In 2015, an estimated 2.4 million people were living with HIV in Western and Central Europe and North America. In the same year, there were roughly 91,000 new HIV infections and 22,000 people died of AIDS-related illnesses.1
More than half of all new HIV infections occurred in the United States of America (USA), and more than a quarter occurred in six countries: France, Germany, Italy, Spain, Turkey and the United Kingdom (UK). The annual number of new HIV infections among adults in the region remained stable between 2010 and 2015.
However, among certain key affected populations such as men who have sex with men, new infections are rising.2
Key affected populations in Western and Central Europe and North America
Nine out of 10 new HIV infections in 2014 were among key affected populations and their sexual partners. HIV prevalence is also considerably higher among key affected populations. However, who is most affected by HIV differs between countries.3
Men who have sex with men accounted for 49% of all new HIV infections across the region in 2014.4 HIV testing data from 2014 reported to UNAIDS show men who have sex with men accounted for more than two-thirds of HIV diagnoses in North America and more than half of HIV diagnoses in Western Europe.
In Central Europe, a larger proportion of new diagnoses were attributed to injecting drug use, including nearly a third of diagnoses in 2014 in the Baltic countries of Estonia, Latvia and Lithuania.5
Men who have sex with men (MSM)
Between 2010 and 2014, the number of HIV diagnoses among men who have sex with men increased by 17% in Western and Central Europe and by more than 8% in North America.6
In Western and Central Europe, more than 80% of new HIV infections in 2014 in Hungary, Croatia and Slovenia were among men who have sex with men.7 In contrast, in Latvia, Lithuania and Estonia where people who inject drugs and their sexual partners are most affected by HIV, men who had sex with men accounted for 10% of new HIV infections in 2014. 8
In Western and Central Europe HIV prevalence among men who have sex with men in 2015 was highest in France and Romania (18%), and lowest in Finland (<1%).
Limited regional data on transgender women suggests that HIV prevalence among this key population is also high.9
The UK has seen a steady increase in HIV infections among men who have sex with men – from 2,860 in 2010 to 3,320 in 2015.10 Although men who have sex with men make up around 1% of the UK’s population, this group accounts for an estimated 43% of people living with HIV in the country.11
In the USA, men who have sex with men account for more than two-thirds of all new HIV diagnoses in the country despite representing just 4% of the population.12 If current diagnosis rates do not change, one in six USA-based men who have sex with men will be diagnosed with HIV in their lifetime.
There are significant disparities by race as this equates to one in two African American/black men who have sex with men, one in four Hispanic/Latino men who have sex with men and one in 11 white men who have sex with men.13
Young African American men who have sex with men are at particular risk of HIV. Among all African American people diagnosed with HIV in 2014, an estimated 57% (11,201) were men who have sex with men. Of these, 39% (4,321) were young men (aged 13 to 24).14
In Canada, around 54% of all new HIV infections occurring in 2014 were among men who have sex with men. It is estimated that 6.7% of men who have sex with men were living with HIV at the end of 2014.15
Migrants from sub-Saharan Africa
In Western and Central Europe, 37% of all new HIV infections occurred among migrants in 2014 . Some migrants will have acquired HIV in their home country, however there is evidence that a considerable proportion of infections are acquired post-migration.
A comprehensive evidence review carried out in 2015 found estimates of post-migration HIV infection to range from as low as 2% among sub Saharan Africans who had migrated to Switzerland to 62% among black Caribbean men who have sex with men who had migrated to the UK.16
In the UK around 2,700 of the 6,095 new HIV diagnoses in 2015 occurred in British-born people, with the remaining new diagnoses occurring among migrants to the UK.17
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 antiretroviral treatment (ART) to undocumented migrants living with HIV.
