From Dublin to Rome: 10 years of the HIV epidemic and response in Europe

From Dublin to Rome: 10 years of the
HIV epidemic and response in Europe

Outline
 Background
 Epidemiological overview
 Key populations
– Men who have sex with men
– Migrants
– People who inject drugs
– Prisoners
– Sex workers
 Late diagnosis
 Treatment
 Conclusions

Political commitments of particular
importance to EU/EEA Member States
2000 UN Millennium Declaration
2001 UN General Assembly Special Session on HIV/AIDS (UNGASS)
2004 Dublin Declaration
2004 Vilnius Declaration
2007 Bremen Declaration
2006
2009
2014
2011 UN General Assembly Resolution: Intensifying Efforts to Eliminate HIV and AIDS
2012 European Action Plan on HIV/AIDS 2012-2015 (WHO Regional Office for Europe)
EU Commission Communication and Action Plan on HIV/AIDS

Monitoring implementation of the Dublin
Declaration
2008 2010
2012

Dublin outputs 2015
Key population reports Evidence briefs Special topic report
Men who have sex with men HIV testing
10-years of responding to
the HIV epidemic in Europe
Migrants MSM and HIV Continuum of HIV care
People who inject drugs HIV prevention
Prisoners HIV treatment
Sex workers
Leadership and
resources
Data gaps in the HIV
response

55 countries covered by the Dublin Declaration
Including the 53 countries of the WHO European Region and Lichtenstein and Kosovo (This designation is without prejudice to positions on status, and is in
line with UNSCR 1244 and the ICJ Opinion on the Kosovo Declaration of Independence)

Response rates: 2014 reporting round
Albania Finland Liechtenstein Serbia
Andorra France Lithuania Slovakia
Armenia Georgia Luxembourg Slovenia
Austria Germany Malta Spain
Azerbaijan Greece Moldova Sweden
Belarus Hungary Monaco Switzerland
Belgium Iceland Montenegro Tajikistan
Bosnia & Herzegovina Ireland Netherlands TFYROM
Bulgaria Israel Norway Turkey
Croatia Italy Poland Turkmenistan
Cyprus Kazakhstan Portugal Ukraine
Czech Republic Kosovo Romania United Kingdom
Denmark Kyrgyzstan Russia Uzbekistan
Estonia Latvia San Marino
Overall submission rate: 49/55 = 89%

Monitoring HIV/AIDS in Europe
Know your epidemic – Know your response

Epidemiological overview
2004–2013

Rate of newly reported HIV diagnoses
EU/EEA vs. non-EU/EEA countries, 2004–2013
Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013; Data from Russia excluded due to incomplete reporting during the period

HIV infections diagnosed, EU/EEA
2004-2013, transmission mode and origin
Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013. Data from Estonia and Poland excluded due to incomplete reporting on
transmission mode during the period; cases from Italy and Spain excluded due to increasing national coverage over the period.

Proportion of HIV diagnoses among natives
and migrants, EU/EEA, 2013
Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013

AIDS related deaths
EU/EEA, 2004-2013
Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2014; Data from Finland, Italy and Sweden
excluded due to incomplete reporting on death during the period

Rate of newly reported HIV diagnoses
EU/EEA vs. non-EU/EEA countries, 2004–2013

HIV infections diagnosed, non-EU/EEA
2004-2013, transmission route
Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 Data from Russia, Turkey, Turkmenistan, Uzbekistan excluded due to
incomplete reporting during the period or incomplete reporting on transmission mode during the period

HIV prevalence among MSM, 2011–2013
Source: ECDC. Thematic report: Men who have sex with men. Monitoring implementation of the Dublin Declaration on
Partnership to Fight HIV/AIDS in Europe and Central Asia: 2014 progress report. Stockholm: ECDC; 2015

Percentage of new HIV diagnoses acquired
through sex between men, 2013
Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2014; Data from Italy and Sweden excluded due
to incomplete reporting on death during the period

Number of new HIV diagnoses among MSM by
year of diagnosis, EU/EEA, 2004–2013
Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2014; Data from Estonia, Italy, Poland, Sweden
excluded due to incomplete reporting during the period

Number of new HIV diagnoses among MSM by
year and age group, EU/EEA, 2004–2013
Pharris A, Spiteri G, Noori T, Amato-Gauci AJ. Ten years after Dublin: principal trends in HIV surveillance in the
EU/EEA, 2004 to 2013. Euro Surveill. 2014 Nov 27;19(47):20968.

