Fast-track the end of AI​​​DS in the EU - practical evidence-based interventions. Presentation by: Mika Salminen, European HA-REACT project In a two-day meeting under the auspices of the Maltese Presidency of the Council of the European Union (30-31 January 2017), HIV experts from across the European Union discussed how to reverse this trend and how to prepare Europe to achieve the set target of ending AIDS by 2030.

1. Scaling-up harm reduction services for prevention
of HIV among people who inject drugs (PWID)
Joint Action on HIV and co-infection
prevention and harm reduction
HA-REACT
Mika Salminen, Professor
Malta, 30 January 2017

2. > 5
3 to <5
1 to <3
< 1
Not included or
not reporting
Liechtenstein
Luxembourg
Malta
Non-visible countries
HIV diagnoses acquired through injecting drug
use, 2014, EU/EEA
Rate per 100 000 population
Source: ECDC/WHO (2015). HIV/AIDS Surveillance in Europe, 2014

3. HIV prevalence among people who inject
drugs; Europe, 2008–2009
4
10 < 50%
≥ 50%
Not
included,
not
reporting, or
not known
5 < 10%
Source: EMCDDA and Reitox National
Focal Points (EMCDDA countries: EU,
Croatia, Turkey and Norway);
Mathers et al., Lancet 2008 (other
countries). Colour indicates midpoint
of national data, or if not available,
local data. Data for EMCDDA
countries are mostly from 2008–
2009. When data were not available
for 2008–2009, older data were
used.
EMCDDA data are sub-national for
Turkey, UK, France, Slovakia,
Netherlands, Belgium, Poland,
Bulgaria, Spain, Sweden, Ireland,
Latvia, Germany, Lithuania, Romania,
Estonia. For non-EMCDDA countries,
this information is not available.
0 < 5 %

4. 8.2.2017 5
The stairs of change in health
promotion (Puska & McAlister 1982)
6. Community Organisation /
Policy change
5. Environmental support
4. Social support
3. Practical skills
2. Persuasion
1. Knowledge

5. 8.2.2017 6
Policy change in mid 1990-ies in Finland: from
naïve to pragmatic public health based drug policy
• Abandonment of a
naïve/heroic approach in
favour of a pragmatic/humble
policy
• Development of Low threshold
health service centers (LTHSC)
tailored to the needs of the
target group (IDU)
• Governmental policy
programmes, 1998, 2000 and
2004-7
• Law on infectious diseases:
mandatory requirement for
municipal harm reduction,
incl. NSP
• Framework of the LTHSC
operational parameters
– Anonymity service without
any kind of identification
– Reachability of the location
and the services
– User-friendly atmosphere
– Dialogue with the users
– Practical approach to the
operation
– ideological and moral Non-
judgementality
– Realistic hierarchy of goals

6. 8.2.2017 8
Growth of the LTHSC network
• First Low Threshold Health Service
Centre opened 1997
• Since expanded to > 35 municipalities
• Service mix:
– Health advice
– Exchange of injection equipment
– Vaccinations
– Low threshold testing
– Food and
– Smallscale outpatient services
– Outreach and peer-peer work
• Referrals to:
– Maintenance and substitution
therapy for opiate users
– Detoxification services
– other social- and health services
• Municipal responsibility!
• Close cooperation with NGO-sector

7. 8.2.2017 9
Effectiveness indicators evaluated
Impact indicators
• Changes in prevalence and incidence
of blood-borne infections (i.e. HBV,
HCV, HIV)
• Sustaining low prevalence of HIV
among IDU
• Absense of negative effects (i.e.
increases in drug use, recruitment of
younger users)
Targets set in 2004-2007 governmental
policy
• Improving scenario: reduction in HIV-
incidence to less than 30 cases
among IDU/year
Coverage & operational indicators
• Numbers and proportion of IDU
reached
• Regional coverage
• Numbers of equipment exchanged in
relation to estimated need
• % returned equipment
• HBV and HAV Vaccination coverage
• Acceptance of services
• Awareness of infection status
Economical indicators (cost/ benefit)
• Crude scenario-type estimates

8. 8.2.2017 10
Coverage
• Numbers and proportion of IDU
reached
• Regional coverage
• Equipment exchanged and
estimated need
• Return rate for equipment
• Hepatitis vaccination coverage
• Acceptance of services
• Awareness of own infection
status
Coverage in 2006 estimated at
70.8 % (target > 60 %)
Partly met: full coverage of major
cities, partial or spotty coverage of small
municipalities, total coverage 2.3
population (target: cover all regions
where need exists)
Half of calculated need met
(target: no re-use)
> 98 % (target 90 %)
Regional coverage > 90 % (target
> 75 %)
High among target group
Annual testing rate 10-15 %
(target > 10 % within system)