By contrast, Portugal and the UK currently provide treatment, regardless of a person’s immigration status.18
Despite this, many migrants living with HIV in the UK continue to encounter difficulties in accessing HIV treatment, care and support and the provision of HIV treatment for this group remains a politically contentious issue.19
Undocumented migrants find it particularly difficult to register with a local doctor as they are often required to prove their identity and do not understand the country’s treatment entitlement rules or application process.20
African Americans are one of the groups most affected by HIV in the USA. This group accounted for 41% of the total number of people living with HIV in the USA in 2014, despite making up just 12% of the population.21
Moreover, in 2013 AIDS-related illnesses were the sixth leading cause of death among both African American men and women aged 25-34.22
African American men and women in the USA are most likely to be infected with HIV through unprotected sex with a man or by injecting drugs. Other factors, such as heightened levels of poverty, lack of access to adequate healthcare, and stigma surrounding men who have sex with men also increase this group's risk of HIV infection.23
From 2005 to 2014, the number of new HIV diagnoses among African American women fell by 42%, although it is still high compared to women from other racial or ethnic groups. In 2014, an estimated 1,350 Hispanic/Latino women and 1,483 white women were diagnosed with HIV, compared to 5,128 African American/black women.24
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.25
People who inject drugs (PWID)
People who inject drugs (sometimes referred to as PWID) accounted for 15% of all new HIV infections across the region in 2014.26
In the USA heroin use increased among men and women in most age groups and across all income levels, with a total increase of 63% between 2002 and 2013. This trend coincided with an increase in hepatitis C virus infections and new outbreaks of HIV associated with injecting drug use.27
Despite this, the annual number of new HIV diagnoses among people who inject drugs in North America decreased by 26% between 2010 and 2014.
An estimated 8% of new HIV infections in 2014 in the USA were among people who inject drugs.28 Of those living with HIV in the country, around 18% are injecting drug users.29 The majority of people who are living with HIV who inject drugs are African Americans (46%).30
In Canada, an estimated 4.1% of people who inject drugs were living with HIV at the end of 2014.31
Over the last decade, new HIV diagnoses among people who inject drugs in Western and Central Europe have remained fairly stable overall, standing at 4% of all new HIV infections in Western Europe and 9% in Central Europe in 2014.32 This is due to significant efforts in the region to expand harm reduction programmes.
However, while the vast majority of countries in the region have seen HIV prevalence decline or stabilise among people who inject drugs, a number of countries are facing a worsening epidemic among this group. In 2015, the countries with the highest prevalence of HIV infection among people who inject drugs in the region was Estonia (48%), followed by Latvia (27%) and Romania (21%).
In the Czech Republic, where drug use is decriminalised and coverage of harm-reduction services is relatively high, HIV prevalence among people who inject drugs was 0.2% in 2013.33
Outbreaks related to injecting drug use in areas of Greece and Romania led to approximately a 20-fold increase in HIV diagnoses among people who inject drugs in these two countries between 2010 and 2012 which still had an effect on the number of new diagnoses in 2015.34
HIV prevalence among female sex workers in Western Europe is generally thought to be low (1% or less).35
However, higher HIV prevalence rates have been recorded in certain countries. For example, a 2015 study of sex workers in Portugal found reported HIV prevalence of 7.4% among female sex workers.36
A 2013 evidence review found HIV prevalence among female sex workers in Spain to be 13% and high rates among female 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.37 38
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.39
Studies conducted in Belgium, the Czech Republic, Germany and Spain between 2011 and 2015 suggest HIV prevalence among male sex workers to be high.40 For example, the German study found male sex workers were 6.5 times more likely to test positive for a sexually transmitted infection (STI) than their female counterparts.41
In comparison, the 2015 Portugal study mentioned above found HIV prevalence among male sex workers to be 5%, a lower rate than among female sex workers, but 17.6% among transgender female sex workers.42
Data on national HIV prevalence among sex workers in both the USA and Canada is very limited.43
HIV testing and counselling (HTC) in Western and Central Europe and North America
The number of HIV tests performed in Western and Central Europe and the USA continues to steadily increase. However, late diagnosis of HIV, indicated by low CD4 counts, is a major issue. Nearly half of all people in Western and Central Europe diagnosed with HIV in 2014 recorded CD4 counts below 350, and 27% displayed advanced HIV infection (CD4 counts below 200).44
In 2015 the percentage of people diagnosed with HIV with CD4 counts under 350 stood at 54.5% in Italy, 55.7% in Germany, 66.1% in Romania and 65.3% in Lithuania.45
