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POLICY BRIEF
2013
HIV in the European Region:
Using Evidence to Strengthen
Policy and Programmes
The full report was
written by researchers
from the London School
of Hygiene & Tropical
Medicine:
Lucy Platt,
Emma Jolley,
Vivian Hope,
Alisher Latypov,
Ford Hickson,
Lucy Reynolds and
Tim Rhodes
The number of
HIV cases in
the WHO European
Region continues
to increase and by
2011 reached over
1.2 million individuals.
Between 2006 and
2010 there have been
127 new diagnoses
each year per million
people in the Region”
“
This policy brief draws upon systematic reviews and secondary data
analyses regarding HIV among key vulnerable populations in the
European Region from the full report, “HIV Epidemics in the European
Region: Vulnerability and Response”.
The epidemic situation
The number of HIV cases in the WHO European Region continues to increase and by 2011
reached over 1.2 million individuals. Between 2006 and 2010 there have been an average of
127 newly diagnosed HIV infections each year per million people in the Region. The continuing
increase in new HIV cases in the European Region is largely attributable to the epidemics
in Eastern Europe and Central Asia (called ‘East’ in this report)—see Figure 1. An average of
74 and 11 newly diagnosed HIV infections per million were reported in Western Europe (‘West’)
and in Central Europe (‘Centre’) between 2006 and 2010. In contrast, 273 new diagnoses per
million population were reported in the East. In those five years, new diagnoses were relatively
stable in the West and Centre, but increased (by around 30%) in the East, with the highest
rates of new diagnoses in Estonia, Russian Federation and Ukraine. It is important to note
that case report data is only as robust as the HIV surveillance systems producing them.
All relevant citations and reviewed evidence are contained in the full report. The review covers
the following 53 countries of the WHO European Region and Lichtenstein:
West: Andorra, Austria, Belgium, Denmark, Finland, France, Germany, Greece, Iceland,
Ireland, Israel, Italy, Liechtenstein, Luxembourg, Malta, Monaco, The Netherlands, Norway,
Portugal, San Marino, Spain, Sweden, Switzerland, United Kingdom
Centre: Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic,
Hungary, Montenegro, Poland, Romania, Serbia, Slovakia, Slovenia, the former Yugoslav
Republic of Macedonia, Turkey
East: Armenia, Azerbaijan, Belarus, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia,
Lithuania, Republic of Moldova, Russian Federation, Tajikistan, Turkmenistan, Ukraine,
Uzbekistan
2 HIV in the European Region: Using Evidence to Strengthen Policy and Programmes
Figure 1:
Annual Number of HIV Case Reports by European Region, 2006 – 10
Sources: ECDC and WHO Regional Office for Europe HIV/AIDS surveillance in Europe (2011) and Russian AIDS Centre
Report (2011). Data for most recent years may be revised due to delays in case reporting.
...new diagnoses
increased in the
East, with the
highest rates of
new diagnoses in
Estonia, Russian
Federation and
Ukraine.
Three key populations at high risk contribute disproportionately to the European Region
epidemic: people who inject drugs (PWID), sex workers (SW), and men who have sex with
men (MSM). Figure 2 shows European Region HIV diagnoses reported per million population
by reported exposure—for PWID (or ‘Injecting Drug Users’, IDU) in red, for all heterosexual
exposures including sex work-related exposure in orange, and for MSM in green.
Figure 2: Annual HIV Case Reports per Million Population by European Region and Reported
Exposure for PWID (or Injecting Drug Users, IDU), 2006 – 10
Sources: ECDC and WHO Regional Office for Europe HIV/AIDS surveillance in Europe (2011) and Russian AIDS Centre
Report (2011).
Note: Other not known = Between 2006 and 2010 there were 740 with other transmission risk, that is, either haemophiliac/
transfusion recipient or nosocomial infection. In the East, a large proportion of HIV case reports had no information on
exposure type people who inject drugs; PWID = people who inject drugs IDU = injecting drug user; MSM = men having
sex with men.
