Aser Garcia Rada: The resurgence of HIV/ AIDS in Europe—let’s focus on priorities

Aser García Rada_BMJI was recently invited to a meeting on HIV/AIDS that was hosted in Athens by the European Commission. Although the grass is greener on the EU side, the epidemic still poses relevant challenges. Contrary to the overall global decline in new HIV infections, 29 381 people were newly diagnosed across the EU in 2012, 1% more than in 2011. Late presenters represent 49% of new diagnoses. In the WHO European region—which includes Central Asia—131 202 new cases were reported (8% higher than in 2011). On the whole, 2.2m people live with HIV in the European region, with around half of those people unaware that they are infected.

This increase is heterogeneous, affecting mostly eastern Europe and certain key population groups. Since 2006, HIV diagnoses have more than doubled in Greece, Romania, the Czech Republic, and Hungary. Lithuania, Bulgaria, Slovakia, and Iceland have reported increases of more than 50%.

According to Alessandro Pirona from the European Monitoring Center for Drugs and Drug Addiction (EMCDDA), there are more than 80 million drug users in the EU, 1.3m of them problem opioid users. During the 90s, people who inject drugs (PWID) drove the HIV epidemic in southern and western European countries, but during the last decade, they are driving it in eastern Europe and central Asia. Eastern Europe is a big concern, both for the surge of new cases among PWID, and for the lack of response from their authorities. For instance, while Greece and Romania contributed to around 2% of the total number of newly reported HIV diagnoses among PWID in 2010, by 2012 this had shot up to an alarming 37%.

Cases in these countries may even be underreported because of institutional denial and social stigma, while harm reduction strategies are widely underused or virtually nonexistent. In Russia, for example, opioid substitution treatment remains banned. This was denounced by Luis Mendao, from the European AIDS Treatment Group, who recalled the demagogy and populism with which evidence based public health interventions are systematically denied, and the discrimination it poses for patients.

Men having sex with men (MSM) represent 40% of all new cases throughout the EU, an increase of 11% since 2006. This too may be underreported in eastern Europe, as many patients won’t reveal their sexual orientation to their healthcare providers. Among MSM, condom use is less than 60% in half of EU countries. Anastasia Pharris, from the European Centre for Disease Prevention and Control (ECDC), announced that a new ECDC guide on preventing infection among MSM will be released by the end of 2014.

Migrants represent two fifths of the HIV cases reported in the EU (2007-11). New HIV cases in migrants increased until 2010, but have since decreased. There has been a discrete decrease among Latin Americans, and a sharper decline among heterosexual sub-Saharan African migrants (52% fewer cases from 2006 to 2012), according to Pharris [1]. The causes for these declines remain debatable: better access to therapies in Africa, lower immigration levels, a growing number of policies that restrict access to healthcare for migrants, etc. It’s worth noting though that in the UK—one of the countries with the highest rates of new cases for each 100 000 inhabitants, together with Estonia, Latvia, and Belgium—an increasing number of migrants are acquiring the infection once in the country.

Although more than 85% of those who require antiretroviral therapy (ART) in EU countries receive it, vulnerable groups still find access difficult. For instance, less than half of EU countries make ART available for undocumented migrants, especially northern and eastern European countries.

Generally, ART costs €10 000-12 000 for a year’s treatment of a patient. A joint procurement agreement was signed in June at EU level to help with regulating costs and certain patents will expire soon, but an increasing number of diagnoses will mean ART continues to be a big expense. This will also have to be added to the high cost of new hepatitis C (HVC) therapiesup to $80 000 for each patient—for those coinfected. On average, 25% of all HIV patients across the EU are coinfected with HVC, with higher rates among PWID [up to 80%] and those in eastern European countries. NGOs, patient associations, and other civil society organisations should take advantage of recent governmental efforts being made to pressure pharmaceutical companies to lower the pricing of HVC therapies.

The World Health Organization has also drawn attention to the health inequalities that affect the most vulnerable of HIV patients. In the lead up to the International AIDS Conference in Melbourne, Australia, which started earlier this week, the agency stated that globally the people most at risk of HIV are not getting the health services they need. The agency warned that: “Failure to provide adequate HIV services for key groups—MSM, people in prison, PWID, sex workers, and transgender people—threatens global progress on the HIV response.” New WHO guidelines on HIV prevention, diagnosis, treatment, and care for such populations have just been released.

It may seem too early to make conclusions, but in the EU the general trends show that austerity measures may very well be enhancing health inequalities. Therefore, although a general public health perspective remains necessary, efforts and resources should be increasingly focused in specific regions and population groups.

[1] HIV among migrants in the EU/EEA: epidemiological trends 2007-2012. V Hernando, A Pharris, D Alvarez, Y Rivero, S Monge, T Noori, AJ Amato-Gauci, J del Amo. Fifth European Conference on Migrant and Ethnic Minority Health. Granada, Spain 10-12 April 2014. Research not yet published.

Aser García Rada is a paediatrician who currently works at the primary care center Las Calesas in Madrid, Spain. He is also a freelance journalist.

Competing interests: I was paid expenses by the EU Commission for attending the HIV meeting in Athens that is mentioned in this blog.

See more on Aser’s biography.