HIV/AIDS trends and challenges in the European region

This article reviews how the epidemic has spread differently in parts of Europe, and addresses the synergies between preventing and treating HIV/AIDS in the context of the new global goal of universal access by 2010 to HIV/AIDS prevention, treatment, care and support services for all in need. [ref 3]

WHO and UNAIDS estimate that at the end of 2005, 2.32 (1.56-3.19) million people were living with HIV/AIDS in the 52 countries of the European Region – the majority of these (1.6 million) in the countries of eastern Europe and central Asia.[ref 4] The estimated HIV prevalence in adults now exceeds 1% in three European countries: Estonia, the Russian Federation and Ukraine. [ref 5] Yet the promise of increased access to highly active antiretroviral therapy (HAART) for people in need allows us to develop a comprehensive public health response to the epidemic that fully integrates prevention, treatment, care and support. Evidence indicates that introducing treatment in affected communities can reduce the fear, stigma and discrimination that often surround HIV/AIDS, increase demand for the uptake of HIV testing and counselling, and reinforce prevention efforts [ref 6] HAART also reduces the level of HIV in the body to undetectable levels in many patients. [ref 7] While the virus is never eliminated - and no one is cured - the risk of a person on effective treatment transmitting HIV is greatly reduced. Coupled with strategies to emphasise safer approaches in behaviour towards HIV/AIDS, there will be a considerable impact on the spread of HIV infection.

Western Europe
In western Europe, after a period of relative decline and stability, following peaks in HIV incidence in 1983 (among homosexual men) and 1987/88 (among intravenous drug injectors), the rate of newly diagnosed HIV infection is once again increasing in some countries[ref 8] and has increased greatly for the area as a whole since 2001 (see Fig 1). Persons infected through heterosexual contact increased markedly in 2001 and 2002, mostly due to cases diagnosed in heterosexuals originating from countries with generalised epidemics – mainly countries in sub-Saharan Africa – and where infections were probably acquired in those countries.[ref 9] Western European countries experiencing such increases include, notably, the United Kingdom and Ireland, but also Belgium, Denmark, Germany, Sweden and Switzerland. [ref 10] However, it is not only among heterosexuals that infections have increased. The number of cases among men who have sex with men also increased in western European countries from 2001 to 2003 and again in some countries in 2004. [ref 11] Following the introduction and widespread use of HAART in countries in this region, AIDS incidence (see Fig. 2) and AIDS deaths declined sharply in the mid/late-1990s [ref 12] and continued to fall, albeit with a slight levelling off after 1998. [ref 13] HIV/AIDS is endemic in western Europe and, coupled with recent increases in HIV and AIDS in some western European countries, this raises important concerns about the vulnerability of migrants, increased risky behaviour among homosexual and bisexual men, treatment complacency, weakening government commitment and waning or ineffective preventionefforts.

Central Europe
The overall rates of both newly diagnosed HIV infections and AIDS cases in central Europe remain relatively low and unchanged in recent years. Just over 34,000 HIV infections were reported in this region by early 2006. The majority of all cases are in Romania and Poland. In the same period, 14,869 cases of AIDS and 7,093 AIDS deaths were reported. [ref 14] Trends of newly reported HIV cases (see Fig 1) and of AIDS deaths have stabilized over the past decade, while the numbers of reported AIDS cases have declined slowly in the last six years (see Fig 2). Nevertheless, high levels of risk behaviour coupled with low levels of knowledge and poorly developed prevention and treatment services in some central European countries create the conditions for the spread of HIV/AIDS. [ref 15]

Eastern Europe and Central Asia
The majority of people living with HIV/AIDS in Europe are from countries in eastern Europe and central Asia. Here, overall rates of newly diagnosed HIV infection increased dramatically between 1995 and 2001, mainly among injecting drug users (IDUs). [ref 16] In many eastern European and central Asian countries, more than 80% of reported HIV cases are among IDUs. Well documented epidemics of HIV among IDUs have been reported in Belarus, Estonia, Latvia, Lithuania, Kazakhstan, the Republic of Moldova, the Russian Federation and Ukraine. In some countries in eastern Europe – notably Estonia, Latvia, Russia and Ukraine - the increase in HIV incidence rates are among the highest in the world. By the end of 2005, the Russian Federation reported a cumulative total of over 333,332 HIV infections, [ref 17] but only just over 1400 AIDS cases and about 1000 AIDS deaths. In 2002 and 2003 the annual number of new HIV diagnoses in eastern Europe and central Asia declined, [ref 18] but this should not lead to complacency as reported cases greatly underestimate the number of actual cases and the number of new infections in 2004 was still greater than 49,000. Moreover, eastern Europe and central Asia have the highest incidence of tuberculosis and multi-drug resistant tuberculosis in Europe. [ref 19] TB/HIV coinfection is associated with a higher morbidity and mortality among people living with AIDS and increased tuberculosis transmission to the general population. [ref 20]

Antiretroviral therapy
Inequities in access to HIV/AIDS treatment and care are most evident in the inadequate provision of HAART in many European countries. It is estimated that as of the end of 2005, 42 of the 52 countries in the region had ”good“ access, measured as greater than 75% of those in need receiving it. [ref 21] There is an urgent need to scale up access to antiretroviral therapy (ART) especially in eastern European countries (particularly the Russian Federation and Ukraine) where the gaps between treatment access and treatment need are immense, and reported AIDS cases are rapidly increasing (see Fig. 2). Moreover, countries with good access face the challenge of not only maintaining this status but of scaling up to universal access by 2010.

