What is the current situation of HIV in Europe and Central Asia? How can we more effectively prevent new infections? Presentation by Anastasia Pharris, European Centre for Disease Prevention and Control (ECDC) at Glasgow HIV Drug Therapy Conference 28 October 2018

1. Strategies to reduce HIV incidence in Europe
Anastasia Pharris, European Centre for Disease Prevention and Control (ECDC)
Glasgow HIV Drug Therapy
28 October 2018

2. Employed by ECDC
No disclosures

3. What is the situation of HIV in Europe and Central Asia?
How can we more effectively prevent new infections?

4. Source: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2017– 2016 data
@ECDC_HIVAIDS
>160 000 people were diagnosed with HIV in the WHO
European Region in 2016

5. Source: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2017– 2016 data
East
80%
≈ 128,000
Centre
4%
≈ 5,800
West
16%
≈ 26,000
>160 000 people were diagnosed with HIV in the WHO
European Region in 2016
@ECDC_HIVAIDS

6. 0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
NewHIVinfections(global)
Global
Estimated new HIV infections are decreasing globally
but increasing in the European region
Source: UNAIDS 2018, ECDC/WHO, HIV Surveillance in Europe 2017, 2016 data
@ECDC_HIVAIDS

7. 0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Europeandsub-regions
NewHIVinfections(global)
Global
Europe and Central Asia
Estimated new HIV infections are decreasing globally
but increasing in the European region
Source: UNAIDS 2018, ECDC/WHO, HIV Surveillance in Europe 2017, 2016 data
@ECDC_HIVAIDS

8. 0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Europeandsub-regions
NewHIVinfections(global)
Global
Europe and Central Asia
West
Centre
East
Estimated new HIV infections are decreasing globally
but increasing in the European region
Source: UNAIDS 2018, ECDC/WHO, HIV Surveillance in Europe 2017, 2016 data
@ECDC_HIVAIDS

9. Source: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2017– 2016 data
Transmission risk pattern differs by sub-region
MSM
IDU
HETERO
MSM
IDU
HETERO
MSM
IDUHETERO
45% born
abroad
@ECDC_HIVAIDS

10. Source: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2017– 2016 data
Transmission risk pattern differs by sub-region
MSM
IDU
HETERO
MSM
IDU
HETERO
MSM
IDUHETERO
45% born
abroad
45% born
abroad
9% born
abroad
1% born
abroad
@ECDC_HIVAIDS

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

12. Fast Track Targets by 2020
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

13. Progress toward achieving the 1st 90
90% of all PLHIV who know their status (n=39)
Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.
Latest available data reported, ranging from 2014-2017.
Target reached Above regional average Below regional average
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Global target 90%
Europe and Central Asia 80%
@ECDC_HIVAIDS

14. Progress toward achieving the 1st 90
Sub-regional variation: West, Centre, East
Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.
Europe and
Central Asia
80%

15. Fast Track Targets by 2020
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

16. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Global target 90%
Europe and Central Asia 64%
Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.
Latest available data reported, ranging from 2014-2017.
Progress toward achieving the 2nd 90
90% of those diagnosed on ART (n=39)
Target reached Above regional average Below regional average
@ECDC_HIVAIDS

17. Progress toward achieving the 2nd 90
Significant sub-regional variation: West, Centre, East
Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data. @ECDC_HIVAIDS
Europe and
Central Asia
64%

18. Fast Track Targets by 2020
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

19. Progress toward achieving the 3rd 90
90% of those on ART virally suppressed (n=33)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Global target 90%
Europe and Central Asia 84%
Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.
Latest available data reported, ranging from 2014-2017.
Target reached Above regional average Below regional average
@ECDC_HIVAIDS

20. Progress toward achieving the 3rd 90
Significant sub-regional variation: West, Centre, East
Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.
@ECDC_HIVAIDS
Europe and
Central Asia
84%

21. Fast Track Targets by 2020
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

22. Progress toward achieving the overall target
73% of all PLHIV virally suppressed (n=32)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.
Latest available data reported, ranging from 2014-2017.
Europe and Central Asia 43%
Target reached Above regional average Below regional average
Global target 73%
@ECDC_HIVAIDS

23. Progress toward achieving the overall 90-90-90 target
Significant sub-regional variation: West, Centre, East
Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.
@ECDC_HIVAIDS
Europe and
Central Asia
43%

