HIV in Europe between progress and disparities in the fight against the virus

In 2025, HIV is no longer a global health emergency, but remains an accurate indicator of inequality. This can be clearly seen in the European Union, where the battle against the virus is being played out on two opposing fronts: on the one hand the advanced and widespread prevention of countries such as Spain, and on the other the structural fragilities of south-eastern Europe, where stigma, bureaucracy and migration flows continue to slow down progress.

Europe as a whole has drastically reduced new infections over the last ten years. But beneath the surface of the data lies a rift that is not only health-related: it is political, economic and cultural. In the centres of Athens and Sofia, where infectious wards operate at the limit of resources, doctors speak of a ‘silent emergency’. In Madrid, on the other hand, health authorities celebrate the 60% drop in new cases in a decade and the arrival of PrEP in pharmacies.

Meanwhile, cuts in international funding and growing migratory pressure risk reversing the trend in precisely the most exposed countries. HIV, today, is less a disease and more a litmus test of the European health system: where welfare holds, the virus retreats; where the meshes of care are loosened, it advances again.

Greece: between migration, stigma and bureaucracy

In Greece, HIV is intertwined with the migration crisis and an already fragile healthcare system. According to official data from the National Public Health Organisation, there were 650 new diagnoses in 2024, and almost 40 per cent of them involve people of non-Greek origin, mainly from sub-Saharan Africa and Eastern Europe. More than half of the positive migrants – 55% – come to treatment at an advanced stage, when the infection has already compromised the immune system. “The problem is not only access to treatment, but the delay in connecting patients to specialised centres, especially in refugee camps on islands,” explains Dr Giota Lourida, infectious diseases specialist at the Evaggelismos Hospital in Athens.

Greece also provides free anti-retroviral therapy to undocumented migrants, but many remain in a ‘grey zone’: they lose access to the healthcare system once their asylum application is rejected, and can only receive basic medication, not complementary treatment.

Recent laws facilitating arrests and repatriations for those who remain in the country after their permits have been revoked exacerbate the situation: ‘It is almost impossible to ensure a continuous course of treatment,’ says Dr Konstantinos Protopapas, an HIV specialist at Attikon Hospital. ‘And when they do manage to access treatment, they often leave for other European countries without leaving a medical trail or a supply of drugs.

The introduction of pre-exposure prophylaxis (PrEP), approved by parliament in 2022, only became a reality in May 2025, but remains accessible only in 24 hospital pharmacies – 17 of them in Athens – making prevention in rural areas and islands almost impossible.

Bulgaria: free care but deep-rooted stigma

In Bulgaria, treatment is modern and free for everyone, insured or not. Over 2,600 people with HIV are now in the care of health centres, with 99% being treated. Yet the social burden of infection remains enormous.

A survey conducted by the institute ‘Trend’ for the association Health Without Borders photographs a country where only a quarter of citizens would be willing to have an HIV-positive friend, and just 3% would agree to marry one. Less than 20% know about PrEP, and barely 21% know that those on treatment can have healthy children.

“Medicine has made great strides,” explains Professor Nina Yancheva, director of the Sofia Hospital for Infectious Diseases, “but social prejudice runs faster than science.

Bulgaria records between 200 and 300 new cases per year, an incidence lower than the EU average. However, specialised centres, such as the one in Sofia, are working at the limit: ‘We follow more than 1,600 patients,’ Yancheva adds, ‘and the chronic shortage of nursing staff puts the continuity of care at risk.

Croatia: few cases, but too many late arrivals

In Croatia, HIV remains at a low level – 58 new cases in 2024, with an incidence of 2.3 per 100,000 inhabitants, against a European average of 5.3 -, but six out of 10 diagnoses occur at an advanced stage.

According to the Croatian Institute of Public Health, almost 40 per cent of people who started treatment in 2024 already had a known diagnosis abroad. A sign that migration, again, has a strong influence. Qualitative surveys show that more than experienced discrimination, the fear of stigmatisation prevails – a fear that holds back testing and access to services.

Spain: the European model of prevention

In Spain, however, the trajectory is opposite. From 2013 to 2023, new diagnoses dropped by 60% to 3,196 cases. Fifty-five per cent involve men who have sex with men, but the most affected group remains the 25-34 age group.

The Spanish success is the result of an integrated approach: PrEP is available throughout the country, now also in pharmacies, together with free condom distribution and widespread awareness campaigns.

‘We have no cuts in either prevention or treatment,’ explains Dr María Velasco, spokesperson for the Spanish Society of Infectious Diseases. Our patients have universal access to treatment and diagnoses are decreasing’.

The unresolved issue remains the diagnostic delay, which mainly affects women, the elderly and foreigners. ‘In part,’ Velasco adds, ‘because many migrants get infected here, not before they arrive. We need prevention strategies for them too’.

The Netherlands: towards the goal of ‘zero new infections

The Netherlands is also among the European leaders in the response to HIV. In 2023, some 424 new diagnoses were registered, with a curve now close to stabilisation and rates among the lowest in the European Union. According to the Stichting HIV Monitoring report 2024, more than 96% of people on treatment have achieved viral suppression, a result that guarantees not only individual health but also the non-transmissibility of the virus.

Amsterdam, in particular, has become a case study: thanks to an integrated approach of widespread testing, immediate access to treatment and PrEP programmes, the city is close to its goal of ‘zero new infections’, with an 85% drop since 2010.

Italy: clinical advances, delays in diagnosis

In Italy, the fight against HIV is marked by a paradox: universal access to treatment is guaranteed, but diagnosis still comes too late. According to the latest report of the Istituto Superiore di Sanità, around 1,900 new diagnoses were notified in 2023, equivalent to 4 cases per 100,000 inhabitants, a figure that is steadily declining but with 60 per cent late diagnoses. It is also estimated that between 13 and 15 thousand people are living with the infection without knowing it.

Antiretroviral therapy is free and widely available, with viral suppression rates among the highest in Europe. However, prevention remains the weak point: PrEP is only accessible in some regions, and the HIV test, although free and anonymous, is often linked to bureaucratic routes that discourage spontaneous screening.

Experts emphasise the need for more widespread testing strategies, campaigns targeting young people and vulnerable groups, and a cultural change that overcomes the stigma that is still ingrained, especially in less informed segments of the population.

Global cuts, local risks

Meanwhile, the European context is moving in a climate of uncertainty. Cuts in international funding – from PEPFAR to UNAIDS – are also likely to have indirect effects in Europe. According to a 2025 UNAIDS estimate, the 24% reduction in global funding could cause up to 10 million new infections and nearly 3 million additional deaths by 2030.

‘The effects will also be seen here,’ warns Dr Lourida from Athens. Greek NGOs working with migrants are already reducing their testing and prevention programmes. It is a vicious circle: less diagnosis, more infections’.

The goal set by UNAIDS – to bring new infections to zero by 2030 – seems more distant today. Europe, even with its successes, remains an uneven patchwork, where geography and income still determine the possibility of living (and living) with HIV. As Protopapas reminds us, ‘as long as the fight against HIV remains confined to specialists and does not become a cultural battle, we will continue to chase the emergency instead of preventing it’.

*This article is part of the European collaborative journalism project “Pulse” and was contributed by Kostas Zafeiropoulos (Efsyn, Greece), Martina Bozukova (Mediapool, Bulgaria), Francisco Sánchez Becerril (El Confidencial, Spain) and Marina Kelava (H-Alter.org, Croatia).

By Silvia Martelli