At the end of 2008 it is estimated that around 850,000 people were living with HIV in Western and Central Europe.¹ Although the number of people living with HIV and AIDS in Europe is relatively small when compared to the number of people living with HIV in areas such as Asia and sub-Saharan Africa, HIV/AIDS in Western and Central Europe is still considered a major public health issue.² Recent evidence shows increasing rates of HIV transmission in a number of European countries, particularly among men who have sex with men (MSM). The number of people living with HIV who are unaware of their status is alarmingly high and many people are diagnosed with HIV at a late stage, reducing the likelihood of treatment success.

More encouragingly, the number of people dying from AIDS in this region has significantly decreased since the introduction of combination antiretroviral treatment in the mid-1990s. Most Western and Central European countries benefit from wealthy economies, stable infrastructures and developed healthcare systems, and so the majority of people needing antiretroviral treatment are receiving it. Many people now consider HIV as a chronic disease, instead of a death sentence.

This page focuses on the countries in Western and Central Europe as defined by the World Health Organisation (WHO). Countries in the west include: Andorra, Austria, Belgium, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, Monaco, Netherlands, Norway, Portugal, San Marino, Spain, Sweden, Switzerland, and the United Kingdom. Countries in the centre include: Albania, Bosnia & Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Hungary, Former Yugoslav Republic of Macedonia, Montenegro, Poland, Romania, Serbia, Slovakia, Slovenia and Turkey.

HIV prevalence and transmission in Europe

Generally HIV and AIDS have affected Western Europe more than Central Europe. At an estimated 0.6 percent, Switzerland has the highest HIV prevalence, followed closely by France, Italy, Portugal and Spain.⁴ In 2008 the highest number of new infections was  7,370 new HIV infections in the UK,⁵ followed by France, which reported 4,068.⁶ With the exception of Poland and Romania, HIV prevalence in Central Europe has remained at a relatively low level. Bosnia and Herzegovina, Croatia, Macedonia, Slovakia and Slovenia all have HIV prevalence figures under 0.1%.

In both Western and Central Europe heterosexual transmission accounts for just over a half of newly diagnosed cases.⁸ This includes HIV infections among persons originating from countries with high HIV prevalence. If these cases were not included, men who have sex with men (MSM) would make up the largest share of new diagnoses in this region. Around 40 percent of reported HIV diagnoses in Western Europe are a result of sex between men.⁹ In Central Europe this figure is slightly less, at around 30 percent.¹⁰

Injecting drug use (IDU) accounts for a small share of new HIV diagnoses in both Western and Central Europe.¹¹ In these regions there has been a steady decline in new HIV infections among injecting drug users since the beginning of the century,¹² which could be explained by the increasing availability of harm reduction measures, such as needle exchanges. However, not all European countries are witnessing a decline; IDU is still an important factor in several countries, including Italy, Portugal, Spain and Poland.¹³

The problem is most severe in Eastern Europe, where around 57 percent of new infections are attributed to IDU. Find out more about HIV and AIDS in Eastern Europe.

HIV testing in Europe

HIV testing policies vary between countries in Western and Central Europe. Most countries have HIV testing facilities in STD clinics, hospitals, drug treatment clinics and antenatal clinics.¹⁴ Some countries include general practitioners in their main testing strategy, whilst in other countries local doctors play a minor role or none at all.¹⁵ In most countries the total number of HIV tests increased between 2003 and 2008. Testing rates are highest in Austria, Belgium and France.¹⁶

Most countries provide routine testing for pregnant women and those presenting at STD clinics.¹⁷ In these areas testing uptake increases with ‘opt-out’ policies – whereby a test is performed unless the patient asks not to have one. Testing uptake is also thought to be high among injecting drug users in Western and Central Europe, due to the availability of HIV testing at drug treatment centres.¹⁸

HIV testing and late diagnosis

Since the introduction of combination antiretroviral therapy in the mid-1990s there has been a significant decline in AIDS-related mortality in Western and Central Europe. Most people living with HIV in these regions have access to combination therapy, which reduces their chances of acquiring AIDS-related illnesses. It is thought the widespread availability of antiretroviral therapy should provide an incentive for individuals to get tested for HIV, as, once diagnosed, the drugs will help them stay healthy for longer.

