HIV: epidemiological challenges in Europe

Epidemiological Challenges in Europe

Anastasia Pharris

European Centre for Disease Prevention and Control, Stockholm

EACS, Milan, 26 October 2017

Employed by ECDC

No conflicts of interest or disclosures

2

Acknowledgements

Teymur Noori, ECDCAnnemarie Stengaard, WHO Regional Office for Europe

3

• What is the epidemiology of HIV in the European Region?

• Is the European response sufficient?

• What are our challenges and opportunities in the decade ahead?

New HIV diagnoses in Europe, 2015

Source: ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015

<2 per 100 000

>50 per 100 000

20 to <50 per 100 000

10 to <20 per 100 000

2 to <10 per 100 000

WHO European Region

5

More than 150 000 new diagnoses(17.6 per 100 000 population)

79% in the East18% in the West3% in the Centre

Reported routes of HIV transmission*, by European sub-region, 2015

6

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Region West Centre East

Source: ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015

* Among those with known route of transmission

Heterosexual

Sex between men

Injecting drug use

Mother to child

Reported routes of HIV transmission*, by European sub-region, 2015

7

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Region West Centre East

Source: ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015

* Among those with known route of transmission

Heterosexual

Sex between men

Injecting drug use

Mother to child

Estimated new HIV infections are decreasing globally

1,400,000

1,600,000

1,800,000

2,000,000

2,200,000

2,400,000

2,600,000

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Nu

mb

er

of

new

dia

gno

ses

(glo

bal

)

Year of diagnosis

Global

Source: ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015. UNAIDS/WHO global estimates.

Global

Estimated new HIV infections are decreasing globally,but increasing in the WHO European Region

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

1,400,000

1,600,000

1,800,000

2,000,000

2,200,000

2,400,000

2,600,000

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Nu

mb

er

new

dia

gno

ses

(Eu

rop

ean

re

gio

n)

Nu

mb

er

of

new

dia

gno

ses

(glo

bal

)

Year of diagnosis

Global

WHO European Region

Source: ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015. UNAIDS/WHO global estimates.

Estimated new HIV infections are decreasing globally, but increasing in the WHO European Region

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

1,400,000

1,600,000

1,800,000

2,000,000

2,200,000

2,400,000

2,600,000

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

WHO European Region

Global

East

West

Centre

Source: ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015. UNAIDS/WHO global estimates.

HIV diagnoses, Eastern Europe

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Nu

mb

er o

f ca

ses

Year of diagnosis

Heterosexual +100%

Sex between men +1000%

Injecting drug use -38%

Source: ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015

IDU-driven epidemic, with increasing heterosexual transmission

HIV diagnoses, Central Europe

0

200

400

600

800

1000

1200

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Nu

mb

er o

f ca

ses

Year of diagnosis

Source: ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015

MSM/heterosexual-transmission driven epidemic

Heterosexual +83%

Sex between men +300%

Injecting drug use +200%

Heterosexual

-41%

Injecting drug use

-50%

Sex between men

+7%

Source: ECDC/WHO (2015). HIV/AIDS Surveillance in Europe, 2014

Data is adjusted for reporting delay. Cases 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.

Source: ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015

0

2000

4000

6000

8000

10000

12000

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

MSM are the only group where infections have increased, however….

HIV diagnoses, Western Europe

Proportion of HIV diagnoses among migrants, EU/EEA, 2007-2015

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2007 2008 2009 2010 2011 2012 2013 2014 2015

Western Europe

Central and EasternEurope

Sub-Saharan Africa

South and SoutheastAsia

Other

Latin America andCaribbean

Migrants play an important role in some European countries

37%

Where do migrants get infected with HIV (prior to or after arrival to Europe)?

18%

Source: Rice BD, Elford J, Yin Z et al (2012). A new method to assign country of HIV infection among heterosexuals born abroad and diagnosed with HIV in the UK. AIDS 26 (15): 1961-6

7%

Clinic-based estimate CD4-based estimate

Source: Rice BD, Elford J, Yin Z et al (2012). A new method to assign country of HIV infection among heterosexuals born abroad and diagnosed with HIV in the UK. AIDS 26 (15): 1961-6

Where do migrants get infected with HIV (prior to or after arrival to the Europe)?