9. 8.2.2017 11
Policy indicators
Three scenarios of IDU HIV epidemic
evolution in government drug policy
programme 2004 – 2007
1. Worsening situation
> 100 cases annually
2. Unchanged
30 – 50 cases annually
3. Improved situation
< 30 annual HIV cases

10. 8.2.2017 12
Cost effectiveness
• Current direct additional
total national costs of LTHSC
services are estimated to be
less than
5M €
• Given a median estimate of
approximately 15.000 users,
annual additional cost per
IDU is 670 €
• In contrast, annual
healthcare cost due to HIV-
infection can be up to 10000
€
• Suggests cost-effectiveness
Modelling the Direct Cost of the HIV/Aids Epidemic Mean
PLWHA lifetime 13 years, stdev 10 y,
Cost level 10 k€/PLWHA/year
€0
€20
€40
€60
€80
€100
€120
€140
€160
1990 2000 2010 2020 2030 2040
Millions
Years modelled
Annualundiscountedcost(€)
€0
€500
€1,000
€1,500
€2,000
€2,500
€3,000
Millions
Cumulativeundiscountedcost(€)
Annual cost, 100 cases/y
Annual cost, 500 cases/y
Cumulative cost, 100 cases/y
Cumulative cost, 500 cases/y

11. 8.2.2017 13
Correlation of service increase and annually
reported cases of HIV infection
0
20
40
60
80
100
AnnualHIVrate
0
1125000
2250000
3375000
4500000
Equipmentexange

12. 8.2.2017 14
Comparison of outcomes
Annual incidence of HIV-infection
newly reported cases/million population
0
200
400
600
800
1000
1200
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Incidence(log-scale)
Incidence - Example
Incidence - Finland

13. Objectives of HA-REACT Joint Action
 Zero new HIV, reduced HCV and TB among PWID in the EU by 2020
 Improved prevention and treatment of blood-borne infections and
TB in priority regions and priority groups in the European Union
Purpose
Improved capacity to respond to HIV and co-infection risks and
provide harm reduction with specific focus on people who inject
drugs (PWID) in the EU
Direct beneficiaries: professionals working with PWID
Ultimate beneficiaries: people who inject drugs

14. ECDC & EMCDDA
joint guidance
– Comprehensive Guidance
document
• Based on evidence and fully referenced
– Two part evidence assessment
1. Needle and syringe programmes and other
interventions for preventing hepatitis C, HIV
and injecting risk behaviour
2. Drug treatment for preventing hepatitis C, HIV
and injecting risk behaviour
16
Seven interventions, one
aim: no infections

15. Seven key recommended interventions
• INJECTION EQUIPMENT: Provision of and
legal access to clean drug injection
equipment, including sufficient supply of
sterile needles and syringes, free of charge,
as part of a combined multi-component
approach, implemented through harm-
reduction, counselling and treatment
programmes
• VACCINATION: hepatitis A and B, tetanus,
influenza vaccines, and, in particular for HIV-
positive individuals, pneumococcal vaccine
• DRUG DEPENDENCE TREATMENT: Opioid
substitution treatment and other effective
forms of drug treatment
• TESTING: Voluntary diagnostic testing with
informed consent for HIV, HCV, (HBV for
unvaccinated) and other infections including
TB should be routinely offered and linked to
referral to treatment
17
INFECTIOUS DISEASE TREATMENT: Antiviral
treatment based on clinical indications for those
who are HIV, HBV or HCV-infected. Anti-
tuberculosis treatment for active TB cases. TB
prophylactic therapy should be considered for
latent TB cases.
HEALTH PROMOTION: health promotion focused
on safer injecting behaviour; sexual health
including condom use; and disease prevention,
testing and treatment
TARGETED DELIVERY OF SERVICES: Services
should be combined and organised and delivered
according to user needs and local conditions; this
includes the provision of services through fixed
sites offering drug treatment, harm reduction,
counselling and testing, and referrals to general
primary health and specialist medical services.
COMBINE THESE KEY INTERVENTIONS TO ENHANCE PREVENTION
SYNERGY AND EFFECTIVENESS

16. Activity basics
Budget: approx. 3,75 million EUR
co-funding by EC – 80%
Duration: October 2015 – September 2018
Coordination: National Institute for Health and
Welfare (THL), Finland
Partners: 23 partners from 18 countries

