In 2013, an estimated 2.3 million people were living with HIV in Western and Central Europe and North America. In the same year, there were roughly 88,000 new HIV infections and 27,000 people died of AIDS-related illnesses.1
The United States of America (USA) accounts for the majority of people living with HIV in the region (56%). Four countries in Western Europe account for a further quarter of this number - France (8%), Spain (6%), United Kingdom (5%) and Italy (5%).2
Key affected populations in Western and Central Europe and North America
HIV disproportionally affects men who have sex with men (MSM) and African American communities, particularly African American women and migrants from high prevalence countries in sub-Saharan Africa. In Western and Central Europe, people who inject drugs (PWID) and their sexual partners, transgender people (TG), prisoners and sex workers are also at a heightened risk of HIV.3 Modes of transmission vary greatly between countries.
Men who have sex with men (MSM)
Between 2005 and 2014, the number of HIV diagnoses among men who have sex with men increased by 15% in Western Europe and more than tripled in Central Europe (from 276 in 2005, to 878 in 2014).4 The UK has seen a steady increase in HIV infections among this group – from 2,860 in 2010, to 3,360 in 2014.5
In the USA, MSM account for the majority of new HIV infections (63%), despite representing just 4% of the population. Young African American MSM are at particular risk of HIV. In 2010, there were 4,800 new HIV infections among young African American MSM aged 13-24.6 In Canada, 14.9% of MSM are living with HIV.7
Migrants from sub-Saharan Africa
In Western and Central Europe, in 2014, 37% of all new HIV infections occurred among migrants from outside of this region. Some acquired HIV in their home country, while others acquired HIV on their arrival, indicating the need for targeted interventions for this group.8 In the UK in 2014, 55% of men and 62% of women living with HIV were from sub-Saharan Africa.9
High HIV prevalence among migrants has much to do with restrictive health policies, preventing access to treatment. Treatment has a public health benefit by reducing viral load and preventing further transmission of HIV - reducing long-term health costs. However, 16 European countries (including Spain and Sweden) do not provide treatment to undocumented migrants living with HIV. By contrast, Portugal and the United Kingdom provide ART regardless of a person’s immigration status.10
African Americans are one of the groups most affected by HIV in the USA and accounted for 46% of all people living with HIV (506,000) in 2013.11 Moreover, AIDS-related illnesses are the fifth leading cause of death among African American men and the seventh leading cause of death in African American women aged 25-44.12
Indeed, HIV impacts more upon women than men. For example, the rate of new infections is twice as high among heterosexual women compared to heterosexual men. Moreover, African American women represented 60% of all women living with HIV in the country. Nonetheless, there was a 21% decrease in HIV incidence among African American women between 2008 and 2010.13
One of the biggest risk factors for African American women is being the sexual partner of an African American bisexual man who may not know or want to reveal his HIV status.14
People who inject drugs (PWID)
Over the last decade, new HIV diagnoses among people who inject drugs in Western and Central Europe have remained fairly stable. In 2014, HIV transmission due to injecting drug use accounted for 3% of all new HIV infections in Western Europe and 5% in Central Europe.15
This is due to significant efforts by countries to scale up harm reduction programmes. Moreover, where PWID account for a significant proportion of prisoners, HIV prevalence among inmates has also declined.16 One study in France has reported a 2% HIV prevalence among both male and female inmates.17
While the vast majority of countries in this region have seen HIV prevalence decline or stabilise among this group, since 2011, both Greece and Romania have seen localised HIV outbreaks among PWID.18 Between 2010 and 2013, HIV prevalence among PWID in Romania increased from 3% to 29%.19
In Canada, an estimated 10.9% of PWID are living with HIV.20
HIV prevalence among female sex workers in Western Europe is generally thought to be low (1% or less).21 Higher HIV prevalence rates have been recorded among sex workers in Portugal and Spain (both 13%) and among sex workers who also inject drugs in the Netherlands. Prevalence is also relatively high in Italy and Spain among migrant street and transgender sex workers.22 23
HIV prevalence is similarly low among this group in Central Europe - between 1% and 2%. HIV prevalence has been recorded at under 1% in Albania, Bosnia and Herzegovina, Bulgaria, the Czech Republic, Kosovo, Romania and Serbia. A 2% prevalence was detected among sex workers in Poland and Croatia.24
Data on national HIV prevalence among sex workers in both the USA and Canada is very limited.25
HIV testing and counselling (HTC) in Western and Central Europe and North America
Late diagnosis of HIV is a key challenge throughout Western and Central Europe.
