National Health Insurance
Prevalence of HIV/AIDS in Medical Schemes

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The REF Study 2005 provided excellent data on the status of the epidemic in medical schemes in 2005. The study is discussed in more detail in Policy Brief 3 on chronic disease. The graph below shows the age and gender profile for HIV/AIDS in medical schemes, as defined by the Entry and Verification Criteria in use at the time. Essentially, the criteria require for diagnosis that there is documented proof to demonstrate that the patient qualifies for ART in accordance with the National Antiretroviral Treatment Guidelines. A “treated patient” needs to have received any of the following classes of medicines in two of the three preceding months: protease inhibitors (PI); nucleoside and nucleotide reverse transcriptase inhibitors (NRTI); or non-nucleoside reverse transcriptase inhibitors (NNRTI).

Figure 5: Rate of HIV/AIDS on Antiretroviral Medicines in Medical Schemes in 2005

These “diagnosed” and “treated patient” prevalences are not directly comparable to the ASSA2003 expected prevalence as the medical scheme experience is only those who have been tested and have been found to be eligible for ARVs. The medical scheme prevalence though has extended the understanding of the age range of people needing treatment. The ASSA model may be underestimating those needing treatment at the oldest ages as it assumes that sexual activity ceases at age 59. This may be changed in future versions of the model.

In order to determine the expected future prevalence in medical schemes, it was agreed with Dr Leigh Johnson that the progression in the epidemic should be applied to the medical scheme base figures. This has been done since 2004 and the same rate of progression was then applied to the improved figures from the REF Study 2005.

There is some evidence of the extent of private sector provision of ARVs by considering the numbers covered on disease management programmes and using the Risk Equalisation Fund figures.

A difficult estimate to make is the extent of HIV/AIDS in future medical schemes or a phased NHI. The issue is that the additional medical scheme members and beneficiaries are being taken from a pool with higher levels of HIV. As a crude first estimate some sort of linear relationship from the medical scheme “treated patient” prevalence rate to the population “Stage 5: Receiving ARVs” prevalence rate is needed by age and gender. However this ignores the complexity that it would probably be easier to access ART as a member of a medical scheme than through the public sector. This means that a greater number of people from WHO Stage 3 may move to Stage 5 and be on treatment in a mandatory system. The private sector has also typically placed people on ART earlier as clinical evidence emerged about the optimum time to begin treatment. The public sector guidelines have at times lagged best practice from the Southern African HIV Clinicians Society. In addition, being on ART impacts on survival time and the ability to infect others. Much more work is needed on this issue to develop a reasonable estimate of the HIV epidemic at various stages of a phased NHI.

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