However, in Europe, rates of late diagnosis have either remained stable or have increased.¹⁹ Many people in Western and Central Europe do not get tested for HIV and many do not know they are infected with the virus. In the European Union it is estimated that around a third of those living with HIV are unaware of their infection.²⁰ In the UK just over a quarter of people with HIV do not know their status,²¹ and in Poland estimates are as high as 50 percent.²² Worrying evidence from across Europe suggests that opportunities to diagnose HIV infections are often missed, particularly in healthcare settings.²³

Late diagnosis of HIV has serious implications for both the individual and for public health. If a person is diagnosed at a late stage they are more likely to develop an AIDS-related illness, are less likely to respond to antiretroviral treatment and are at an increased risk of mortality. Onward transmission of HIV is also an issue, as it is thought that people are more likely to take precautions to prevent transmission if they know they are infected with the virus.^{24 25}

Even though there is a high testing uptake in France, (around half of the French population have had an HIV test), an estimated 40 percent of new HIV diagnoses are diagnosed late. This is because people who are most at risk of late diagnosis are those who are least likely to be reached by testing programmes – for example, marginalised groups such as migrants, and older, heterosexual men with stable partners and children.²⁶ As these groups are typically not thought of as ‘high-risk’ for HIV infection, they are not targeted by testing programmes, and so are at a greater risk of being diagnosed late. ^{27 28}

This problem is not confined to France: in Italy between 2002 and 2006 the majority of late diagnoses were among foreign-born and heterosexual males.²⁹ A review of the current literature of late diagnosis in Europe found a number of common characteristics among those who were diagnosed late, including: migrant status, being older, being heterosexual, being male and living in low HIV prevalence areas.³⁰

HIV prevention in Europe

After the first AIDS diagnoses were reported in Europe at the beginning of the 1980s, HIV prevention programmes and campaigns were set up to alter the behaviours that were putting people at risk of contracting the virus.³¹ Some of these programmes have been successful, especially in reducing the incidence of mother-to-child transmission of HIV (PMTCT), preventing HIV transmission in healthcare settings, and reducing HIV transmission among injecting drug users. However, overall, the number of new HIV infections in Western and Central Europe is still high, and, among MSM, there are signs of increasing transmission.

Successful HIV prevention programmes in Europe

Preventing mother-to-child-transmission (PMTCT)

In most parts of Western and Central Europe the number of HIV infections that result from mother to child transmission have been significantly reduced as most countries routinely test all pregnant women for HIV. If a woman tests positive she will have access to antiretroviral drugs, which significantly reduces the chances of HIV transmission from mother to child. HIV positive women are also encouraged to avoid breastfeeding, as this too can transmit HIV. As a result of these PMTCT initiatives, in 2007 in Western and Central Europe 268 cases of MTCT of HIV were reported³² - a relatively small number compared to many other parts of the world.

Preventing HIV transmission in healthcare settings

HIV prevention initiatives have also been successful in reducing HIV infections within healthcare settings. The risk of HIV-infected blood donations entering the blood supply in Western and Central European countries is low, as all blood donations are screened for HIV and those who think they may be at risk of HIV infection are discouraged from donating blood.³³ As a result, in 2007 a relatively small number (79 people) became infected with HIV through blood transfusions in the region.³⁴

The widespread adoption of universal precautions has also lowered the risk of exposure to HIV for healthcare workers in medical settings.

Harm reduction measures

Europe was the first continent to introduce harm reduction measures in the 1980s after a number of IDUs were infected with hepatitis B and hepatitis C through sharing injecting equipment. The need for harm reduction programmes was greatly intensified when an increasing number of IDUs were becoming infected with HIV.

Today, harm reduction programmes such as needle exchanges, operate and are legal in most Western and Central European countries.³⁵ It is thought that these measures have succeeded in reducing the number of new HIV infections among IDUs.³⁶

Even though most countries in Western Europe have made it a national public health objective to reduce drug-related harm, coverage is still not sufficient to make every injection a safe one. In Sweden for example, there are only two NSPs serving only 5 percent of the total number of IDUs in the country.³⁷

Some European countries are still battling with their HIV epidemics among IDUs; in Portugal the estimated adult HIV prevalence among IDUs is between 12-20.5 percent and in Spain some estimates are as high as 40 percent.³⁸

Challenges that remain

Preventing HIV transmission among men who have sex with men (MSM)

In most Central and Western European countries MSM make up a significant share of new HIV cases. Worrying trends show that since the availability of HAART in the mid-1990s, some countries have seen an increase in diagnoses among this group.^{39 40} One study concluded that HIV diagnoses among MSM in Western and Central Europe have almost doubled since 2000.⁴¹ The UK witnessed the largest rise, with an increase of 91 percent between 2000 and 2006.⁴²

