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HIV & AIDS in Western & Central Europe
At the end of 2011 it was estimated that around 900,000 people were living with HIV in Western and Central Europe. 1 The HIV epidemic is fairly stable as a whole, with HIV prevalence having changed little since 2004. 2 Although the number of people living with HIV and AIDS in the region is relatively small when compared to areas such as Asia and sub-Saharan Africa, HIV and AIDS in Western and Central Europe is still considered to be a major public health issue; 30,000 people were infected in 2011. 3 4 5
Evidence shows increasing rates of HIV transmission in a number of European countries, particularly among men who have sex with men (MSM). 6 Additionally, 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 total AIDS-related deaths in this region have significantly decreased since the introduction of combination antiretroviral treatment (ART) in the mid-1990s, from 7,800 in 2005 to 7,000 in 2011. 7 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). 8 Countries in Western Europe include: Andorra, Austria, Belgium, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, Malta, Monaco, Netherlands, Norway, Portugal, San Marino, Spain, Sweden, Switzerland, and the United Kingdom. Countries in Central Europe 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 Western and Central Europe
Generally, HIV and AIDS have affected Western Europe more than Central Europe. At an estimated 0.7 percent, Portugal has the highest HIV prevalence, followed by Austria, France, Italy and Spain at 0.4 percent. 9 In 2011 the UK reported 6,271 new HIV diagnoses, which is a 21 percent decline from the peak of 2005. 10 11 France had the second highest number of new diagnoses (4,075) followed by Italy (3,461). 12 HIV prevalence in Central Europe has remained at a relatively low level: Croatia, Slovakia and Slovenia all have HIV prevalence figures under 0.1%. 13
The people who are most vulnerable to HIV infection vary between countries, areas and communities within Western and Central Europe. However, generally in the region key populations at higher risk include injecting drug users (IDUs) and their sexual partners, MSM, transgender people, prisoners, sex workers and migrants. 14 Laws that protect these key populations have been implemented in many countries in the region and can help to overcome some of the barriers that many at-risk groups face to accessing HIV services. 15
In 2011, MSM transmission accounted for 40.1 percent of new infections in Western Europe, and 27.3 percent in Central Europe. This is the dominant transmission route across the region. 16
In contrast, injecting drug use accounted for double the new infections in Central Europe (8.2 percent) than Western Europe (4.2 percent) in 2011. 17 There has been a steady decline in new HIV infections among injecting drug users in Western Europe especially, since the beginning of the century, 18 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, and there have been some large increases in particular localised areas. 19 Poland has reached a prevalence of 18 percent in some areas among IDUs, 20 and in Greece and Romania there have been significant increases in cases of HIV among this group. 21 22
HIV testing in Western and Central Europe
In most countries the total number of HIV tests increased between 2004 and 2011, with France and Belarus reporting the highest number of tests in 2011. 23 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. 24 Some countries include general practitioners in their main testing strategy, whilst in other countries local doctors play a minor role or none at all, demonstrating a need to ensure coherence and define best practice across Western and Central Europe. 25
Most countries provide routine testing for pregnant women and those presenting at STD clinics. 26 Testing uptake increases with ‘opt-out’ policies – whereby a test is performed unless the patient asks not to have one. Going against this, in July 2013 the Greek Health Minister announced compulsory HIV testing would be enforced, prioritising sex workers, injecting drug users and undocumented migrants. This has been condemned by rights activists as a breach of human rights. 27
A 2013 report found that only 11 out of 24 reporting EU countries had compulsory procedures in place for partner notification. This means a patient diagnosed with HIV is required to inform their recent sexual partners of their diagnosis; this can be provider initiated, patient initiated or both. Partner notification is important to help stop late diagnoses in these partners. 28
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. 29 Most people living with HIV in these regions have access to combination therapy, which reduces their chances of acquiring AIDS-related illnesses. With the roll-out of ARVs there was a general expectation that the widespread availability of antiretroviral therapy would act as an incentive for individuals to get tested for HIV, as once diagnosed the drugs will help them stay healthy for longer. 30
However, in Western and Central Europe, rates of late diagnosis have remained high at 49 percent of all new HIV infections in 2011. 31 As a result, many people are unaware that they are living with HIV. For example, in the UK just under a quarter of people living with HIV are unaware that they are infected, 32 and in Poland estimates are as high as 50 percent. 33 Worrying evidence from across Western and Central Europe suggests that opportunities to diagnose HIV infections are often missed, particularly in healthcare settings. 34 For example, a study in France found that 29,000 people were living with an undiagnosed HIV infection in 2010. 35 In some European countries, testing among injecting drug users is particularly low and 48 percent of IDUs in the region are diagnosed late. 36
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. As people are more likely to take precautions to prevent transmission if they know they are infected with the virus, late or no diagnosis can increase the risk that HIV will be transmitted, which has wider public health implications. 37 38
Although testing uptake is high 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 targetted or reached by testing programmes – for example marginalised groups such as migrants, people living in low prevalence areas and older, heterosexual men with stable partners. 39 40 41 42
HIV prevention in Western and Central Europe
After the first AIDS diagnoses were reported in Europe at the beginning of the 1980s, HIV prevention programmes and campaigns were set up. 43 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, in many cases, reducing HIV transmission among injecting drug users. However, the overall number of new HIV infections in Western and Central Europe is still high, and transmission is increasing among MSM.