People who inject drugs
Between 2006 and 2010, 25% of case reports in the European Region were associated with
injecting drug use, with much higher proportions in the East (33%) than West (5%) and Centre
(7%). The rate of HIV diagnoses linked to injecting drug use is 25 times higher in the East compared
HIV in the European Region: Using Evidence to Strengthen Policy and Programmes 3
to the West and over 100 times greater in the East compared to the Centre. The countries with the
highest levels of reported diagnosed cases among PWID in the European Region were Ukraine
(153 per million people), Russian Federation (98 per million people), and Kazakhstan (78 per million
people) (see Annex Figure 1). HIV prevalence among PWID is highest in Estonia
(55.3%), Spain (34.5%), Russian Federation (28.9%), Republic of Moldova (28.6%)
and Ukraine (22.9%). It is lowest in Albania, Croatia, Cyprus, Hungary, the former Yugoslav Republic of Macedonia and Slovenia. Though there are exceptions, risk factors
found generally to be linked to HIV among PWID are: a history of injecting with previously
used injecting equipment; injecting with greater frequency; injecting opiates as opposed
to amphetamines; a longer history of injecting; and being of female gender. For example,
data from Ukraine suggest that female PWID are at increased risk of psychological,
of HIV Case
Reports
physical (including sexual) and economic violence from male partners, which constrains
between
capacity to negotiate safer sex and safer injecting practices and access to help services,
2006 – 10 are
associated
consequently elevating their HIV risk. Contact with criminal justice agencies, including
with injecting
experience of incarceration, also emerge as risk factors for HIV. The available data,
drug use
including qualitative reports, suggest a relationship between street-based policing
practices, including extra-judicial ones such as police violence, and increased HIV
vulnerability, including through reduced capacity for risk avoidance as a consequence
of safety short-cuts and rushed injections borne out of a fear of detection or arrest.
25%
West
Centre
East
Sex workers
HIV remains relatively low among female sex workers, with HIV prevalence levels mostly below
the 10% mark (Annex Figure 2). A history of injecting drug use is a prime risk factor for HIV
among SWs in many countries. Other factors associated with higher odds of HIV or STIs among
SWs include: migration from Africa (though some studies show no such associations); lack of
service contact through outreach; contact with HIV testing and STI services; street-based sex
work; and unprotected sex with either non-paying partners or clients. In the West, HIV prevalence
is higher among male and transgender SWs than female SWs (even when drug injecting is
lower), reflecting the higher HIV prevalence among MSM, the main client group of male SWs.
Consistent condom use with clients is generally the norm among SWs, but it is much less common
with non-paying sexual partners. In countries where sex work is regulated, the benefits of this are
denied to migrant sex workers without legal residency rights who are not accorded the same
rights as non-migrants. There is some evidence that decriminalization of sex work can reduce
incidences of violence and improve the mental health of sex workers. Sex work in the European
Region has undergone changes, with the acquisition of clients often via internet and mobile
phones, a growing number of indoor SWs across the region (off-street sex work), and increased
involvement of women with migrant status who lack legal residency rights.
Men who have sex with men
Sex between men was reported for 10% of all HIV diagnoses in the European Region and
higher in the West (36%) than Centre (22%) or East (0.5%). From 2006 – 2010, the annual
average HIV diagnoses linked to sex between men was in the West over 10 times higher than in
the Centre, and almost 20 times higher than in the East (Annex Figure 3). It was highest in the
United Kingdom (43.4 diagnoses per million people), Netherlands (43.0) and Spain (37.3). But the
Centre and East have witnessed marked increases in the number of reported diagnoses
associated with sex between men in the last five years. Overall, HIV prevalence levels are
highest in the West, but vary from as low as 1.6% in Switzerland to nearly 20% in Spain. Primary
HIV risk factors among MSM are: inconsistent condom use; unprotected anal intercourse; and
a history of STIs. The epidemics among MSM in the West are likely to be perpetuated by a
core group of MSM engaging in high risk behaviours with a high number of sex partners. Under
reporting of MSM risk status in surveillance systems is likely in settings where social stigma is
greatest, arguably in the East of the region.
