Presentation from the opening session of the 17th European AIDS Conference (EACS) 2019, Basel, Switzerland. Presenter: Anastasia Pharris, European Centre for Disease Prevention and Control.

1. 90-90-90 Goals in Europe: In Action
Anastasia Pharris
European Centre for Disease Prevention and Control (ECDC)
6 November 2019

2. Employed by ECDC
No disclosures

3. Is the European Region on track to end AIDS by 2030?
What do the 90-90-90 targets tell us about where the
European response needs strengthening?
What is the status of HIV epidemiology in the region?

4. 160 000 people were diagnosed with HIV in 2017
WEST
14%
≈ 22,000 cases
Rate = 6.9/100,000
CENTRE
4%
≈ 6,200 cases
Rate = 3.2/100,000
EAST
82%
≈ 131,000 cases
Rate = 51.1/100,000
Source: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2018– 2017 data @ECDC_HIVAIDS

5. 300 000 people in the region have contracted HIV
since EACS 2017
Source: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2018– 2017 data @ECDC_HIVAIDS
2.2 million people are living with HIV
in the WHO European Region

6. Estimated new HIV infections are decreasing globally
and in the Western sub-region
but increasing in the European region
@ECDC_HIVAIDS
Global
East
West
Centre
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
NewHIVinfections(Europe)
NewHIVinfections(global)
Year
Source: UNAIDS 2019
-23%

7. Estimated new HIV infections are decreasing globally
and in the Western sub-region
but increasing in the European region
@ECDC_HIVAIDS
Global
East
West
Centre
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
NewHIVinfections(Europe)
NewHIVinfections(global)
Year
Source: UNAIDS 2019
-30%
-23%

8. Countries with declines in the rate of new HIV diagnoses in
men who have sex with men, 2008-2017
Source: ECDC/WHO (2018). HIV/AIDS Surveillance in Europe 2018– 2017 data
0
2
4
6
8
10
12
14
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
RateofnewdiagnosesinMSMper100000malepopulation
Year of diagnosis
Belgium
Greece
Luxembourg
Netherlands
Spain
United Kingdom
Switzerland
@ECDC_HIVAIDS

9. Estimated new HIV infections decreasing in the Western
sub-region but increasing in Centre and East
but increasing in the European region
@ECDC_HIVAIDS
WHO
European
Region
Global
East
West
Centre
-30%
+125%
+60%
-23%
Source: UNAIDS 2019

10. Estimated new HIV infections decreasing in the Western
sub-region but increasing in Centre and East
and overall in the European region
@ECDC_HIVAIDS
WHO
European
Region
Global
East
West
Centre
-30%
+125%
+60%
+45%
-23%
Source: UNAIDS 2019

11. @ECDC_HIVAIDS
Transmission risk pattern differs by sub-region
45% born
abroad
47% born
abroad
10% born
abroad
1% born
abroad
Source: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2018– 2017 data
HETERO
♂
MSM
HETERO
♀
MSM
IDU
HETERO
♂
HETERO
♀
IDU
MSM
HETERO
♂
HETERO
♀
IDU

12. 3 groups where HIV incidence is increasing

13. Men who have sex with men in Centre and East
+90%
+530%
-16%
Source: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2018– 2017 data @ECDC_HIVAIDS

14. +160%
+1%
- 47%
+105%
Source: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2018– 2017 data
+160%
+1%
- 47%
+105%
@ECDC_HIVAIDS
Heterosexual men and women in East in older age groups

15. Between 1/3-2/3 of
migrants acquired HIV
post-migration
MSM migrants were
particularly affected with
and 40%-72% estimated
to have acquired HIV
post-migration
Source: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2018– 2017 data;
Alvarez del-Arco, et al. High levels of post-migration HIV acquisition within nine European countries. AIDS, 2017;
Zheng et al. Post migration acquisition of HIV: Estimates from four European countries. 2017. Submitted to peer-reviewed journal. @ECDC_HIVAIDS
Migrants: Intra-European and those who acquired HIV post-
migration
0
2,000
4,000
6,000
8,000
10,000
12,000
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
NewHIVdiagnoses
Year
Migrants from outside of Europe Migrants from within Europe

16. Is the European Region on track to end AIDS by 2030?
What do the 90-90-90 targets tell us about where the
European response needs strengthening?
What is the status of HIV epidemiology in the region?