Specific prevention efforts and challenges
Many countries in Europe address the needs of key populations who are more at risk of HIV. However, there is also a need to address the barriers that people face both in wider access to healthcare and specifically HIV services. These could include stigma within society, the criminalization of some people’s behaviour and discriminatory rules and regulations within and outside of the healthcare system. 44
Prevention of mother-to-child transmission of HIV (PMTCT)
In most 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 be recommended to begin taking antiretroviral drugs straight away in line with the 2013 WHO Treatment Guidelines. 45 This will significantly reduce the chance of HIV transmission from mother to child. HIV-positive women are also encouraged to avoid breastfeeding, as this too can transmit HIV; baby formula feed is recommended instead. 46 As a result of these PMTCT initiatives, in 2011, only 1 percent of new infections were a result of mother-to-child transmission - a relatively small percentage compared to many other parts of the world. 47
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. 48 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 and opioid substitution therapy, operate and are legal in most Western and Central European countries. 49 It is thought that these measures have succeeded in reducing the number of new HIV infections among IDUs. 50
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 needle syringe programmes. 51 The WHO recommends that in Europe, HIV services for IDUs should be integrated into existing general services for people who inject dugs, in order to ensure coverage. 52 However, HIV prevention appears to be becoming less of a concern in drugs policy in Europe, possibly due to the overall drop in infections, combined with funding constraints during the economic decline. 53
Some European countries are still battling with their HIV epidemics among injecting drug users; in Portugal the estimated adult HIV prevalence among IDUs is between 4.9 and 17.2 percent and in Spain it is around 32 percent. 54 In Estonia, the number of new IDU-related HIV infections almost tripled between 2008 and 2009. 55 It is thought that the economic crisis in Greece contributed to a 57 percent rise in new HIV infections between 2010 and 2011, the majority of which were amongst IDUs. 56 57
Preventing HIV transmission among men who have sex with men (MSM)
In most Western and Central European countries MSM make up a significant proportion of new HIV cases. Worrying trends show that since the mid-1990s, some countries have seen an increase in diagnoses among this group. 58 59 The number of men who have sex with men newly diagnosed with HIV infection increased from 6,905 in 2004 to 8,758 in 2011. 60 The UK has witnessed a constant increase since 2007, with 3,010 diagnoses in 2011. 61
It has been suggested 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. 62 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. 63 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.” 64
The percentage of MSM reporting unprotected anal sex in the region is similar in Germany, the UK and France (between 51 and 56 percent), but is much lower in Swizerland at 41 percent. 65
Preventing heterosexual HIV transmission
Heterosexual transmission accounts for 46 percent of HIV cases in the WHO European Region. 66 Part of the European region World Health Organisation’s Action Plan for HIV and AIDS is to ensure that comprehensive and age-appropriate sex education is rolled out throughout the region, so that individuals understand the importance of using condoms to protect against HIV. 67 Partners of people at higher risk such as injecting drug users are also thought to be especially at risk of infection through sexual contact. For serodiscordant couples, where one partner is HIV positive and the other negative, ARV treatment as prevention where an HIV-positive person starts treatment early to help prevent transmission, is recommended in the WHO Treatment Guidelines of 2013. 68
Migrant groups and HIV prevention
It can be especially difficult to target migrant groups with prevention messages, as migrant communities or individuals tend to be among the most marginalised people in society. 69 Studies have shown that language problems, legal barriers, policies that prevent migrants working and social marginalisation make it difficult for migrants to be reached by HIV prevention initiatives. 70 Moreover, there are often tensions between EU and national policies around equal rights to health, which can help migrants to access healthcare, and those related to illegal residence status, which can act as a barrier to accessing healthcare. 71
In Europe, 16 countries do not provide ART to undocumented migrants at all. Others only provide emergency care, which is ended when a patient's condition is considered stable, such as is the policy in Greece, (although the definition of 'stable' is uncertain). Portugal is an example of a country that considers ART essential regardless of immigration status, and the UK followed suit with this policy in 2012. In 2010, of all HIV infections in Europe, 35 percent were of sub-Saharan African origin, highlighting the extreme numbers of people whose health is threatened by restrictive treatment policies for migrants. 72