Number of new HIV diagnoses among MSM, non-
EU/EEA countries, 2004–2013
Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2014; Data from Russia, Turkey, Turkmenistan, Uzbekistan excluded
due to incomplete reporting during the period or incomplete reporting on transmission mode during the period

Late diagnosis by transmission mode reported by
EU/EEA countries, 2013
Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2014

Reported percentage of condom use
among MSM, 2011–2013

HIV testing among MSM over the last year,
2011–2013

Percentage of countries reporting gaps in HIV
prevention services for different key populations
Key population
Percentage of countries reporting gaps in HIV
prevention services
EU/EEA countries Non-EU/EEA countries
Men who have sex with men 67% 72%
Prisoners 67% 55%
Undocumented migrants 50% 62%
People who inject drugs 46% 65%
Migrants in general 36% 47%
Source: ECDC. Evidence brief: HIV prevention in Europe. Stockholm: ECDC; 2015.

Prevention at scale
EU/EEA countries Non-EU/EEA countries
Yes No Yes No
People who inject drugs 27 3 17 1
Men who have sex with men 23 7 16 2
Prisoners 21 9 18 0
Sex workers 20 10 15 2
Migrants in general 16 12 10 6
Undocumented migrants 9 19 4 10
Governments reporting whether prevention is delivered at the scale required to
meet the needs of the majority of key populations in their programmes
Source: ECDC. Evidence brief: HIV prevention in Europe. Stockholm: ECDC; 2015.

Priority areas for action* (MSM)
1. Address low rates of HIV testing, late diagnosis and the
undiagnosed fraction among MSM
 Expand proven approaches that increase uptake and frequency of
testing and promote earlier testing, e.g. through community-
based testing services
 Target MSM who are most at risk and most likely to have
undiagnosed infection
 Develop and implement country-specific testing guidelines for
MSM
 Address barriers to testing, for example stigma and discrimination
in healthcare settings
*To be taken forward by health policy advisors, implementers, programmatic and surveillance experts, NGOs, etc.

Priority areas for action (MSM)
2. Strengthen and expand prevention programmes for MSM
 Develop and implement targeted prevention interventions for
MSM subgroups at increased risk of HIV, for example younger
MSM
 Scale up programmes to address gaps in coverage and ensure that
MSM have access to comprehensive services (condoms,
lubricants, diagnosis and treatment of other STIs)
 Improve and share evidence about innovative and effective
approaches to HIV prevention among MSM
 Ensure there is sustainable funding and capacity to deliver
prevention programmes for MSM

Priority areas for action (MSM)
3. Improve data availability and data quality with regard to HIV
and MSM
 Collect country-specific data on MSM subgroups that are at
increased risk of HIV infection
 Improve data availability/data quality on risk behaviours, risk-
reduction strategies and factors that limit uptake of services and
preventive measures
 Improve the availability and quality of epidemiological and
behavioural data, for example through joint funding, capacity
building, and harmonised data collection tools

Proportion HIV diagnoses among migrants*,
by country of report, EU/EEA, 2013 (n= 29 157)

Proportion of migrants among all new HIV
diagnoses reported in EU/EEA countries with
known country of origin, 2004–2013
to incomplete reporting during the period

New HIV cases due to heterosexual transmission in
migrants from countries with generalised epidemics
reported by EU/EEA countries, 2004–2013
to incomplete reporting during the period.

Availability of ART for undocumented migrants
living in Europe, 2014
YES
NO
Source: ECDC. From Dublin to Rome: ten years of responding to HIV in Europe and Central Asia: Stockholm, ECDC; 2014

Priority areas for action (Migrants)
1. Strengthen prevention programmes for migrants
 Promote increased uptake of HIV testing among migrants who are
most at risk, in particular migrants from countries with generalised
epidemics and migrant MSM, to reach the undiagnosed and
reduce late diagnosis, including through community-based
approaches
 Develop more effective prevention interventions targeted at
migrants most affected by HIV, including migrants from countries
with generalised HIV epidemics, migrant MSM and migrants who
inject drugs, and targeted prevention programmes for migrants at
risk of acquiring HIV after arrival

2. Address barriers to provision of services for undocumented
migrants
 Consider reviewing or revising laws and policies that prevent
migrants, in particular undocumented migrants, from accessing
essential HIV prevention and testing services
 Take steps to ensure that ART is made available to undocumented
migrants
 Support coordinated action to address barriers to provision and
uptake of services