18%

Source: Rice BD, Elford J, Yin Z et al (2012). A new method to assign country of HIV infection among heterosexuals born abroad and diagnosed with HIV in the UK. AIDS 26 (15): 1961-6

24%

7%

Clinic-based estimate CD4-based estimate

46%

Source: Rice BD, Elford J, Yin Z et al (2012). A new method to assign country of HIV infection among heterosexuals born abroad and diagnosed with HIV in the UK. AIDS 26 (15): 1961-6

Why is this important?

Screening newly arrived migrants at point of entry is not enough

Some sub-populations of migrants are at-risk for HIV acquisition many years after arrival to Europe

Countries should develop and deliver targeted primary HIV prevention programmes to migrant populations at risk

• What is the epidemiology of HIV in the European Region?

• Is the European response sufficient?

• What are our challenges and opportunities in the decade ahead?

Sustainable Development Goals and UNAIDS “Fast-track commitments”

Goals for Europe and Central Asia

√ To reduce new HIV infections to fewer than 63 080 by 2020

√ To reduce AIDS-related death

√ To eliminate HIV-related stigma and discrimination by 2020

Will we make it?

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

New

HIV

dia

gno

ses

Year

HIV Region 2020 target

HIV EU/EEA 2020 target

Fast Track Targets by 2020

73%of all people living

with HIV

VIRALLY SUPPRESSED

=

Target 1 Target 2 Target 3 Target 4

diagnosed with HIV

ON ART

living with HIV

DIAGNOSED

on ART

VIRALLY SUPPRESSED

% PLHIV who are diagnosed

Source: ECDC. Thematic report: HIV continuum of care. Monitoring implementation of the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia: 2017 progress report. Stockholm: ECDC; 2017.

>90%

80-90%

<50%

60-69%

70-79%

No/incomplete data

50-59%

Target 90%

West 84%

Centre 84%

East 57%

Source: ECDC/WHO Europe (2016). HIV/AIDS Surveillance in Europe, 2015

Testing: Too many people living with HIV are diagnosed late

*CD4<350 at diagnosis

51%

Persons with CD4 cell count <350 mm3 at HIV diagnosis, by European sub-region

0

10

20

30

40

50

60

70

2007 2008 2009 2010 2011 2012 2013 2014 2015

% d

iagn

ose

d la

te (

CD

4<3

50

mm

3)

Year of diagnosis

East

West

Centre

Source: ECDC/WHO Europe (2016). HIV/AIDS Surveillance in Europe, 2015

Fast Track Targets by 2020

73%of all people living

with HIV

VIRALLY SUPPRESSED

=

Target 1 Target 2 Target 3 Target 4

diagnosed with HIV

ON ART

living with HIV

DIAGNOSED

on ART

VIRALLY SUPPRESSED

Proportion of diagnosed PLHIV on ARTTarget 90%

Source: ECDC. Thematic report: HIV continuum of care. Monitoring implementation of the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia: 2017 progress report. Stockholm: ECDC; 2017; Pokrovskaya, HIV Glasgow, 2014

>90%

West 88%

Centre 69%

East 45%

80-89%

<50%

50-59%

60-69%

No/incomplete data

60-72%

Policies on ART initiation in European countries 2014 (n=48)

2015

Source: ECDC. HIV treatment and care. Stockholm: ECDC; 2017.

4

29

15

1028

8

1

0

5

10

15

20

25

30

35

40

45

50

2014 2016

Nu

mb

er o

f co

un

trie

s/A

RT

po

licy

200 cells/mm3

350 cells/mm3

500 cells/mm3

Initiation regardlessof CD4 count

Policies on ART initiation in European countries 2014 (n=48)

2015

Source: ECDC. HIV treatment and care. Stockholm: ECDC; 2017.

4

29

15

1028

8

1

0

5

10

15

20

25

30

35

40

45

50

2014 2016

Nu

mb

er o

f co

un

trie

s/A

RT

po

licy

200 cells/mm3

350 cells/mm3

500 cells/mm3

Initiation regardlessof CD4 count

Policies on ART initiation in European countries 2014 (n=48) and 2016 (n=47)

2015

Source: ECDC. HIV treatment and care. Stockholm: ECDC; 2017.