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. 73
“i found out about my status wen i came to this country as i was supposed to go for all blood tests…to my surprise the results came back positive, i was so worried and confused…i haven’t told my family for fear of the stigma surrounding HIV in the African people. i have learned to deal and accept my condition im now on meds as my cd4 count was very low, but i refuse to let disease take control of my life” Charles, living in the UK 74
Interventions that involve migrant communities in their design and implementation or utilise peer support can be more effective. This is important in overcoming cultural factors that increase vulnerability, such as taboos or prejudice within migrant communities and ensuring that services are culturally sensitive. 75 However, in Central Europe there are fewer HIV prevention programmes for migrants that involve users in their design. 76 Successful initiatives of this kind include Réseau d’Associations Africaines et Caribéennes in France which promotes the HIV-related needs of migrant groups at a national level through bringing together 34 migrant and HIV NGOs. 77
Antiretroviral treatment in Western and Central Europe
Antiretroviral treatment is widely available for people living with HIV in Western and Central Europe with 430,000 people in high-income European countries receiving it. 78 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, resulting in 7,000 AIDS-related deaths in 2011. 79 The main causes of death among people living with HIV in Europe are TB and end-stage liver disease caused by viral hepatitis C. 80 Reasons why people in Western and Central Europe still die from AIDS include:
- A high number of late diagnoses
Despite the provision of universal healthcare across the region, there are still high numbers of people receiving a late HIV diagnosis and delayed initiation on to antiretroviral treatment. Social inequality, particularly low education levels, has been linked to late initiation of ART. 81
- Access to treatment and care for migrants
Studies have found that migrants are affected by cultural, socio-economic, linguistic, and administrative barriers to HIV treatment and care. 82 83 Some countries, however, such as the UK, have implemented guidelines that aim to minimise any interruptions to the treatment and care received by migrants living with HIV. 84 The guidelines were implemented in response to evidence of the adverse effects of rapid dispersal on HIV-positive asylum seekers. 85
- Drug resistance
As antiretroviral drugs have been available in Western and Central Europe for some time, there is a greater chance of transmission of HIV strains that are resistant to antiretroviral drugs, evident in the 35 percent rise in such transmissions since 2003. 86 AIDS deaths due to drug resistance are not uncommon in the region. Fortunately due to the greater variety of antiretroviral drugs and close monitoring, second-line therapy is readily available in many European countries. 87
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. Antiretroviral drugs are keeping people alive for longer, which means they have to contend with HIV-related illnesses and age-related illnesses. Cardiovascular conditions and non-AIDS defining cancers are more prominent among people living with HIV in high-income areas. 88
Funding the HIV response in Western and Central Europe
One of the priorities for the European Action Plan for HIV/AIDS 2012-2015 is to focus on funding, ensuring that services are cost-effective and sustainable. 89 Since 2010, the economic downturn has affected the provision of healthcare in Europe. Several countries reported increases in HIV among IDUs, which may have been caused by budget cuts to harm reduction services. 90 In Romania, where there has been a decrease in access to sterile syringes, the rate of new infections among IDUs rose suddenly from an average 3-5 per year, to 12 in 2010 and 62 in 2011. In Greece, cases went from around 16 annually to 190 in 2011.
There have been reports in this country of drug users self-infecting with HIV in order to access benefits and to gain faster access to drug substitution programmes, which sometimes have waiting lists of up to three years. 91 These incidents show the need to ensure that HIV services are safeguarded during economically challenging times. 92 93
The way forward
The shape of the HIV and 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. 94
- 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.
- Governments should ensure that HIV services within the healthcare system are safeguarded during the economic downturn. 95
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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