One study in France found that 29,000 people were living with an undiagnosed HIV infection.26. In 2014, 40% of adults in the United Kingdom tested for HIV who were found to be HIV-positive, were diagnosed at a late stage of infection.27 Over the past decade, 81% of the 2,000 AIDS-related deaths in England and Wales were the result of a late diagnosis.28
In many countries, more than half of people diagnosed with HIV have CD4 counts under 350 including Italy (53%), Greece (51%), Romania (58%) and Slovenia (62%). 61.5% of newly diagnosed people in Albania had a CD4 count under 200.29
In 2012, an estimated one in three MSM were tested for HIV across this region, however, coverage varies greatly by country. In the USA, the Netherlands and Portugal, 50% to 74% of MSM accessed HTC. At the lower end, coverage in Canada and most Western European countries ranged between 25% and 49%.30 In United States, a third of African Americans have never been tested for HIV.31 In Canada, 25% of people living with HIV are unaware of their status (17,000).32
The scaling up of HIV testing for earlier diagnosis and more effective treatment and care is a major priority for this region.33
HIV prevention programmes in Western and Central Europe and North America
- Needle and syringe programmes (NSPs)
Most European countries reach the recommended WHO target of 200 syringes distributed per PWID.35 However, Belgium, France and Turkey distribute less than 100 per person.36 Across this region, NSPs are provided through a number of means including fixed sites, outreach and mobile units as well as pharmacies (in Belgium, France, Ireland, the Netherlands, Portugal, Spain and the UK) and vending machines (in Austria, France, Germany, Luxembourg and the UK).37
Data on NSP provision is not collected in North America making it difficult to understand the current level of service provision. In the USA, 194 NSPs are thought to be operating across 33 states. NSPs are also available in Canada, although coverage varies both between provinces and within provinces themselves.38 In 2012, just 23 syringes were distributed per PWID across North America, putting it far behind other high-income regions.39
- Opioid substitution therapy (OST)
More than half of opioid users accessed OST in Europe in 2012 - about 734,000 people. The most significant increases between 2011 and 2012 were in Turkey - 8,000 to 28,656 and Greece which saw a 45% increase. By contrast, OST access in Italy fell from 110,000 to 98,460 in the same period.40 In England and Wales, progress in the provision of OST is being threatened by a drive towards abstinence-based treatment even though these approaches often lead people to stop their treatment.41
OST is available in both the USA and Canada but is not accessed by all those who need it. In the USA, just 2,500 sites provide OST. The most recent data from 2009 showed that 640,000 people accessed OST, up from 96,000 in 2005.42 All ten Canadian provinces offer methadone maintenance therapy (MMT), however, the number of OST sites is unknown due to a lack of monitoring.43
Reducing HIV-related stigma and discrimination
Eliminating stigma and discrimination is an important objective of the WHO European Action Plan for HIV/AIDS and several countries in Western and Central Europe include tackling HIV-related stigma and discrimination in their national HIV strategies (such as France, Germany, Slovenia and Slovakia). Activities are mainly information campaigns and an annual AIDS Day which take place in schools and workplaces (e.g. Denmark, Finland, France, Germany, Greece, Iceland, Israel, Luxembourg and Spain).44
Some countries in Central Europe (e.g. Kosovo, Montenegro, Serbia and Slovakia) also have programmes or training targeting specific groups such as health and education professionals, the police, prison officers, judiciary, religious leaders and the media - the Global Fund supports many of these programmes. In Armenia, an HIV training course has been introduced at the National Institute of Health for healthcare managers, physicians and other healthcare workers to eliminate HIV-related stigma and discrimination by this group.45
Antiretroviral treatment (ART) in Western and Central Europe and North America
Antiretroviral treatment coverage for people living with HIV in Central and Western Europe and North America is an estimated 51%.46
The WHO European Action Plan for HIV/AIDS set an ART coverage target of 80% and for everyone with a CD4 count of under 350 to be on treatment by 2015. Countries in Western and Central Europe have made significant progress in delivering antiretroviral treatment to people living with HIV and most are on track to reach the 80% target.47 For example, in the UK, treatment coverage is over 90%.48