17. EU Priority groups
Comprehensive prevention
service package
Integrated, comprehensive public health service
approach with an emphasis on capacity development
8.2.2017 Mika Salminen/Outi Karvonen 19
Coordi-
nation
Dissemi
nation
Evalu-
ation
Selected
partner countries
for capacity
development
Direct support
from the project
funds
Partners with
existing
comprehensive
services packages
and/or
experience in
overcoming
structural barriers
and issues of
sustainability
EU Priority
Regions
Direct
support
Training and
bench-
marking

18. Focusing the action: use of ECDC and EMCDDA objective
selection criteria
8.2.2017 Mika Salminen/Outi Karvonen 20
AT BE BG HR CY CZ DK EE FI FR DE EL HU IS IE IT LV LT LU MT NL NO PL PT RO SK SI ES SE UK
HIV trend
HIV case reports and prevalence
(15% weight; no increase in case
reports or prevalence=0;
increase in one=1; increase in
both=2; high without an
increase=1)
0 0 2 0 0 0 0 1 0 0 0 1 0 0 0 0 2 1 0 0 0 0 0 0 2 0 0 0 0 0
Transmission risk
prevalence of injecting drug use,
changes in injecting risk
behaviour (HCV prevalence and
trends) (10% weight; no
changes=0; moderate increase
in one criteria=1; increase in >1
criteria=2)
0 0 2 0 1 2 0 2 2 2 0 0 0 2 0 0 0 0
OST coverage
% estimated problem opiate
user population receiving OST
(cut-off 30%) (25% weight; OST
coverage >30%=0; no data=1;
OST coverage <30%=2)
0 1 1 0 0 0 1 1 1 0 0 0 2 1 0 0 2 2 0 0 0 0 2 1 1 2 0 0 1 0
NSP coverage
Number of syringes given out
per PWID per year (cut-off 100
syringes) (25% weight; NSP
coverage >100=0; no data=1;
NSP coverage<100=2)
1 2 1 0 2 0 1 0 0 1 1 2 2 1 1 1 2 1 0 1 1 0 1 1 2 2 1 0 1 1
Taking part in the Joint Action x x x x x x x x x x x x x x x x x x x x
Scores (maximum 2)
0,3 0,8 1 0 0,6 0 0,5 0,6 0,3 0,3 0,3 0,9 1,2 0,5 0,3 0,3 1,5 0,9 0 0,3 0,3 0 0,8 0,5 1,3 1 0,3 0 0,5 0,3
Ranking of those participating in
the JA (1=greatest
need/opportunity to improve
harm reduction situation) 6 3 8 5 2 1 4 6
NO ALERT – no evidence for increase in case reports or HIV/HCV prevalence and/or transmission risk and/or low intervention coverage
CONCERN - Subnational increase in HIV/HCV prevalence and/or transmission risk or consistent but non-significant rise at national level.
ALERT – evidence for significant increase in case reports or HIV/HCV prevalence and/or increase in transmission risk and/or low intervention coverage.
Information unknown/not reported to EMCDDA/ECDC.
Table 1: Indicators of HIV trend, transmission risk and prevention coverage

19. HA-REACT Work Packages
 WP1. Coordination
 WP2. Dissemination
 WP3. Evaluation
 WP4. Testing and linkage to care
 WP5. Scaling up harm reduction
 WP6. Harm reduction and continuity of care in prisons
 WP7. Integrated care
 WP8 Sustainability and long-term funding

20. Starting activities
• 1st Steering Committee in
Luxembourg, 8-9 December
2015
• Kick-off in Vilnius, 14 January
2016
• 1st Advisory Board and 2nd
Steering Committee in Vilnius,
15 Jan 2016
• 3rd Steering Committee in Berlin
on 12 May
• Logical Framework Approach
workshops during spring
2016 in Budapest, Riga,
Vilnius, Prague

21. Recent and next activities
• October 6-7, 2016, Berlin (Germany)
Study tour for prison staff from Czech Republic
• October 2016, Madrid and Barcelona (Spain)
Study visits for participants from Latvia (WP5)
• October 26, 2016, Budapest (Hungary)
HA-REACT Sustainable Funding meeting
• November 2-3, 2016, Riga (Latvia):
HA-REACT Partnership Forum in Riga,
• November 4, 2016, Riga (Latvia):
2nd Advisory Board
• November 4, 2016, Riga (Latvia):
4th Steering Committee
• November 15-17, 2016, Latvia
Training on HIV/HCV testing
• December 13-15, 2016, Hungary
Training on HIV/HCV testing
• January 31, 2017, Malta
CHAFEA Symposium (in connection with HepHIV conference)
• March 7-9, 2017, Warsaw
International training seminar on OST and harm reduction in prisons
• April 5-6, 2017, Vilnius (Lithuania)
International workshop on models of care
Meeting on sustainable funding

22. Thank you !
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