 Together with the rapid improvements in mortality, this results in a growing prevalence rate, while still at a low level. People in Germany do benefit from the state-owned health care system that compares favourably with other countries. The system is mandatory and covers expenses related to HIV diagnosis and treatment. In general, people are likely to be diagnosed early, will be entitled to compensation for any HIV-related costs, and will receive optimal therapy in sufficient dosage.
Germany was very active in providing information about the risks and methods of contracting HIV when it first emerged as a threat. This helped in keeping the incidence rate low over a long period of time. More recently this situation has changed. Attention has shifted so that people no longer view HIV as potentially lethal. Young people are less well-informed and are less concerned about the risks. Deutsche AIDS-Hilfe, the national AIDS organisation, has observed HIV diagnosis is happening later.13 This is particularly so in females – perhaps because they are not typically thought of as being at risk. As a result, women tend to be diagnosed late – in many cases not before stage 4 – and so have a poorer chance of recovery. Hence, despite some good news HIV remains a major public health problem in Germany.
It might be thought that the comparatively controlled HIV situation in Germany means finding insurance is easy. It is not quite so simple. Standard application forms for both life and disability insurance are typically long and wide-ranging with a clear emphasis on health-related questions. A question on an existing HIV infection is standard but questions about risky behaviour with regard to HIV are not common. In addition, for higher sums assured, testing for HIV is usually still obligatory. People with HIV will, in general, only be considered for life cover while disability insurance is usually not available to them.
At the same time there is a strong tendency towards simplified underwriting in Germany, especially in the context of disability cover for employees triggered by their respective employer’s initiative. These schemes are treated to a great extent like group insurance, which in fact they are not – as applying for insurance is facultative for each single employee. Within these simplified underwriting questionnaires, HIV can nowadays easily go undetected as they usually concentrate on days absent from work. HIV-positives, in an early stage or with well-functioning treatment, in most cases won’t fail these criteria and thus will be able to obtain insurance cover. In common with other European countries, the number of HIV-related claims in Germany has at no time been significant. Today, claims for disability fail because there is limited impact on the ability to work. The most common triggers for disability claims nowadays are mental health issues; while bodily harm has been reduced, the psychological burden of HIV seems to remain.
In 2014 a large gay association conducted a survey among some German primary insurers, asking about their approach to people with HIV and those suffering from “full-blown” AIDS. They were motivated by the experience of their members who had applied for insurance but were declined without any further assessment. The overall response by insurers was mixed. Around half of the insurers did not even respond to the survey, while the others emphasised their willingness to offer cover based on individual assessment. They stressed their knowledge of advancements in medical treatment and often referred to their reinsurer’s guidelines. So while it is quite possible for people with HIV to receive a fair assessment and obtain life cover under certain circumstances, it is important to know to which insurer they should turn.
The insurance business is not typically fast moving. Insurers’ assumptions are based on past evidence, so changes will only be made if new evidence has proven to be stable. The speed of progress in HIV treatment has been remarkable; perhaps a little too fast for some insurers in Europe to have reacted. Today HIV remains a serious public health concern. Nevertheless, insurance cover can be offered to many people who have HIV. The examples of Spain, the UK and Germany show that different approaches have been chosen to make this possible. Europe has travelled a long way towards insuring people living with HIV but there is still a long stretch of road ahead.