17. 73%
of all people living
with HIV
VIRALLY
SUPPRESSED
=
Target 1 Target 2 Target 3
diagnosed with HIV
ON ART
living with HIV
DIAGNOSED
on ART
VIRALLY
SUPPRESSED
Overall target
Fast Track Targets by 2020

18. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Target reached Above regional average Below regional average
Progress toward achieving the 1st 90:
90% of all PLHIV who know their status (n=43 countries)
Global target 90%
Overall percentage 80%
Source: Dublin Declaration data 2019, unpublished. @ECDC_HIVAIDS

19. Rate of undiagnosed HIV varies across the region
Source: Dublin Declaration data 2019, unpublished. @ECDC_HIVAIDS
438 000 people
living with
undiagnosed
HIV in Europe

20. Is the number of people living with undiagnosed HIV in the
WHO European region declining?
0
500000
1000000
1500000
2000000
2500000
2015 2016 2017 2018
Estimatednumberofindividuals
Year
Diagnosed
Undiagnosed
Source: UNAIDS Estimates and Global Monitoring, 2019
@ECDC_HIVAIDS
Reduction of
undiagnosed by
100,000!

21. Time from HIV infection to diagnosis in the EU/EEA
Source: van Sighem Ard, Pharris Anastasia, Quinten Chantal, Noori Teymur, Amato-Gauci Andrew J. Reduction in undiagnosed HIV infection in the
European Union/European Economic Area, 2012 to 2016. Euro Surveill. 2017;22(48):pii=17-00771.
Median time from infection
to diagnosis is 2.9 years
@ECDC_HIVAIDS

22. 53%
*Diagnosed late=CD4<350 cells/mm3 at diagnosis,
infections reported as acute are excluded
Proportion of people diagnosed late*,
WHO European Region, 2017
Age group TransmissionSub-region Gender
@ECDC_HIVAIDSSource: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2018– 2017 data

23. Urgent need to strengthen testing programmes
Effective and recommended
approaches to increasing
testing uptake and earlier
diagnosis
Antenatal screening
Sexual health clinics
Provider-initiated
testing in health
care settings
Community testing
Partner notification
Indicator condition
testing
Self-testing/
self-sampling
Pharmacies
Prisons
@ECDC_HIVAIDS
Low coverage in most
countries
resulting in missed
opportunities for early HIV
diagnosis.

24. 73%
of all people living
with HIV
VIRALLY
SUPPRESSED
=
Target 1 Target 2 Target 3
diagnosed with HIV
ON ART
living with HIV
DIAGNOSED
on ART
VIRALLY
SUPPRESSED
Overall target
Fast Track Targets by 2020

25. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Progress toward achieving the 2nd 90:
90% of those diagnosed on ART (n=45 countries)
Target reached Above regional average Below regional average
Global target 90%
Overall percentage 65%
Source: Dublin Declaration data 2019, unpublished. @ECDC_HIVAIDS

26. 4
29
48
16
10
5
28
8
1
1
0
5
10
15
20
25
30
35
40
45
50
55
2014 2015 2016 2018
Nrofcountries/ARTpolicy
200 cells/mm3
350 cells/mm3
500 cells/mm3
Initiation regardless
of CD4 count
ART initiation policies in European countries
2014 (n=49), 2016 (n=47), 2018 (n=54)
Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data. @ECDC_HIVAIDS

27. Evidence of increased ART coverage in the European Region
0
200000
400000
600000
800000
1000000
1200000
1400000
1600000
2015 2016 2017 2018
Estimatednumberofindividuals
Year
Source: UNAIDS Estimates and Global Monitoring, 2019
On ART
Not on ART
@ECDC_HIVAIDS
440,000 more people
on ART since 2015
~1 million people
remain untreated

28. Linkage to HIV care* by sub-region, 2017
*Linkage to HIV care=time between diagnosis date and first CD4 date; those with missing
data, previously diagnosed positive or died within 91 days of diagnosis are excluded
Source: ECDC/WHO (2018). HIV/AIDS Surveillance in Europe 2018– 2017 data
@ECDC_HIVAIDS