3. Strengthen the evidence base on HIV and migrants
 Improve monitoring of HIV prevalence, incidence and post-arrival
acquisition among migrants
 Collect country-specific data to identify sub-groups of migrants who are
most at risk
 Improve availability and quality of data on HIV testing and late diagnosis
among migrants and sub-groups of migrants who may be at increased
risk of HIV
 Collect data on risk behaviour and risk reduction, including condom use,
among sub-groups of migrants most at risk of HIV infection
 Improve the availability and quality of epidemiological and behavioural
data, including through joint funding and harmonised data collection
tools

HIV prevalence among PWID, 2011–2013
Source: ECDC. Thematic report: People who inject drugs. Monitoring implementation of the Dublin Declaration on Partnership
to Fight HIV/AIDS in Europe and Central Asia: 2014 progress report. Stockholm: ECDC; 2015

HIV cases among PWID, as reported by EU/EEA
countries, 2004–2013
to incomplete reporting during the period

HIV cases among PWID, as reported by non-
EU/EEA countries, 2004–2013
Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2014; Data from Russia, Turkey, Turkmenistan, Uzbekistan excluded
due to incomplete reporting during the period or incomplete reporting on transmission mode during the period

Reported HIV testing rates among PWID,
2011–2013

Number of syringes distributed per PWID per year
by NSP, 2011–2013

Opioid substitution coverage among PWID,
2011–2013

HIV treatment, care and support programmes reported
to be delivered at scale for PWID in EU/EEA and non-
EU/EEA countries, 2014,
EU countries
Are HIV treatment programmes
delivered at scale for PWID?
Are HIV care and support
programmes delivered at scale
for PWID?
Yes No Yes No
Government 29 1 27 3
Civil society 17 5 11 11
Non-EU/EEA
countries
Are HIV treatment programmes
delivered at scale for PWID?
Are HIV care and support
programmes delivered at scale
for PWID?
Yes No Yes No
Government 16 2 15 3
Civil society 11 1 6 6

Priority areas for action (PWID)
1. Strengthen prevention programmes for PWID
 Scale up NSP and OST coverage in countries where coverage is currently
low
 Promote increased access to, and uptake of, HIV testing among PWID to
reach the undiagnosed and reduce late diagnosis; community-based
approaches should be used
 Consider reviewing or revising laws that criminalise drug use and drug-
related activities and hinder HIV prevention and outreach work
 Reduce stigma and discrimination towards PWID, particularly in
healthcare settings
 Provide comprehensive prevention, screening and treatment
programmes that address other drug-related diseases, such as HCV

2. Improve data on HIV and drug-related infectious diseases among PWID
 Enhance monitoring of HIV incidence and prevalence among PWID, in
particular in countries where there is a risk of ongoing HIV transmission
or of HIV outbreaks in this population
 Improve availability of population size estimates for people who inject
drugs and problem opioid users in order to provide a basis for
calculating intervention coverage
 Collect data on overlapping risk between PWID and other at risk
populations, including MSM, sex workers, and migrants; also collect data
on the risk of contracting HIV for sexual partners of PWID
 Improve qualitative data on factors that limit uptake of services by
PWID, including the extent to which stigma and discrimination plays a
role

3. Ensure that there is adequate funding for HIV surveillance and
HIV prevention programmes for PWID
 Increase investments in epidemiological and behavioural
surveillance
 Sustain funding for HIV prevention interventions for PWID in
countries where programmes have been dependent on external
sources of funding
 Consider establishing regional financing mechanisms for HIV
prevention programmes for PWID in low- and middle-income
countries in the region

Reported HIV prevalence among prisoners,
2011–2013
Source: ECDC. Thematic report: Prisoners. Monitoring implementation of the Dublin Declaration on Partnership to Fight
HIV/AIDS in Europe and Central Asia: 2014 progress report. Stockholm: ECDC; 2015

Reported HIV prevalence rates in prisoners and
people who inject drugs
Countries Prisoners People who inject
drugs
EU/EEA
Estonia 12% 50–60%
Latvia 7% 24.5%
Spain 6% 16.4%
Non-EU/EEA
Azerbaijan 5.8% 9.5%
Kyrgyzstan 7.6% 12.4%
Tajikistan 8.4% 13.5%
Ukraine 11% 19.7%