...data from
Ukraine suggest
that female PWID are
at increased risk of
psychological, physical
(including sexual) and
economic violence from
male partners, which
constrains capacity to
negotiate safer sex and
safer injecting practices
and access to help
services, consequently
elevating their HIV risk.”
“
4 HIV in the European Region: Using Evidence to Strengthen Policy and Programmes
Intersecting epidemics
SWs involved in
injecting drug use
have higher HIV
prevalence than
SWs who do not
inject drugs.
The HIV epidemics of the European Region in key populations at high risk are intersecting
epidemics, in which sexual risks intersect with those related to injecting drug use. SWs involved
in injecting drug use have higher HIV prevalence than SWs who do not inject drugs, and HIV
prevalence in SWs is highest in the East where HIV prevalence is highest among PWID. SWs
who inject drugs are more vulnerable not only to HIV, but also to violence, increased problems
with mental health, reduced condom use and unwanted pregnancies. New analyses of vulnerability and risk factors conducted herein showed a strong and consistent association between
an increased number of people imprisoned and increased HIV prevalence among PWID and
FSWs. Prison, an effect of criminalisation of drug use and sex work, is a risk environment for the
transmission of HIV.
A good way to compare the scale and nature of the European Region HIV epidemics is to compare
HIV case data per 1 million population, according to the reported exposure. Figure 3, using box
plots, illustrates the situation in the three regions by comparing 5-year averages of reported HIV
cases by exposure. The exposure group ‘heterosexual’ includes sex work-related transmission.
Even accepting how risk practices overlap, for instance, with some sex workers injecting drugs,
and the variation in frequencies of reported HIV cases within each sub-region, data suggest that
the epidemic is concentrated among MSM and PWID in the West, with far lower transmission in
the Centre concentrated among MSM, and higher transmission in the East concentrated among
PWID and strong contribution of heterosexual transmission. These dynamics are presented
graphically below.
Figure 3:
Regions
Comparison of 5-year Averages of Reported HIV Cases by Exposure in the Three
Prison, an
effect of
criminalisation
of drug use and
sex work, is a risk
environment for the
transmission of HIV.”
“
Source: ECDC and WHO Regional Office for Europe HIV/AIDS surveillance in Europe (2011) and Russian AIDS Centre
Report (2011).
Note: MSM = men who have sex with men; PWID = people who inject drugs; Boxes show the median score as a line and
the 25th percentile and 75th percentile of the data distribution as the lower and upper parts of the box. The area in the box
therefore represents the middle 50% of the observations. The “whiskers” show the smallest and largest observation.
Centre: Heterosexual exposure much higher in one country (Cyprus) than in all the others, explaining the maximum of 26
cases per million population. East: “other/unknown” category has two outliers at high level (Estonia 303 cases per million,
and Russian Federation 211 cases per million).
HIV in the European Region: Using Evidence to Strengthen Policy and Programmes 5
Will the HIV epidemic spread beyond key populations at high risk?
In many countries in the European Region, it is unlikely that the HIV epidemic will spread much
beyond the key populations at high risk if existing HIV prevention measures are
maintained or enhanced. However, there is potential for the epidemic to spread
beyond PWID, SW and MSM—with increasing heterosexual transmission—
in some countries in the East, notably Ukraine, Republic of Moldova, Estonia
and the Russian Federation. In these countries, surveillance among general population groups such as pregnant women should be reviewed and incorporated as a
response to the epidemic.
