August 7, 2025
In the span of just a few decades, HIV has transformed from a global health crisis into a chronic, manageable condition. This evolution is not only a testament to scientific ingenuity but also a call to reframe how we assess and support individuals living with the virus—clinically, socially, and financially.
From fatal to functional: The treatment revolution
The early days of HIV were marked by fear and uncertainty. Diagnoses often came with dire prognoses, and treatment options were limited, complex, and riddled with side effects. The first antiretroviral therapy (ART) approved in 1987—zidovudine (AZT)—offered hope but adherence and resistance were a formidable challenge.
By the mid-1990s, the introduction of triple therapy, or highly active antiretroviral therapy (HAART), marked a turning point. These regimens significantly reduced viral loads and improved survival, though they still demanded rigorous adherence. Over time, pharmaceutical innovation delivered more tolerable, simplified regimens—including once-daily pills and, more recently, long-acting injectable treatments administered as infrequently as every two months.
Today, the treatment landscape includes over 30 unique drugs across 10 classes, offering flexibility and resilience against resistance. Pre-exposure prophylaxis (PrEP) has also emerged as a powerful preventive tool, reducing transmission risk by up to 99% when taken consistently.
Underwriting in the age of HIV management
As treatment has advanced, so too must your approach to underwriting. HIV is no longer a categorical exclusion—it is a nuanced risk that can be evaluated with the same rigor applied to other chronic conditions.
Key underwriting considerations include:
- CD4 count and viral load: The cornerstone of HIV risk assessment lies in two metrics. A CD4 count above 400 cells/mm³ indicates a healthy immune system, while an undetectable viral load (typically <20 copies/mL) reflects effective treatment.
- Treatment adherence: Consistent medication use is critical. Underwriters should look for evidence of stable regimens and minimal treatment changes, the lack of which may signal resistance or non-compliance.
- Comorbidities and lifestyle factors: HIV can increase the risk of cardiovascular disease and certain cancers. Additionally, higher rates of smoking, alcohol use, and drug use in some HIV-positive populations warrant careful evaluation.
- Social determinants and access to care: While not always quantifiable, access to healthcare, medication affordability, and support systems can influence long-term outcomes and should be considered in a holistic risk profile.
A new standard for underwriting guidelines
Life insurers have a unique opportunity—and responsibility?—to reflect the realities of modern medicine. With appropriate metrics and a data-driven approach, many individuals living with HIV are not only insurable but represent standard or near-standard risk profiles.
This shift is more than procedural. It is a recognition of progress and a signal that the insurance industry is evolving alongside the science it depends on. With data-driven tools that expand insights into multidimensional risks along the condition spectrum, the opportunities to issue more business and extend coverage to more people are there for the taking.
Watch our webinar series, From uninsurable to opportunity: The evolving mortality of hepatitis C, HIV, and cystic fibrosis, to learn more.
Derek Cole, PharmD, is a senior clinical consultant at Milliman IntelliScript.
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