Furthermore, despite increases in testing levels, in 2015 the European Centre for Disease Prevention and Control reported 72% of countries to have HIV testing rates below 50% among men who have sex with men and 36% to have testing rates below 50% among people who inject drugs. Testing rates were better among sex workers with 92% of countries reporting testing rates above 50%.46
In the USA, 13% of people living with HIV are unaware they have the virus.47 Although the proportion of people testing for HIV has increased in recent years it is estimated that only 54% have ever tested for HIV.48
According to the most recent data available (2011–2015), in America between 50% and 75% of both men who have sex with men and people who inject drugs have been tested for HIV.49 Around a third of African Americans have never been tested for HIV.50
In Canada, 25% of people living with HIV are unaware of their status.51 Less than 50% of men who have sex with men have tested for HIV. However, testing rates among people who inject drugs is high at more than 75%.52
HIV prevention programmes in Western and Central Europe and North America
In 2015, 50% to 60% of reporting countries in Western and Central Europe reported high access to harm reduction services, particularly needle and syringe programmes and opioid substitution therapy.53 As a result, the number of people who inject drugs newly diagnosed with HIV has fallen from 2,161 in 2005 to 1,126 in 2014.54
- Needle and syringe programmes (NSPs)
Almost all European countries provide clean injecting equipment at specialised outlets free of charge.55 Most reach the recommended World Health Organization (WHO) target of 200 syringes per person who injects drugs.56
However, Belgium, France and Turkey distribute less than 100 syringes per person.57
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).58
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.59
One study estimated that the availability of clean needles in the USA covered just 18% of drug injections in 2014, including 2.8% coverage by NSPs.60
NSPs are also available in Canada, although coverage varies both between provinces and within provinces themselves.61
- Opioid substitution therapy (OST)
In Europe, an estimated 680,000 people who inject drugs received opioid substitution treatment (OST) in 2014 although numbers have fallen by around 50,000 since 2010.62
Methadone is the most commonly prescribed opioid substitution drug, received by 61% of people enrolled in substitution therapy. A further 37% are treated with buprenorphine-based medications.63
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.64
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 2005.65
All ten Canadian provinces offer methadone maintenance therapy (MMT), however, the number of OST sites is unknown due to a lack of monitoring.66
Pre-exposure prophylaxis (PrEP)
Pre-exposure prophylaxis (often referred to as ‘PrEP’), whereby someone who is at heightened risk of HIV takes antiretroviral drugs before possible exposure to the virus to greatly reduce the risk of transmission, is available in Canada, France and USA. A further 17 European countries were engaged with PrEP trials in 2015.67
As of 2016, issues surrounding which government body should fund PrEP in the UK were affecting people’s ability to access the treatment.68
Reducing HIV-related stigma and discrimination
HIV-related stigma and discrimination is prevalent in the region. For example, a 2014 survey of people living with HIV from 14 European countries found 32% had experienced HIV-related discrimination in the past three years. Almost half of these cases (46%) were linked to healthcare settings.69
As of 2016, Belarus, Estonia, Germany, Moldova, Poland, Portugal, Ukraine, the UK have all participated in the People Living with HIV Stigma Index, which measure and detects changing trends in relation to stigma and discrimination. Both Canada and the USA have formed survey implementation teams but are yet to report findings.70
Eliminating stigma and discrimination is an important objective of the WHO European Action Plan for HIV/AIDS. Several countries in Western and Central Europe include tackling HIV-related stigma and discrimination in their national HIV strategies (e.g. 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, Iceland, Israel and Luxembourg).71
Some countries in Central Europe (e.g. 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.72
Antiretroviral treatment (ART) in Western and Central Europe and North America
An estimated 86% of people living with HIV in Western and Central Europe and North America knew their HIV status in 2015, and around 59% were on ART. This equates to 61% of women and 59% of men living with HIV in the region on ART.73
In 2015, approximately 90% of the people who had initiated ART remained on treatment after 12 months. As a result, nearly half (47%) of all people living with HIV in Western and Central Europe and North America had achieved the viral suppression necessary to greatly reduced the likelihood of HIV transmission.74
In 2016, the WHO’s Regional Office for Europe released a 2016–2021 action plan on HIV/AIDS and viral hepatitis. This adopted 2015 WHO treatment guidelines that all people living with HIV should be started on treatment regardless of CD4 count.75
The plan commits to ensuring that 90% of all people living with HIV know their HIV status, 90% of all people with diagnosed HIV infection receive ART and 90% of all people on ART are virally suppressed by 2030, in line with UNAIDS’ Fast-Track targets.