In the East, there is emerging evidence of the potential for sexual transmission of
HIV among PWID involved in sex work. The high prevalence of syphilis reported
alongside HIV observed in the Russian Federation, Ukraine, Republic of Moldova
and the Central Asian Republics suggests that conditions may exist for increased
sexual transmission of HIV among SWs. In some central European countries
including the Czech Republic, Slovakia, and increasingly Hungary, many injectors
report amphetamines and methamphetamines as their primary drug, which
can be associated with higher-risk sexual behaviours. The majority of PWID in
surveys across the European Region report inconsistent condom use with their
regular partners. Male PWID often have sexual partners who do not inject, and
these partners can be at risk of sexual HIV transmission. Some studies in the
East suggest that high proportions of MSM may inject drugs, while a substantial
proportion of MSM in the region, especially in the East, report also having sex with
women.
Are data collected to adequately track changes in epidemic trends
and responses?
HIV surveillance activities are generally well established in the European Region. Among 50
countries considered (excluding Andorra, Lichtenstein, Monaco and San Marino), all have HIV
case reporting systems. In a third of countries (18) there is evidence to suggest ‘comprehensive’
surveillance among PWID, MSM and SWs (i.e., monitoring HIV prevalence or risk in all three
groups); in another third (18) there is ‘extensive’ surveillance (i.e., monitoring HIV prevalence or
risk in two of the groups); in nine ‘focused’ surveillance (i.e., monitoring HIV prevalence or risk in
one of the groups); and in five, a ‘basic’ approach relying solely on HIV case report - see Annex
Figure 4.
Overall, surveillance of HIV prevalence or risk is better established among PWID than among
SWs and MSM, with very little data available among people classified as migrants and male
SWs. All but one country (Turkmenistan) in the Centre and East have generated survey-based
estimates of HIV prevalence among PWID. While there is a strong culture to collect and
aggregate epidemic data, the systematic collection of routine data on the delivery of
key interventions and combination service packages, and population sizes of PWID,
SWs and MSM (the denominators for coverage estimates) is weak. As a consequence, the
data on coverage of HIV prevention programmes is patchy. A key challenge in collecting data
to inform interventions is the regulatory and social context in which sex work, drug use and sex
between men takes place. In contexts where sex work is heavily regulated or sex between men
remains stigmatised, conducting HIV related surveillance studies among people with few rights
or representation can create ethical or safety challenges. There are some useful lessons in good
surveillance practice in the European Region, including the European Men’s Internet Survey
(EMIS) among MSM, the sentinel surveillance of HIV and risk among PWID in Spain, the
United Kingdom and Italy, and sentinel surveillance among SWs in Central Asia.
Overall,
surveillance of
HIV prevalence or risk
is better established
among PWID than
among SWs and MSM,
with very little data
available among people
classified as migrants
and male SWs.”
“
6 HIV in the European Region: Using Evidence to Strengthen Policy and Programmes
HIV testing rates are higher in the East, especially in the Russian Federation. This may result from
mandatory testing of migrants and the practice of ‘opt-out’ rather than ‘opt-in’ testing polices in
various health service settings as well as an occupational requirement. There is some evidence
that HIV testing contributes to behaviours that lead to reduced HIV risk among PWID and SWs
and unprotected anal intercourse among MSM, but there is a need to evaluate the effectiveness
and cost-effectiveness of wide-spread population testing that occurs in the East.
Surveillance
systems need to be
better at assessing
epidemic trends
as well as giving
indicators of
intervention
coverage.
Taken together, data collection systems should be further strengthened regarding their reach
of key populations at high risk, their frequency of data collection, and their capacity to assess
trends in epidemic spread and intervention coverage. Importantly, surveillance systems provide
unrealised opportunities to collate data on indicators of coverage of HIV prevention and the extent
to which these are provided as part of a combination package.
Are the types and coverage of HIV prevention programmes
adequate?