29. 73%
of all people living
with HIV
VIRALLY
SUPPRESSED
=
Target 1 Target 2 Target 3
diagnosed with HIV
ON ART
living with HIV
DIAGNOSED
on ART
VIRALLY
SUPPRESSED
Overall target
Fast Track Targets by 2020

30. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Progress toward achieving the 3rd 90:
90% of those on ART virally suppressed (n=38 countries)
Target reached Above regional average Below regional average
Global target 90%
Overall percentage 86%
Source: Dublin Declaration data 2019, unpublished. @ECDC_HIVAIDS

31. 73%
of all people living
with HIV
VIRALLY
SUPPRESSED
=
Target 1 Target 2 Target 3
diagnosed with HIV
ON ART
living with HIV
DIAGNOSED
on ART
VIRALLY
SUPPRESSED
Overall target
Fast Track Targets by 2020

32. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Progress toward achieving the overall target:
73% of all PLHIV virally suppressed (n=36 countries)
Target reached Above regional average Below regional average
Global target 73%
Overall percentage 44%
Target needed?
Source: ECDC, Dublin Declaration data 2019, unpublished. @ECDC_HIVAIDS

33. Evidence of increase in people living with supressed viral load
0
200000
400000
600000
800000
1000000
1200000
1400000
1600000
2015 2016 2017 2018
Estimatednumberofindividuals
Year
Viral load
suppressed
Viral load not
suppressed
Source: UNAIDS Estimates and Global Monitoring, 2019
@ECDC_HIVAIDS
~1.2 million people
living with
unsuppressed virus in
Europe

34. Undiagnosed
Diagnosed but
not on treatment
Treated but not
virally supressed
WEST
N ≈ 195,000
CENTRE
N ≈ 20,000
EAST
N ≈ 990,000
52%
31%
41%
28%27%
21%
56%
33%
11%
N ≈ 1,200,000
People living with
unsuppressed virus
Distribution of people with transmissible levels of
virus by sub-region, reported in 2019
Source: ECDC Dublin Declaration data 2019, unpublished. @ECDC_HIVAIDS

35. 100%
86%
78% 75%
100%
90%
50%
39%
100%
84%
75% 71%
100%
87%
77%
70%
100%
86%
75%
67%
100%
88%
81%
76%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Living with
HIV
Diagnosed Receiving
ART
Virally
suppressed
Living with
HIV
Diagnosed Receiving
ART
Virally
suppressed
Living with
HIV
Diagnosed Receiving
ART
Virally
suppressed
MSM (n=10) PWID (n=8) Migrants (n=5)
Comparison of the continuum of care for key populations
against the general population continua, 2018
@ECDC_HIVAIDS
Source: ECDC. Continuum of HIV Care. Monitoring implementation of the Dublin Declaration on partnership to fight HIV/AIDS in Europe and Central
Asia: 2018 progress report.. https://www.ecdc.europa.eu/sites/default/files/documents/HIV-continuum-of-care-monitoring-dublin-declaration-
progress-report-2018.pdf

36. Opioid substitution therapy (OST) provision in
Europe and Central Asia
Source: ECDC. HIV and PWID. Monitoring implementation of the Dublin Declaration on partnership to fight HIV/AIDS in
Europe and Central Asia: 2018 progress report Stockholm: ECDC; 2019.
Coverage <40% is not
sufficient to reduce
drug-related harm
@ECDC_HIVAIDS

37. Source: ECDC. HIV and PWID. Monitoring implementation of the Dublin Declaration on partnership to fight HIV/AIDS in
Europe and Central Asia: 2018 progress report Stockholm: ECDC; 2019.
Average number of needles/syringes provided per
person who injects drugs, Europe and Central Asia
Coverage of 200 n/s
per PWID
recommended
@ECDC_HIVAIDS

38. Is the European Region on track to end AIDS by 2030?
What do the 90-90-90 targets tell us about where the
European response needs strengthening?
What is the status of HIV epidemiology in the region?

39. Global ART coverage = 62%
Source: ECDC, Dublin Declaration data 2019, unpublished. @ECDC_HIVAIDS
90%
81%
73%
Are we on track to reach the 90-90-90 targets by 2020?

40. Source: ECDC, Dublin Declaration data 2019, unpublished. @ECDC_HIVAIDS
90%
81%
73%
Are we on track to reach the 90-90-90 targets by 2020?