Reported availability of OST in prisons, 2014

Reported availability of NSP in prisons, 2014

Mandatory HIV testing in prisons, 2014

Priority areas for action (Prisoners)
1. Strengthen and expand targeted HIV prevention interventions
and HCV programmes for prisoners
 Scale up provision of opioid substitution therapy, needle and
syringe programmes and condoms in prisons.
 Improve awareness of policy-makers, prison managers and staff,
and healthcare professionals working in prison settings of the
public health importance of preventing and controlling drug-
related infectious diseases among prisoners
 Scale up provision of screening and treatment for hepatitis C and
other co-infections in prisons, particularly in non-EU/EEA
countries

2. Improve data on HIV and other infectious diseases among
prisoners
 Enhance monitoring of HIV and HCV incidence and prevalence
among prisoners and sub-groups of prisoners at increased risk
 Collect data on drug injecting and sexual risk behaviour in prison
settings
 Strengthen the evidence base on harm reduction interventions in
prisons, including learning lessons about feasibility and
effectiveness from countries in the region that are implementing
such interventions
 Improve the availability and quality of epidemiological and
behavioural data through joint funding, capacity building and
harmonised data collection tools

3. Improve collaboration on issues related to HIV and prisoners
 Promote regional sharing of evidence and experience and
increased dialogue and collaboration between countries and
between government and civil society
 Strengthen links at country level between the health, justice and
social service sectors
 Strengthen collaboration between infectious disease prevention
and drug treatment networks in prisons and outside

Reported HIV prevalence among sex workers,
2011–2013
Source: ECDC. Thematic report: Sex workers. Monitoring implementation of the Dublin Declaration on Partnership to Fight

Reported rates of condom use among sex workers,
2011–2013

Reported rates of HIV testing among sex workers,
2011–2013

HIV response in countries reporting high HIV
prevalence (<5%) among female sex workers
Country
HIV
prevalence
HIV
testing
HIV
testing
delivered
at scale
HIV
prevention
delivered at
scale
Priority for
prevention
funding
(ranking)
Condom
use
Belarus 5.8% 63.4% Yes Yes Yes 81.8%
Estonia 6.2% 66.7% Yes No 2 97.6%
Latvia 22.2% 49.6% No Yes 3 85.5%
Moldova 11.6% 22% Yes No 3 87.5%
Portugal 5.7% 55% Yes Yes 3 97.8%
Ukraine 7.3% 63.1% Yes No 3 96.7%

Countries reporting that HIV treatment and HIV care
and support for sex workers are not delivered at scale
EU/EEA countries HIV treatment for sex
workers not delivered at
scale
HIV care and support for sex
workers not delivered at scale
Government Finland, Greece, Italy, Malta Cyprus, Estonia, Finland, France,
Greece, Italy, Lithuania, Malta,
Poland
Civil society Denmark, Greece, Slovakia,
Spain
Denmark, Greece, Hungary, Italy,
Latvia, Norway, Portugal, Slovakia,
Spain, Sweden, UK
Non-EU/EEA
countries
HIV treatment for sex
workers not delivered at
scale
HIV care and support for sex
workers not delivered at scale
Government - Albania, Israel, Moldova, Serbia
Civil society Ukraine Albania, Georgia, Moldova,
Montenegro, Serbia, Tajikistan,
Ukraine

Priority areas for action (Sex workers)
1. Strengthen prevention and testing programmes for sex workers
 Ensure HIV prevention and testing programmes for sex workers
are delivered at scale in countries where coverage is low and HIV
incidence and prevalence in this population is high
 Develop more effective approaches to reach most-at-risk sex
workers with prevention interventions, and to increase uptake of
HIV testing in these subgroups of sex workers
 Implement comprehensive, integrated prevention and harm
reduction programmes for sex workers with multiple risk factors
for HIV including sex workers who inject drugs, male sex workers,
transgender sex workers and migrant sex workers

2. Address barriers to provision and uptake of services for sex
workers
 Reduce general and HIV-related stigma and discrimination
towards sex workers, in particular in healthcare settings
 Consider reviewing or revising laws criminalising sex work or
activities related to sex work that also serve to hinder prevention
and outreach work
 Consider monitoring the legal context for sex work and the impact
of this on provision and uptake of HIV services by sex workers
 Support coordinated action by networks and projects to address
barriers to provision and uptake of services

1. Improve data on HIV and sex workers
 Enhance monitoring of HIV incidence and of HIV prevalence trends
among sex workers, particularly in countries where prevalence in this
population is high or apparently increasing
 Collect disaggregated data for female, male and transgender sex
workers
 Improve availability and quality of data on risk reduction behaviours,
including condom use among male sex workers, sex workers who inject
drugs, transgender sex workers and migrant sex workers, and condom
use with non-commercial sexual partners
 Enhance monitoring of the dynamics of sex work including the impact of
migration, mobility and trafficking on subgroups of sex workers at
increased risk