Prevention efforts
Two decades of experience, controlled scientific studies and descriptive case analyses have demonstrated the effectiveness of HIV prevention. HIV prevention strategies can reduce the number of new infections and be cost-effective. There is no one correct way to provide prevention services; on the contrary, countries and cities where prevention has been most successful have responded with a range of interventions or core components, [ref 22] often combining them in an integrated and comprehensive strategic response.

Interventions developed for HIVprevention in infants, for example, provide a unique opportunity to link HIV prevention with treatment and care services for HIV-infected women, infants and other family members. Such interventions are an important entry point for the provision of quality treatment and care, including ART [ref 23]. Nevertheless, the vast majority of people living with HIV/AIDS will need to be reached through other means. In eastern Europe, this implies outreach to IDUs with harm reduction programmes and, where possible, opioid substitution treatment. An important milestone with regard to the latter was the inclusion of methadone and buprenorphine on the WHO Model List of Essential Medicines in 2005.

Challenges to halt and reverse the spread of HIV
Access to HIV/AIDS treatment offers new opportunities as well as new imperatives for strengthening prevention efforts. [ref 24] In some wealthy countries with wide access to treatment, a resurgence in risky behaviour and rising rates of some sexually transmitted infections have been seen in specific populations – for example in men who have sex with men in western Europe. [ref 25] Inaccurate and unrealistic perceptions of the benefits of treatment must not be allowed to undermine prevention efforts. Better information and counselling are needed to ensure that the beneficial preventive effect of HAART – reducing stigma and increasing demand for testing and counselling – are not lost. These messages must be an integral part of any ART programme. Another challenge ahead is to make the most of the synergies between prevention and treatment so that they have a naturally accelerating effect. New, country-specific initiatives are required that emphasise the benefits of knowing one’s HIV status, addressing stigma and discrimination and integrating prevention services with treatment, care and community action. This requires reaching out to vulnerable communities and ensuring that people living with HIV and their communities are meaningfully engaged in shaping and scaling up a comprehensive response to the epidemic. Finally, an unbiased analysis of the epidemiological data is a prerequisite for both understanding the extent of the epidemic and the specificities of those affected. [ref 26] Attempts to focus on e.g. a feminisation of the epidemic in Europe or young people as being a particularly affected age group must be held up against the data collated as a part of national case reporting and refuted where incorrect. [ref 27]

Conclusion
It is important to acknowledge that HAART is not a treatment that can be successfully provided without a range of ancillary services and without without adapting, where necessary, existing social and health services. To do this it may also be necessary to influence opinion leaders [ref 28] and change the perceptions of the community at large. To achieve good practice in this field it is essential to have reliable situation assessments, good data, pragmatic approaches to prevention, treatment, care and support services, and the employment of multiple strategies that lead to integrated and comprehensive approaches. There is a growing demand for the development of approaches to ensure access to prevention and treatment interventions for men and women from vulnerable groups such as injecting drug users, ethnic minorities, migrants, refugees, sex workers and trafficked women, who often come to antenatal care or other services too late to benefit from available interventions. Linkages must be established between mainstream health services, harm reduction programmes and programmes for marginalized groups, and there are ample examples of how this can be achieved. [ref 29] Several other impeding issues in Europe which need to be urgently addressed include:

• increasing access to HAART, harm reduction services and opioid substitution treatment for injecting drug users;

• strengthening counselling and testing services for pregnant women and HIV-positive women of childbearing age;

• capacity building and the training of health care workers on harm reduction, PMTCT interventions and concomitant counselling needs;

• the improvement of surveillance, monitoring and evaluation; and

• addressing the sexual and reproductive health of people living with HIV/AIDS.

Contact Jeffrey Lazarus:

[jla@euro.who.int] for more information on HIV/AIDS in the European Region and the role of WHO.

An earlier version of this article appeared in Choices magazine, December 2004.

Authors:
Jeffrey V. Lazarus is the advocacy and community relations officer in the WHO/Europe Sexually transmitted infections/HIV/AIDS programme. He is also on the board of the Danish member association of IPPF, and a lecturer at Lund University and Copenhagen University.

Martin Donoghoe is an adviser on HIV/AIDS, injecting drug use and harm reduction at the WHO/Europe Sexually transmitted infections/HIV/ AIDS programme. His previous appointments include that of associate director for the Open Society Institute’s International Harm Reduction Development Program and as a scientist with WHO in the Programme on Substance Abuse.