It has been said that the increase in HIV diagnoses among MSM is linked to an increase in high-risk behaviour. In the 1980s HIV prevention campaigns successfully alerted people to the dangers of HIV, which accounted for a decline in the frequency of high-risk behaviours. In the 1990s the introduction of combination antiretroviral treatment turned HIV from a death sentence into a chronic disease, and it is thought that this may have created a sense of complacency and an increase in high-risk sexual activity.⁴³ Françoise Barré-Sinoussi, the virologist who co-discovered HIV as the cause of AIDS, claims

“...some people in my country, France, and other Western countries have become complacent – they see HIV/AIDS as a chronic disease – not as one that can kill.” ⁴⁴

A study in Turkey showed that only 36.7 percent of MSM reported using a condom the last time they had anal sex with a male partner,⁴⁵ and in London the percentage of MSM reporting unprotected anal intercourse rose from 30 percent to 42 percent over a four-year period.⁴⁶ Similarly surveys from Germany have reported an increase in unsafe sexual contact among MSM since 1996, after a previous ten years of declining occurrence of high-risk sexual behaviour.⁴⁷ In Denmark a 2006 survey revealed an increase in the incidence of unsafe sex from the results of previous years.⁴⁸

Preventing heterosexual HIV transmission

Over half of all new HIV diagnoses in Western and Central Europe result from heterosexual transmission. Some people who become infected with HIV are the sexual partners of those in high-risk groups. However a large number of HIV diagnoses are among migrants, who have moved to the region from countries with generalised epidemics.⁴⁹

It can be especially difficult to target this group with prevention messages, as migrant communities tend to be among the most marginalised groups in society and are often hard to reach. Studies have shown that cultural, socioeconomic, linguistic and administrative or legal barriers make it difficult for migrants to be reached by HIV prevention initiatives.⁵⁰

A number of European countries are taking measures to increase awareness of HIV among their migrant populations. Many countries offer voluntary counselling and testing and provide health information leaflets (in a number of foreign languages) to all immigrants upon arrival.⁵¹ Countries are working with non-governmental organisations and community representatives in an attempt to target specific at-risk groups.

HIV treatment

HIV treatment is widely available for people living with HIV in Western and Central Europe. This has meant that the number of people dying from AIDS has been significantly reduced. However, there are still a number of issues concerning antiretroviral treatment and people are still dying from AIDS in this region. The main reasons for this are:

• A high number of late diagnoses. As mentioned earlier, there is still an unacceptably high number of people in Europe who are diagnosed with HIV at a later stage. These people typically respond less well to treatment and are at an increased risk of early mortality.
• Access to treatment and care for migrants. Studies have found that migrants are affected by cultural, socioeconomic, linguistic, and administrative barriers to HIV treatment and care.⁵² These not only affect their access to testing, resulting in late diagnosis, but can also affect their access to antiretroviral treatment once diagnosed.
• Drug resistance. As antiretroviral drugs have been available in Europe for some time, there is a greater chance of transmission of HIV strains that are resistant to antiretroviral drugs. AIDS deaths due to drug resistance are not uncommon in Europe. Fortunately due to the greater variety of potent antiretroviral drugs and close monitoring, there is evidence of a decline in transmitted drug resistance and the overall prevalence of drug resistance in a number of countries.^{53 54 55}
• Ageing and disease progression. Since the availability of combination antiretroviral treatment, Western and Central Europe have been among the first to witness a change in the natural course of HIV infection.⁵⁶ Antiretroviral drugs are keeping people alive for longer, which means that they not only have to contend with HIV related illnesses, but also with illness associated with older age. Cardiovascular conditions and non-AIDS defining cancers are more prominent among people living with HIV in high-income areas.⁵⁷

The way forward for Western and Central Europe

The shape of the HIV/AIDS epidemic in Western and Central Europe has changed significantly since AIDS was first discovered in the early 1980s. Remarkable progress has been made with regards to antiretroviral treatment and preventing transmission among certain groups. However, there is a danger that this progress has contributed to complacency. There are still a high number of new HIV diagnoses each year, a significant proportion of which are diagnosed at a late stage of infection.

In order to make any future progress in Western and Central Europe, the following issues need to be addressed:

• Specific groups need to be targeted with prevention campaigns in order to maintain high levels of safer sex practices.⁵⁸
• The barriers that prevent migrant populations from accessing HIV testing, treatment and care need to be broken down.
• HIV testing has to be promoted to increase the number of people who are aware of their status and to ensure early access to antiretroviral treatment.

Finally, HIV/AIDS surveillance needs to be a priority in all European countries in order to allow for the sharing of best practice and to provide a greater understanding of the region’s epidemic.

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