41. 90%
81%
73%
Are we on track to reach the 90-90-90 targets by 2020?
Source: ECDC, Dublin Declaration data 2019, unpublished. @ECDC_HIVAIDS

42. Are we on track to meet the 2020 targets?
FAST-TRACK TARGET:
75% reduction in new
infections by 2020
(baseline 2010)
WHO
European
Region
East
West
Centre
@ECDC_HIVAIDS
Reaching target would require
105,000
fewer
infections
6,800
fewer
infections
12,000
fewer
infections
122,000
fewer
infections

43. Treatment
gap
Testing
gap
Prevention
gap
1 in 2 PLHIV in Europe
are NOT on ART
 1 in 5 PLHIV in Europe are
unaware of their HIV status
 Low coverage of testing
 1 in 2 people are diagnosed late
Harm reduction
PrEP
Condoms
Europe will not meet the 2020 targets unless we address
these gaps
@ECDC_HIVAIDS

44. Acknowledgements
HIV Surveillance focal points in Europe and Central Asia
Albania: Marjeta Dervishi; Andorra: Jennifer Fernández Garcia; Armenia: Trdat Grigoryan; Austria: Daniela Schmid, Ziad El-Khatib; Azerbaijan: Farhad Singatulov, Shahin Khasiyev; Belarus: Svetlana Sergeenko,
Pavel Yurovski; Belgium: Andre Sasse, Dominique Van Beckhoven; Bosnia and Herzegovina: Dušan Kojić; Bulgaria: Tonka Varleva; Croatia: Tatjana Nemeth Blazic; Cyprus: Linos Hadjihannas, Maria Koliou; Czech
Republic: Marek Maly; Denmark: Susan Cowan; Estonia: Kristi Rüütel; Finland: Kirsi Liitsola, Mika Salminen; France: Françoise Cazein, Josiane Pillonel, Florence Lot; Georgia: Otar Chokoshvili, Maia Tsereteli;
Germany: Barbara Gunsenheimer-Bartmeyer; Greece: Vasilios Raftopoulos, Stavros Patrinos; Hungary: Maria Dudas; Iceland: Haraldur Briem, Gudrun Sigmundsdottir; Ireland: Derval Igoe, Kate O’Donnell;
Israel: Daniel Chemtob, Yana Roshal; Italy: Barbara Suligoi; Kazakhstan: Lolita Ganina, Gulnar Temirkhanov; Kyrgyzstan: Aigul Solpueva; Latvia: Šarlote Konova; Liechtenstein: Andrea Leibold, Marina Jamnicki;
Lithuania: Irma Čaplinskienė; Luxembourg: Aurelie Fischer, Jean-Claude Schmit; Malta: Jackie Maistre Melillo, Tanya Melillo; Republic of Moldova: Silvia Stratulat, Stepan Gheorghita; Monaco: Dominique De
Furst; Montenegro: Alma Cicic; Netherlands: Eline Op de Coul, Ard van Sighem; North Macedonia: Milena Stefanovic, Zarko Karadzovski, Vladimir Mikic, Rumena Gerdovska; Norway: Hans Blystad; Poland:
Magdalena Rosinska; Portugal: Isabel Aldir, Helena Cortes Martins; Romania: Mariana Mardarescu; Russia; San Marino: Andrea Gualtieri, Mauro Fiorini; Serbia: Danijela Simic; Slovakia: Peter Truska; Slovenia:
Irena Klavs, Tanja Kustec, Maja Milavec; Spain: Asuncion Diaz; Sweden: Maria Axelsson; Switzerland: Martin Gebhardt; Tajikistan: Kholnazarov Ramshed, Zukhra Nurlaminova; Turkey: Emel Özdemir Şahin;
Ukraine: Ihor Kuzin, Violetta Martsynovska; and United Kingdom: Valerie Delpech. Also Kosovo: Luljeta Gashi
Dublin Declaration Advisory Group
Kristi Ruutel (Estonia), Daniela Rojas Castro (France), Gesa Kupfer (Germany), Caroline Hurley (Ireland), Silke David (Netherlands), Arild Johan Myrberg (Norway), Isabel Aldir, Daniel Simoes (Portugal),