24. Magnitude and reasons for transmissible virus varies
across sub-regions
Source: ECDC. Dublin Declaration monitoring 2018;
validated unpublished data.
Undiagnosed
Diagnosed but not treated
Treated but not virally supressed
N ≈ 200,000

25. Magnitude and reasons for transmissible virus varies
across sub-regions
Source: ECDC. Dublin Declaration monitoring 2018;
validated unpublished data.
Undiagnosed
Diagnosed but not treated
Treated but not virally supressed
N ≈ 200,000
N ≈ 15,000

26. Magnitude and reasons for transmissible virus varies
across sub-regions
Source: ECDC. Dublin Declaration monitoring 2018;
validated unpublished data.
Undiagnosed
Diagnosed but not treated
Treated but not virally supressed
N ≈ 200,000
N ≈ 15,000
N ≈ 980,000

27. Viral suppression and trends in new HIV diagnoses
0
10
20
30
40
50
60
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Newdiagnosesper100000population
West
Centre
East
Source: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2017– 2016 data and ECDC. Dublin Declaration monitoring
2018; validated unpublished data on the continuum of care.
26% viral suppression
95% increase in diagnoses
72% viral suppression
19% decline in diagnoses
46% viral suppression
147% increase in diagnoses
@ECDC_HIVAIDS

28. What is the situation of HIV in Europe and Central Asia?
How can we more effectively prevent new infections?

29. HIV
Testing
Critical components
to reduce HIV
incidence in Europe

30. Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.
@ECDC_HIVAIDS

31. Proportion of people diagnosed late*, WHO European
Region, 2016
Source: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2017– 2016 data
Age group (years) Transmission
*Diagnosed late=CD4<350 cells/mm3 at diagnosis,
infections reported as acute are excluded
Sub-region Gender
51%
@ECDC_HIVAIDS

32. Median time from infection to diagnosis is still several years
Source: van Sighem, Eurosurveillance, 2017
@ECDC_HIVAIDS

33. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Self-sampling
Self-testing
Other health care settings (pharmacies)
Community testing (lay provider)
Indicator-condition testing
Community testing (medical provider)
Partner notification
Provider initiated in primary care
Provider initiated in secondary care
Routine HIV testing in sexual health clinics
Routine antenatal screening
Full coverage (96-100%) High coverage (61-95%) Medium coverage (30-60%) Low coverage (<30%)
Low coverage of diverse modes of effective HIV testing
Low coverage of
“traditional”
HIV testing
modes
Very low
coverage of
additional HIV
testing modes
Coverage was reported through official country responses to the 2018 Dublin Monitoring questionnaire
@ECDC_HIVAIDS

34. Indicator condition testing can normalise testing and promote its
inclusion into routine systems
Source: ECDC. Dublin Declaration monitoring 2018
1/5 of countries have
full or high coverage

35. Resources to increase indicator condition testing
http://www.opttest.eu/Tools/Implementing-Indicator-Condition-IC-Guided-Testing
• Online e-learning
module for non-HIV
specialists
• Online planning
module
• Slide sets
• Policy briefs
(French, Spanish,
English, Polish,
Estonian, Russian)

36. Implementation of community-based testing by medical staff
in Europe and Central Asia, 2018
Source: ECDC. Dublin Declaration monitoring 2018

37. Implementation of community-based testing by lay providers
in Europe and Central Asia, 2018
Source: ECDC. Dublin Declaration monitoring 2018
High user acceptability
and high positivity
rates among those
tested

38. Implementation of self-testing in Europe and Central Asia, 2018
Source: ECDC. Dublin Declaration monitoring 2018
Should be accompanied
by information on
accessing confirmatory
testing and care

39. Self-sampling

40. Plan and deliver services to enable recommended testing
frequency
Increasing supply
• Variety of modes which make it easy for those in need to test
• Flexible opening hours, weekends, rapid tests, convenient sites, self-testing
Increasing demand
• “Test often!” messaging
• Call backs/reminder services
• Co-location/provision of PrEP and other services
Source: ECDC HIV and hepatitis B and C testing guidance, forthcoming 2018
Recommended HIV testing frequency for groups at risk for HIV infection
at least yearly and up to every 3 months, depending on ongoing risk, sexual
behaviour, history of STIs, PrEP or PEP use, local HIV prevalence/incidence
@ECDC_HIVAIDS

41. HIV
Testing
Critical components
to reduce HIV
incidence in Europe
Rapid linkage to:
Combination
prevention
Acute infection
awareness