Other European countries are making significant progress towards these goals. For example, 96% people living with diagnosed HIV in the UK were on treatment in 2015.77
The USA launched the HIV Care Continuum Initiative in 2013 to systematically identify and re-engage people living with HIV on treatment.78 At the same time, thousands of additional people living with HIV in the USA were enrolled in comprehensive health insurance through the implementation of the Health Care and Education Reconciliation Act 2010.79
Early studies of the Act’s affect on the healthcare of people living with HIV in the USA, such as a 2014 study of five states by the Kaiser Family Foundation, suggest that many have used the systems established under the Act to find more affordable and comprehensive health insurance coverage.80
According to the Kaiser Family Foundation, Medicaid was the largest source of insurance coverage for people with HIV in 2014, estimated to cover more than 40% of people with HIV in care.81
As a result of these interventions, around three out of four (74.5%) people newly diagnosed with HIV were linked to ART within one month of diagnosis in 2014 (the most recent data available). This result exceeded the USA’s annual target of 73.9%. However, only 56.5% of newly diagnosed people were retained in HIV care, below the target of 60.0%.82
Canada’s ability to monitor and, ultimately, meet the global UNAIDS 90-90-90 targets is hampered by the fact that provinces and territories are responsible for HIV testing and treatment. The Public Health Agency of Canada is currently engaging with these bodies to enhance the country’s HIV surveillance system. Until this work has been carried out, national data on ART enrolment and retention is limited.83
Barriers to HIV prevention in Western and Central Europe and North America
“HIV is still intrinsically linked with somehow you having done something wrong, because it’s sexually transmitted. I think that we assume that it’s our fault that we got it. That’s the self-judgement of it. If I didn’t have sex, I wouldn’t have HIV, fact.”
- Person living with HIV, HIV Stigma Index UK, 201584
A number of social barriers exist that prevent key affected populations from accessing HIV services.
Language barriers, marginalisation and social exclusion contribute to the HIV vulnerability of migrants. Many also belong to at-risk sub-populations such as asylum seekers, refugees, sex workers and men who have sex with men.85
Female migrants also commonly report sexual harassment, abuse and rape. All these factors contribute to preventing many female migrants accessing vital HIV services.86
A 2015 review of the European MSM Internet Survey, which was conducted in 2010 across 38 European countries, found men who have sex with men who are living in countries with higher levels of stigma had reduced odds of diagnosed HIV and fewer partners, but higher odds of sexual risk behaviour such as having unprotected sex and unmet prevention needs.87
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.88
Both Portugal and Czech Republic have adopted decriminalisation and de-penalisation of drugs for personal consumption. If other countries in the region followed this could encourage people who inject drugs to engage with HIV prevention and treatment services.
Similarly, decriminalisation of sex work could empower women and men engaged in commercial sex work to seek and utilise HIV prevention and treatment services.89
Economic and legal barriers
A lack of funding is a significant barrier to the scale-up of harm reduction programmes in North America. A lack of government support in Canada means these services are largely delivered by local authorities, community organisations and NGOs.90
As the legality of NSPs in the USA is determined by individual states many have underground NSPs or none at all. Punitive laws also discourage some programmes from making their information public.91
In Greece, expansion of NSP services has slowed down because of the country's financial difficulties.92
Currently, the European Region of the International Lesbian, Gay, Bisexual, Trans and Intersex Association (ILGA Europe) ranks the top five EU countries in terms of LGBT rights as Malta, Belgium, UK, Portugal and Norway.93 Of the 21 countries that have legalised same-sex marriage across the world, 13 are situated in Europe.
A further 13 European countries have legalised civil unions or other forms of recognition for same-sex couples. As of 2016, Austria, Germany, Italy, Hungary and Switzerland were considering legislation to introduce same-sex marriage. Same-sex marriage will be enacted in Finland by March 2017.94
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.95
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.96
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 report high proportions of people living with HIV on ART and, as a result, 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 must remain a high priority for the region.
Moreover, gaps in the provision of HIV services remain with key affected populations facing a number of barriers, particularly men who have sex with men. In Western and Central Europe, increasing rates of HIV infection among men who have sex with men suggest that programmes addressing condom use for this group need to be expanded.97 The widespread use of mobile dating apps among men who have sex with men offers opportunities to do just that.98
It is important that countries in this region continue to provide the necessary resources to tackle the epidemic. 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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