Sladjana Baros (Serbia), Irene Klavs (Slovenia), Gabrella Hok (Sweden), Valerie Delpech, Alison Brown, Cary James (United Kingdom), Olga Varetska (Ukraine), Jean-Luc Sion (European Commission),
Dagmar Hedrich (EMCDDA), Taavi Erkkola, Kim Marsh (UNAIDS), Annemarie Stengaard (WHO Euro), Jordi Casabona (INEGRATE), Axel J. Schmidt (ESTICOM), Annabelle Gourlay, Kholoud Porter
(EuroCoord).
Dublin Declaration focal points in Europe and Central Asia
Cotelnic (Moldova), Alma Cicic, Aleksandra Marjanovic (Montenegro), Silke David (Netherlands), Arild Johan Myrberg (Norway), Anna Marzec- Bogusła(Poland), Roland Bani (Albania), Jennifer Fernández
Garcia (Andorra), Samvel Grigoryan, Arshak Papoyan (Armenia), Irene Rueckerl, Bernhard Benka, Robert Zangerle (Austria), Esmira Almammadova, Natig Zulfugarov (Azerbaijan), Inna Karabakh (Belarus),
Andre Sasse, Dominique Van Beckhoven (Belgium), Dušan Kojić, Indira Hodžić (Bosnia and Herzegovina), Tonka Varleva (Bulgaria), Jasmina Pavlic (Croatia), Ioannis Demetriades (Cyprus), Veronika
Šikolová, Hana Janatova (Czech Republic), Jan Fouchard & Susan Cowan (Denmark), Kristi Rüütel, Liilia Lõhmus, Anna-Liisa Pääsukene (Estonia), Henrikki Brummer-Korvenkontio (Finland), Bernard Faliu
(France), Maia Tsereteli, Otar Chokoshvili, Ana Aslanikashvili (Georgia), Gesa Kupfer, Ulrich Marcus, (Germany), Dimitra Paraskeva, Vasilios Raftopoulos, Stavros Patrinos, (Greece), Maria Dudas, Katalin
Szalay (Hungary), Guðrún Sigmundsdóttir, Þórólfur Guðnason (Iceland), Caroline Hurley, Fiona Lyons, Derval Igoe, Helen Deely, (Ireland), Daniel Chemtob, Yana Roshal (Israel), Anna Caraglia, Francesco
Maraglino, Barbara Suligoi, Lella Cosmaro, (Italy), Alla Yelizarieva, Aliya Bokazhanova (Kazakhstan), Laura Shehu, Pashk Buzhala (Kosovo*), Aikul Ismailova, Nazgul Asylalieva (Kyrgyzstan), Šarlote Konova
(Latvia), Andrea Leibold, Marina Jamnicki Abegg (Liechtenstein), Irma Caplinskiene (Lithuania), Patrick Hoffman, Pierre Weicherding (Luxembourg), Milena Stefanovic, Vladimir Mikic (FYROM), Jackie
Maistre Melillo (Malta), Iulian Oltu, Svetlana Popovici, Tatiana wska, Iwona Wawer, Piotr Wysocki, Magdalena Rosinska (Poland), Isabel Aldir, Teresa Melo (Portugal), Mariana Mardarescu, Adrian
Streinu-Cercel (Romania), Danijela Simic, Sladjana Baros (Serbia), Jan Mikas, Peter Truska, Helena Hudecová, (Slovakia), Irena Klavs, Janez Tomažič (Slovenia), Begona Rodriquez Ortiz de Salazar (Spain),
Louise Mannheimer, Gabriella Hok, (Sweden), Axel J. Schmidt, Sabine Basler (Switzerland), Zukhra Nurlaminova, Sayfuddin Karimov, Dilshod Sayburhonov (Tajikistan), Emel Özdemir Şahin (Turkey),
Valerie Delpech & Alison Brown (United Kingdom), Igor Kuzin (Ukraine) and Zulfiya Abdurakhimova (Uzbekistan).

45. Thank you
ECDC: Teymur Noori, Chantal Quinten, Andrew Amato
WHO Regional Office for Europe: Annemarie Stengaard, Giorgi Kuchukhidze, Nicole Seguy
UNAIDS: Kimberly Marsh, Keith Sabin, Taavi Erkkola
Dublin Declaration consultant team: Rosalie Hayes, Yusef Azad, Cheryl Gower, Alison
Brown, Valerie Delpech
@ECDC_HIVAIDS