4

29

15

1028

8

1

0

5

10

15

20

25

30

35

40

45

50

2014 2016

Nu

mb

er o

f co

un

trie

s/A

RT

po

licy

200 cells/mm3

350 cells/mm3

500 cells/mm3

Initiation regardlessof CD4 count

Availability of ART for undocumented migrants, 2016

Source: ECDC. From Dublin to Rome: ten years of responding to HIV in Europe and Central Asia: Stockholm, ECDC; 2014

Source: ECDC. HIV and migrants. Monitoring implementation of the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia: 2017 progress report Stockholm: ECDC; 2017.

Fast Track Targets by 2020

73%of all people living

with HIV

VIRALLY SUPPRESSED

=

Target 1 Target 2 Target 3 Target 4

diagnosed with HIV

ON ART

living with HIV

DIAGNOSED

on ART

VIRALLY SUPPRESSED

Estimated % PLHIV who are virally supressed

Source: ECDC. Thematic report: HIV continuum of care. Monitoring implementation of the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia: 2017 progress report. Stockholm: ECDC; 2017; Pokrovskaya, HIV Glasgow, 2014

>73%

65-72%

<30%

43-30%

44-54%

No/incomplete data

55-64%

Target needed 90%

UNAIDS target 73%

EU/EEA 65%

Non-EU 24%

• What is the epidemiology of HIV in the European Region?

• Is the European response sufficient?

• What are our challenges and opportunities in the decade ahead?

• What is the epidemiology of HIV in the European Region?

• Is the European response sufficient?

• What are our challenges and opportunities in the decade ahead?

…….Implementing what we already know works!

Despite decades of evidence, harm reduction coverage remains low in parts of Europe

Opiate substitution treatment coverage

Needle and syringe programme coverage

Source: European Monitoring Centre for Drugs and Drug Addiction (2016), Drug-related infectious diseases in Europe. Update from the EMCDDA expert network, November 2016.Publications Office of the European Union, Luxembourg.

Turning the tide?

Source: Brown et al, Eurosurveillance 2017

32% decrease in London infections linked to increased testing, immediate ART, PrEP

Implementation of community-based testing by trained medical staff in Europe and Central Asia

Source: Dublin monitoring data 2016

Implementation of community-based testing by non-medical staff in Europe and Central Asia

Source: Dublin monitoring data 2016

Implementation of home sampling in Europe and Central Asia

Source: Dublin monitoring data 2016

Status of formal PrEP implementation in Europe (as per October 2017)

ECDC. Evidence brief: Pre-exposure prophylaxis for HIV prevention in Europe. Stockholm: ECDC; 2016. (updated)

Hornet/ECDC survey on PrEP(2017)

0

5

10

15

20

25

30

Condom + Healthpromotion

+ STI services + PEP + PrEP

Nr

of

cou

ntr

ies

rep

ort

ing

Combination prevention cascade: European countries with multiple interventions for MSM in place

Source: ECDC. The status of the HIV response in the European union/European Economic Area, 2016. Stockholm. ECDC: 2017.

Most European countries are not implementing a comprehensive

approach to prevention for MSM

2 out of 3 countries report that funds available for HIV prevention are insufficient to reduce the number of new HIV infections

Source: ECDC. The status of the HIV response in the European Union/European Economic Area, 2016. Stockholm. ECDC: 2017.

Using new technology to promote STI/HIV testing

European Testing Week

Mobile optimised HIV Test Finder

EU Test Finder stats

European HIV Testing Week 18-25 Nov 2016

Visits Page views

Friday 18-Nov 4 958 10 821

Saturday 19-Nov 20 640 39 600

Sunday 20-Nov 4 918 9 348

Monday 21-Nov 1 885 3 244

Tuesday 22-Nov 8 300 17 152

Wednesday 23-Nov 9 992 23 414

Thursday 24-Nov 6 463 12 875

Friday 25-Nov 8 458 18 218

Total: 65 614 134 672

63% 81%

Push messages sent to millions of users in

55 countries in 40 languages

Banner ads displayed to users in EU

countries (250K impressions)

EU LGBT Survey; European Union Agency for Fundamental Rights (FRA); 2013

Proportion of gay male respondents who state that no medical staff/health care provider is aware that they are gay.