For PWID, the combination of needle and syringe programmes (NSP), opioid substitution therapy
(OST), and antiretroviral HIV treatment (ART) is widely recommended as a core package. Evidence
indicates that these interventions have enhanced HIV prevention impact when delivered in
combination. The interventions need to be accompanied by uptake in HIV testing and counselling
among PWID to facilitate a timely start of ART. Estimates of NSP, OST and ART coverage among
PWID vary throughout the region, but coverage is generally lowest in the East, where HIV infection
rates are higher and where HIV transmission is strongly PWID-driven. The availability of needles
distributed to PWID varies considerably across the countries (Figure 4). Law enforcement, policing
practices, and national commitments to HIV prevention can limit HIV prevention coverage potential.
There are countries in the region where the legal and social environment has constrained, even
prohibited, the development of proven-to-be-effective HIV prevention intervention, such as OST (in
the Russian Federation, Uzbekistan, Turkmenistan and Turkey).
For PWID, the
combination of
needle and syringe
programmes (NSP),
opioid substitution
treatment (OST),
and antiretroviral
HIV treatment
(ART) is widely
recommended as a
core package.”
“
Figure 4:
Region.
Number of Needles Distributed Per PWID in 2009 or Most Recent year, European
Sources: EMCDDA Statistical Bulletin 2011; Mathers et al, 2010.
Note: PWID = people who inject drugs.
HIV in the European Region: Using Evidence to Strengthen Policy and Programmes 7
Concerning sex work, there is a wealth of evidence showing the positive impact of specialist
services in reducing risk of HIV and STIs among SWs from both the European Region and internationally. Targeted services have the advantages of opening at convenient times and staffed by
people familiar with sex work related issues and are non-judgemental. Yet in many parts of the
European Region the provision of specialist services is low and with a narrow focus on STI/HIV
treatment rather than addressing broader social and health issues that affect SWs. Specialist
sex worker services are relatively sparse in most countries (Figure 5). Across the region, the
Russian Federation, Slovenia, Spain and Germany have the smallest number of sex workertargeted services (<0.2 per 1000 FSWs). Finland, Norway and Luxembourg have the largest
number (>2.8). Where sex work and drug use are closely linked (especially the case in the East),
the lack of integration between sexual health services and drug treatment impairs SW service
provision. Many countries in the West and Centre have legalised the selling of sex, but sex work
remains a criminal and/or administrative offence in a significant number of countries, or remains
unregulated (Figure 6). In countries, such as Germany, where sex work is legal and there are
large network of sexual health clinics, sex-work specific services may be less important than in
countries where SWs are highly marginalised.
Figure 5:
Number of Specialist Sex Worker Services Per 1,000 FSWs in the European Region.
Sources: Data collected from: services4sexworkers.org; Global Fund; International AIDS Alliance; TAMPEP.
Notes: FSW = female sex workers; Services offered include a wide range of sexual health, social support and legal
services and excludes standard STI clinics and health services that treat non-sex working populations.
Accurate data on HIV programme coverage are difficult to collect among MSM. However,
available UNGASS and EMIS 2010 data suggest that coverage is highly variable across the
region, and that direct comparison of reported data is hampered by the different ways countries
define programme coverage. MSM can increasingly be reached with information via the internet,
but access to the internet is unequal between countries and between types of MSM. Health
service access and use is chiefly determined by the legislative and social environments affecting
MSM. Figure 7 depicts a social inclusion index for each country, reflecting the legislative and
social environments affecting MSM throughout the European Region.
Where sex
work and
drug use are
closely linked
(especially the case
in the East), the
lack of integration
between sexual
health services
and drug treatment
impairs SW service
provision.”
“
8 HIV in the European Region: Using Evidence to Strengthen Policy and Programmes
Figure 6:
The enhanced HIV
prevention effects
of combining OST
with NSP and ART
have particular
importance for
countries like the
Russian Federation
and Ukraine
which have
experienced large
HIV outbreaks
among PWID.
Legal Status of Selling Sex in the European Region
Sources: EMCDDA Statistical Bulletin 2011; Mathers et al, 2010.