Srdan Matic is the regional advisor of the WHO/Europe Sexually transmitted infections/HIV/AIDS programme. From 1998 to 2001 he was the director of public health programs at the Open Society Institute/Soros Foundation.

Notes
1 World Bank (2003). Averting AIDS Crises in Eastern Europe and Central Asia Washington: World Bank.

2 Matic S, Lazarus JV, Donoghoe MC (eds, 2006). HIV/AIDS in Europe: Moving from Death Sentence to Chronic Disease Management. Copenhagen, WHO Regional Office for Europe.

3 World Health Organization. http://www.who.int/hiv/universalaccess2010/en/ (accessed 27 April 2006)

4 UNAIDS (2005). AIDS Epidemic Update, December 2005. Geneva, UNAIDS/WHO.

5 UNAIDS (2004). Report on the Global AIDS Epidemic: 4th Global Report. Geneva, UNAIDS.

6 Global HIV Prevention Working Group (2004). HIV Prevention in the Era of Expanded Treatment Access. www.gatesfoundation.org (accessed 5 April 2006).

7 Porco TC, Martin JN, Page-Shafer KA, et al (2004). Decline in HIV infectivity following the introduction of highly active antiretroviral therapy AIDS 18(1):81-8.

8 European Centre for the Epidemiological Monitoring of AIDS (EuroHIV, 2005). HIV/AIDS Surveillance in Europe End-year Report 2004. Saint Maurice: Institut de Veille Sanitaire. No. 71.

9 Hamers FF, Downs AM (2004). The changing face of the HIV epidemic in western Europe: what are the implications for public health policies? Lancet 364:83-94.

10 Ibid.

11 European Centre for the Epidemiological Monitoring of AIDS (EuroHIV, 2005). HIV/AIDS Surveillance in Europe End-year Report 2004. Saint Maurice: Institut de Veille Sanitaire. No. 71.

12 Mocroft A, Brettle R, Kirk O, et al. (2002). Changes in the cause of death among HIV positive subjects across Europe: results from the EuroSIDA study AIDS 16:1663-71

13 WHO Regional Office for Europe. European health for all database, www.euro.who.int/hfadb (accessed 27 April 2005).

14 Sexually transmitted infections/HIV/AIDS programme. WHO/ Europe survey on HIV/AIDS and antiretroviral therapy: 31 March 2006 update of cumulative totals. Copenhagen, WHO Regional Office for Europe, 2006.

15 Hamers FF, Downs AM (2003). HIV in Central and Eastern Europe. Lancet 361:1035-1046.

16 Ibid.

17 AIDS Foundation East-West (AFEW). http://www.afew.org/english/countries/russia.php (accessed 27 April 2006)

18 European Centre for the Epidemiological Monitoring of AIDS (EuroHIV, 2005). HIV/AIDS Surveillance in Europe End-year Report 2004. Saint Maurice: Institut de Veille Sanitaire. No. 71.

19 World Health Organization (2002). ”DOTS Expansion Plan to Stop TB in the WHO European Region 2002-2006.“ Copenhagen, WHO Regional Office for Europe.

20 Corbett EL et al (2003). The growing burden of tuberculosis: global trends and interactions with HIV epidemic. Archives of Internal Medicine, 163:1009-1021.

21 WHO Regional Office for Europe, Sexually transmitted infections/HIV/AIDS Programme (2006). Unpublished data.

22 World Health Organization (2003). Global Health-Sector Strategy for HIV/AIDS 2003-2007: Providing a Framework for Partnership and Action Geneva, WHO.

23 World Health Organization Regional Office for Europe (2004). Strategic Framework for the Prevention of HIV Infection in Infants in Europe. Copenhagen: WHO.

24 Global HIV Prevention Working Group (2004). HIV Prevention in the Era of Expanded Treatment Access. www.gatesfoundation.org (accessed 5 April 2006).

25 Hamers FF and Downs AM (2004). The changing face of the HIV epidemic in western Europe: what are the implications for public health policies? Lancet 364:83-94.

26 Matic S, Lazarus JV, Donoghoe MC (eds, 2006). HIV/AIDS in Europe: Moving from Death Sentence to Chronic Disease Management. Copenhagen, WHO Regional Office for Europe.

27 Lazarus JV, Bollerup A, Matic S (2006). HIV/AIDS In Eastern Europe: More than a Sexual Health Crisis. Central and Eastern European Journal of Public Health, In print.

28 Donoghoe MC, Lazarus JV and Matic S (2005). ”HIV/AIDS in the Transitional Countries of Eastern Europe and Central Asia“. Clinical Medicine 5:487-90

29 Liljestrand J, Bryld J, Lazarus JV, Østergaard LR (2005). HIV/AIDS and Sexual and Reproductive Health and Rights: A manual for NGOs

EATN - European AIDS Treatment News, Volume 15, I – Spring 2006

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