42. Combination prevention for people who inject drugs
Source: ECDC/EMCDDA guidance on prevention of infections in people who
inject drugs 42
INJECTION EQUIPMENT
VACCINATION
DRUG DEPENDENCE TREATMENT
TESTING
INFECTIOUS DISEASE TREATMENT
HEALTH PROMOTION
TARGETED DELIVERY OF SERVICES
….PROVIDED IN COMBINATION
FOR HIGHER IMPACT

43. Density of needle and syringe outlets in the EU, Norway and
Turkey
Percentage of NUTS-III
standardised European
territorial units with one
or more needle/syringe
outlets.
Source: EMCDDA, FONTE
Coverage is far lower in
countries in the Eastern
part of the region
Source: EMCDDA, European Drug Report 2018

44. Low coverage of opiate substitution treatment
Source: EMCDDA, European Drug Report 2018
<5% in most
countries in
the Eastern
part of the
region

45. Evidence-based
combination
prevention
Hepatitis A
and B
vaccination
Condoms
and
lubricants
HIV and STI
testing
Treatment
including
PrEP
Health
promotion
MSM-
competent
health
services
Targeted
care for
MSM living
with HIV
Combination HIV/STI prevention for
men who have sex with men
ECDC, 2014

46. 46
Status of formal PrEP implementation in Europe
October, 2018
• Highly effective and
under-utilised
• Success stories built
on well-developed
testing programmes,
fast linkage to care,
have met 90-90-90
targets
Source: ECDC. Dublin Declaration monitoring
2018; validated unpublished data.

47. Raising awareness about acute infection
https://www.hebikhiv.nl/en/

48. Acute HIV rapid diagnostic and referral trajectory
STI clinic Amsterdam
Diagnosis acute HIV
infection:
Same day referral and
start cART
Online campaign
Self referral
General
practitioner
`
STI clinic
`
Slide courtesy of Godelieve de Bree

49. Trends in diagnoses of recent infections in Amsterdam
Slide courtesy of Godelieve de Bree, data from HIV monitoring foundation, 2016

50. Rapid linkage to:
Combination
prevention
Acute infection
awareness
Rapid linkage to:
Care/ART
Partner notification
Adherence support
HIV
Testing
Critical components
to reduce HIV
incidence in Europe
@ECDC_HIVAIDS

51. Source: ECDC. Dublin Declaration monitoring 2018 @ECDC_HIVAIDS

52. Source: Public Health England, 2017; BHIVA Standards of Care 2018
Rapid linkage and treatment start
Linkage pathways
should be in place
Remove barriers to
confirmatory testing
Clinical standards for
specialist evaluation
(ie BHIVA standards
of 2 weeks or 24
hours if symptoms)

53. Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.
4
29
46
16
10
5
28
8
1
1
0
5
10
15
20
25
30
35
40
45
50
55
2014 2015 2016 2018
Numberofcountries/ARTpolicy
200 cells/mm3
350 cells/mm3
500 cells/mm3
Initiation regardless
of CD4 count
ART initiation policies in European countries
2014 (n=49)
@ECDC_HIVAIDS

54. Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.
4
29
46
16
10
5
28
8
1
1
0
5
10
15
20
25
30
35
40
45
50
55
2014 2015 2016 2018
Numberofcountries/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)
@ECDC_HIVAIDS

55. Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.
4
29
46
16
10
5
28
8
1
1
0
5
10
15
20
25
30
35
40
45
50
55
2014 2015 2016 2018
Numberofcountries/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=52)
@ECDC_HIVAIDS

56. Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.
4
29
46
16
10
5
28
8
1
1
0
5
10
15
20
25
30
35
40
45
50
55
2014 2015 2016 2018
Numberofcountries/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=52)
4 countries
89%
treatment
coverage
16 countries
86%
treatment
coverage
14 countries
69%
treatment
coverage
@ECDC_HIVAIDS

57. Scaling-up ART in Kyiv
Source: Oksana Naduta–Skrynnyk, Kyiv City State Administration
More rapid treatment start
Introduced: 30 day treatment initiation standardIncreased number of ART access points from 4 to 30

58. Partner notification services
• Legal and organisational challenges in some settings
• High positivity rates among contacts who are tested
• Technology can help (web-based, anonymous platforms, apps)
• If accepted, it’s an effective way of engaging partners who may not be
reached by risk-group services linking them to prevention/PrEP
ECDC HIV and hepatitis B and C guidance, forthcoming 2018
To promote early diagnosis and linkage to care, voluntary,
anonymous partner notification services should be offered to
every person with a newly confirmed HIV diagnosis.
@ECDC_HIVAIDS