Stigma

Factors that will affect our work in the coming decade

• Political instability, austerity

• Health care system re-structuring

• Migration

• Aging cohort of PLHIV

• Changes in drug markets and patterns of use

• Mobile technology

Conclusions

• Europe, as a region, is lagging behind in its response to the HIV epidemic and is not on track to reach the 2020 targets

• Effective interventions --frequent testing, immediate linkage to care and ART initiation, PrEP-- are not being applied at scale in many European countries.

• There is good news! Reduced incidence in MSM in select countries, MTCT and IDU

Into the next decade…

• As HIV incidence declines in some populations and regions, it will be concentrated in even harder to reach populations/places

• Uneven application of evidence-based prevention and treatment policies may further exacerbate existing inequalities in HIV incidence and outcomes across Europe

• We have sufficient tools to eliminate new HIV infections in Europe!

Thank you!

Dublin Declaration advisory groupIrene Rueckerl (Austria), Florence Lot, Daniela Rojas Castro, Richard Stranz (France), Gesa Kupfer (Germany), Derval Igoe (Ireland), Lella Cosmaro (Italy), Silke David, Eline Op De Coul (Netherlands), Arild Johan Myrberg (Norway), Olivia Castillo (Spain), Maria Axelsson (Sweden), Valerie Delpech, Alison Brown, Cary James, Brian Rice (United Kingdom), Velina Pendalovska (European Commission), Klaudia Palczak and Dagmar Hedrich (EMCDDA), Taavi Erkkola, Kim Marsh (UNAIDS) and Annemarie Steengard (WHO Regional Office for Europe).

Dublin Declaration focal points in Europe and Central AsiaRoland Bani (Albania), Montse Gessé (Andorra), Samvel Grigoryan (Armenia), Irene Rueckerl, Bernhard Benka, Robert Zangerle (Austria), Esmira Almammadova (Azerbaijan), Inna Karabakh (Belarus), Andre Sasse, Dominique Van Beckhoven (Belgium), Šerifa Godinjak (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), Tamar Kikvidze (Georgia), GesaKupfer, Ulrich Marcus, (Germany), Vasileia Konte, Chryssoula Botsi, Jenny Kremastinou, Theodoros Papadimitriou (Greece), Katalin Szalay (Hungary), Guðrún Sigmundsdóttir (Iceland), Derval Igoe (Ireland), Daniel Chemtob (Israel), Maria Grazia Pompa, Anna Caraglia, Barbara Suligoi, Laura Camoni, Stefania D’Amato, Anna Maria Luzi, Anna Colucci, Marco Floridia, Alessandra Cerioli, Lella Cosmaro, Massimo Oldrini, Laura Rancilio, Maria Stagnitta, Michele Breveglieri, Margherita Errico (Italy), Irina Ivanovna Petrenko (Kazakhstan), Laura Shehu, Pashk Buzhala, Bajram Maxhuni (Kosovo*), Dzhainagul Baiyzbekova(Kyrgyzstan), Šarlote Konova (Latvia), Irma Caplinskiene (Lithuania), Patrick Hoffman (Luxembourg), Jackie Maistre Melillo (Malta), Violeta Teutu (Moldova), Aleksandra Marjanovic (Montenegro), Silke David (Netherlands), Arild Johan Myrberg (Norway), Iwona Wawer, Piotr Wysocki, Adam Adamus (Poland), Antonio Diniz, Teresa Melo (Portugal), Mariana Mardarescu (Romania), Danijela Simic, Sladjana Baros (Serbia), Peter Truska (Slovakia), Irena Klavs (Slovenia), Olivia Castillo (Spain), Maria Axelsson (Sweden), Stefan Enggist, Axel Schmidt (Switzerland), Muratboky Beknazarov (Tajikistan), Nurcan Ersöz (Turkey), Valerie Delpech (United Kingdom), Igor Kuzin (Ukraine) and Zulfiya Abdurakhimova (Uzbekistan).

HIV Surveillance focal points in the EU/EEADaniela Schmid, Alexander Spina (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 (France), Barbara Gunsenheimer-Bartmeyer (Germany), Georgios Nikolopoulos 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 (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).