However, new WHO treatment guidelines now recommend that all people living with HIV start treatment regardless of CD4 count. In October 2015, the European AIDS Clinical Society (EACS), recommended the implementation of these new guidelines across Europe.49
In September 2016 Sweden became the first country in the world to achieve the 90-90-90 Fast-Track targets set out by UNAIDS which aim to ensure that 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression.50
Antiretroviral treatment coverage is unknown in both the USA and Canada. In 2012, 94.2% of mothers in living with HIV in Canada were thought to be receiving treatment.51 In the USA, over half the annual HIV budget (57%) is spent of antiretroviral treatment. However, many people do not have medical insurance and cannot access the treatment they need.52 Late diagnosis, poor treatment adherence and high levels of early treatment discontinuation have also been reported in a number of studies across the USA.53
Barriers to HIV prevention in Western and Central Europe and North America
A large proportion of countries in this region report programmes to reduce HIV-related stigma, particularly towards key affected populations. However, there is very limited data on how this impacts upon the uptake of HIV services or the effectiveness of existing measures to prevent stigma and discrimination.54
Language barriers, marginalisation and social exclusion contribute to the HIV vulnerability of migrants. Many also belong to at-risk sub-populations like asylum seekers, refugees, sex workers and men who have sex with men.55
Female migrants also commonly report sexual harassment, abuse and rape, preventing many from accessing vital HIV services.56 In the USA, women who inject drugs experience stigma as well as fear of exposure to authorities because of strict child custody and welfare laws.57
Economic and legal barriers
A lack of funding is a significant barrier to the scale-up of harm reduction programmes in North America. Uneven medical insurance coverage also means that many cannot afford medication or counselling even if these services are available. A lack of government support in Canada, means these services are largely delivered by local authorities, community organisations and NGOs.58
As the legality of NSPs in the USA is determined by each state, many have underground NSPs or none at all. Punitive laws also discourage some programmes from making their information public.59
In Greece, expansion of NSP services has slowed down because of the country's financial difficulties.60
Physical and geographical barriers
Even in countries with good levels of HIV prevention coverage, gaps exist. Some services are out of reach, particularly for those in rural areas, while other sites have inconvenient opening times. In some countries, young people under 18 cannot access harm reduction services. Moreover, migrants living with HIV frequently go undocumented and the provision of services in rural areas is often underdeveloped.61
Other countries do not monitor the use of these services effectively. For example, Germany has 1,000 NSP sites but no central processing of information. National-level estimates of NSP coverage are not collected in Canada or the USA.62
The future of HIV and AIDS in Western and Central Europe and North America
Western and Central Europe has made great strides in tackling the HIV epidemic in the region. Most countries have reached over 80% of people in need of treatment and HIV prevalence as a result is generally low. However, far too many people are still being diagnosed at a late stage of infection. Early diagnosis and treatment is of high priority to improve people's health and has a public health benefit. If people know their HIV status, they are less likely to transmit the virus to others.
Moreover, gaps in the provision of HIV services remain, with key affected populations facing a number of barriers in particular. It is important that countries in this region continue to provide the necessary resources to tackle the epidemic effectively with Greece and Romania showing how the withdrawal of HIV prevention programme funding can lead to an increase in HIV prevalence.
In North America, greater HIV surveillance is required to better understand the need for HIV prevention services in order to mobilise resources where they are needed most.
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