59. Implementation of assisted partner notification
59Source: ECDC. Dublin Declaration monitoring 2018
¼ of countries have
full or high coverage
Many countries do
not offer or follow up

60. Adherence support
• Empowered role of nursing, social work, & peers!
• Drug and alcohol services and mental health services
• Stigma reduction
• Quality of life

61. Rapid linkage to:
Care/ART
Partner notification
Adherence support
HIV
Testing
Critical components
to reduce HIV
incidence in Europe
Rapid linkage to:
Combination
prevention
Acute infection
awareness
@ECDC_HIVAIDS

62. Rapid linkage to:
Care/ART
Partner notification
Adherence support
HIV
Testing
Partnerships
Plans
Surveillance
systems
Critical components
to reduce HIV
incidence in Europe
Rapid linkage to:
Combination
prevention
Acute infection
awareness
@ECDC_HIVAIDS

63. Source: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2017– 2016 data
Testing + linkage
ART
PWID & MSM
Partners
Adherence
support
Testing + linkage
ART
MSM (PrEP,
condoms)
Partners
Adherence
support
Testing + linkage
MSM (PrEP, acute
infection)
Partners
Adherence
support
Reducing HIV incidence in Europe and Central Asia
@ECDC_HIVAIDS

64. Acknowledgements
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), Irene Klavs (Slovenia), Gabrella Hok (Sweden), Valerie Delpech, Alison Brown, Cary James, Brian Rice
(United Kingdom), Olga Varetska (Ukraine), Jean-Luc Sion (European Commission), Dagmar Hedrich (EMCDDA), Taavi Erkkola, Kim Marsh (UNAIDS),
Annemarie Stengaard (WHO Regional Office for Europe), Jordi Casabona (INEGRATE), Axel J. Schmidt (ESTICOM).
Dublin Declaration focal points in Europe and Central Asia
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 (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 Cotelnic (Moldova), Alma Cicic, Aleksandra Marjanovic (Montenegro), Silke David (Netherlands), Arild Johan Myrberg (Norway), Anna Marzec-
Bogusławska, 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 (United Kingdom), Igor Kuzin
(Ukraine) and Zulfiya Abdurakhimova (Uzbekistan).
HIV Surveillance focal points
Daniela Schmid, Ziad El-Khatib (Austria), Andre Sasse (Belgium), Tonka Varleva (Bulgaria), Tatjana Nemeth Blazic (Croatia); Maria Koliou (Cyprus),
Marek Maly (Czech Republic); Susan Cowan (Denmark), Kristi Ruutel (Estonia), Kirsi Liitsola (Finland), Florence Lot, Francoise Cazein, Josianne Pilonell
(France), Barbara Gunsenheimer-Bartmeyer (Germany), Stavros Patrinos and Dimitra Paraskeva (Greece), Maria Dudas (Hungary), Gudrun
Sigmundsdottir and Haraldur Briem (Iceland), Kate O’Donnell and Derval Igoe (Ireland), Barbara Suligoi (Italy), Šarlote Konova (Latvia), Saulius
Čaplinskas and Irma Čaplinskienė (Lithuania), : Jean-Claude Schmit (Luxembourg), Jackie Maistre Melillo and Tanya Melillo (Malta), Eline Op de Coul
and Ard van Sighem (Netherlands), Hans Blystad (Norway), Magdalena Rosinska (Poland), Helena Cortes Martins (Portugal), Mariana Mardarescu
(Romania), Peter Truska (Slovakia), Irena Klavs (Slovenia), Asuncion Diaz (Spain), Maria Axelsson (Sweden), Valerie Delpech (United Kingdom).

65. Thank you
Teymur Noori, Andrew Amato and Caroline Daamen, ECDC
Dagmar Hedrich, EMCDDA
Annemarie Stengaard, WHO Regional Office for Europe
Rosalie Hayes and Yusef Azad, NAT
Alison Brown and Valerie Delpech, Public Health England
Kholoud Porter, UCL and Annabelle Gourlay, LSHTM
Godelieve de Bree, GDD Amsterdam
Oksana Naduta–Skrynnyk, Kyiv City State Administration
Nikos Dedes, Positive Voice/EATG
@ECDC_HIVAIDS