Late diagnosis is a critical issue in
the EU/EEA

Late HIV diagnosis by transmission mode
EU/EEA, 2013 (n=17 526)

CD4 cell count at diagnosis, by age category
EU/EEA, 2013 (n=17 526)

Proportion of PLHIV eligible for treatment and
receiving it*, (2011-2013)
* Country reported estimates. Most EU/EEA countries could not provide estimates of the number of PLHIV and many provided
the proportion of diagnosed PLHIV on treatment.
• Of 36 countries reporting
data, most report
coverage >85%
• This means that people
diagnosed and eligible
for treatment are
receiving it
• People still do not have
access to treatment,
especially in non-EU
countries
• 11 countries reported
<85%, most outside the
EU

CD4 threshold for initiating HIV treatment
Initiation regardless
of CD4 cell count
5Austria, Belgium, France, Italy, Romania
500 cells/mm3 14 Bosnia and Herzegovina, Czech Republic,
Estonia, Finland, Georgia, Iceland, Israel, Malta,
Netherlands, Poland, Slovakia, Spain, Sweden, Turkey
350 cells/mm3
28Albania, Armenia, Azerbaijan, Belarus, Bulgaria,
Croatia, Cyprus, Denmark, Germany, Greece, Hungary,
Ireland, Kazakhstan, Kosovo, Kyrgyzstan, Lithuania,
Luxembourg, Moldova, Montenegro, Norway, Portugal,
Serbia, Slovenia, Switzerland, Tajikistan, Ukraine,
United Kingdom, Uzbekistan
200 cells/mm3 1Latvia
No data reported
7Andorra, The former Yugoslav Republic of
Macedonia, Liechtenstein, Monaco, Russia, San
Marino, Turkmenistan
Source: ECDC. Evidence brief: HIV and treatment. Stockholm: ECDC; 2015.

Treatment
174 273
2009
333 699
2013
Number of people living with HIV receiving treatment
(in 29 countries reporting consistent data since 2009)
30%
of PLHIV
unaware
of their
HIV status
Source: ECDC. Evidence brief: HIV and treatment. Stockholm: ECDC; 2015.

Average ART cost per patient and year, 2013
European Centre for Disease Prevention and Control. HIV treatment: Increasing uptake and effectiveness in the European Union.
Stockholm: ECDC; 2010

Key priority action 1
PREVENTION
AT SCALE
FOR MSM: there is an urgent need to
improve coverage and effectiveness
of HIV programmes
FOR MIGRANTS: we need to develop
and deliver targeted prevention
programmes to migrants at increased risk
FOR PRISONERS: ensure that essential
HIV prevention interventions, incl.
OST, NSP and condoms, are made
available in all prisons
FOR PWID: there is a need to improve
coverage of NSP and OST programmes,
especially in non-EU/EEA countries

TESTING
AT SCALE
Increase uptake and frequency of
HIV testing among key populations and
promote earlier diagnosis
Expand community-based
approaches
to HIV testing

TREATMENT
AT SCALE There is a need to scale up the
provision of ART, especially in non-
EU/EEA countries
Address the factors that prevent key
populations from accessing treatment
Improve the quality of care and
increase the proportion of people
with an undetectable viral load.
Critical to reducing the long-term impact
of the HIV epidemic in Europe
Provide equal access to HIV
treatment to undocumented migrants

FINANCING
AT SCALE
Sustaining adequate funding for
politically sensitive interventions such as
harm reduction for PWID and prisoners
Managing the costs of antiretroviral
drugs
Ensuring enough resources for core
primary prevention activities
As treatments costs continue to increase, it
will be critical to ensure future financing
of HIV prevention programmes
Sustain funding for civil society
organisations to deliver key services

PREVENTION
AT SCALE
TESTING
AT SCALE
TREATMENT
AT SCALE
FINANCING
AT SCALE
LEADERSHIP

Acknowledgements
 Dublin Declaration focal points in Europe and Central Asia
 Dublin Declaration advisory group
 HIV Surveillance focal points in Europe and Central Asia
 EU Commission, EMCDDA, UNAIDS, WHO

From Dublin to Rome: 10 years of the HIV epidemic and response in Europe

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