Figure 7:
Legislative and Social Environments Affecting MSM Throughout the European Region
Source: Literature review, main report.
Enhancing HIV prevention: What
policy makers and HIV programme
implementers can do
In order to change the epidemic trajectories in the three sub-regions of the European Region—
especially among populations of PWID, SWs and MSM—the following policy and programme
recommendations should be implemented:
HIV in the European Region: Using Evidence to Strengthen Policy and Programmes 9
Preventing HIV among PWID and their sexual partners
1. Scale-up combination HIV prevention for PWID, especially in the Russian Federation,
Ukraine and other countries in the East
The three core HIV prevention interventions of NSP, OST and ART work best if provided
in combination and accompanied by voluntary HIV testing and counselling. Therefore, it is
essential this combination of interventions are sufficiently scaled-up, especially in the East.
Mathematical modelling shows that when core interventions are delivered in combination, a
sufficient coverage level of the target population can be reached to reduce HIV incidence. The
enhanced HIV prevention effects of combining NSP with OST and ART have particular importance for countries like the Russian Federation and Ukraine which have experienced large
HIV outbreaks among PWID. The unavailability of OST in the Russian Federation is a serious
deficit in service provision. Uzbekistan, Turkmenistan and Turkey also lack OST, and pilot
projects need to be expanded in Kazakhstan. Turkey is the priority country to integrate NSP
as part of its service provision for PWID of the five countries not providing NSPs (Andorra,
Iceland, Monaco, San Marino and Turkey). Reviewed data suggests that there is also an
urgent need to maximise the coverage and intensity of HIV prevention in prison settings (for
instance, in Estonia and Lithuania an estimated 58% – 70% of PWID have been in prison at
least once, and in the Russian Federation this figure is 37%). International agencies, including
WHO, therefore recommend a combination of NSP; OST (and other drug dependence treatment); ART; prevention and treatment of STIs; condom programmes; targeted information,
education and communication; diagnosis and treatment of, and vaccination for, viral hepatitis
and prevention, diagnosis and treatment of tuberculosis to prevent HIV among PWID and
their sexual partners. Community based outreach is also recommended as an extraordinarily
effective means of reaching and delivering services. Additionally, evidence supports a place
for supervised injecting centres and other interventions to create safer injecting environments,
as well as the promotion of public policies and structural changes oriented to creating social
environments in which populations at risk have the capacity to access low threshold helping
services and reduce their HIV risk.
2. Implement interventions fostering social and environmental change, to enhance
PWID-targeted HIV prevention programmes, especially in selected countries in the
East
Overall, structural interventions to enable sufficient HIV prevention scale-up are most urgent
in the East. The widely recommended package of combination HIV prevention gives little
attention to social and structural interventions, despite evidence of the critical importance
of social and structural factors shaping HIV risk reduction. The secondary distribution of
sterile injecting equipment through peer networks of PWID is a practical yet under-formalised
example of how to diffuse HIV prevention through social networks. Pharmacies provide a
significant point of access for sterile syringes in many parts of the European Region, and
this delivery channel can be further strengthened (for instance, pharmacy sales are legally
restricted in Sweden). The introduction of supervised injecting centres in six countries in the
European Region goes some way towards addressing the need to create safer injecting environments, and others countries could follow these examples. Broader social interventions,
such as anti-stigma interventions and initiatives to promote the human and access to service
rights of PWID should also be considered.
3. Promote policy reform and legal change, to create enabling environments for HIV risk
reduction
Ecological evidence indicates elevated odds of HIV and HIV risk among PWID in settings
without legal access to HIV prevention such as OST and NSP compared to settings with
access. In some countries in the East, including Russian Federation, Ukraine and Georgia,
the requirement for registration to access drug treatment can result in decreased use of harm
reduction services, reduce access to employment opportunity, increase felt stigma, and leave
The secondary
distribution
of sterile injecting
equipment through
peer networks of
PWID is a practical
yet under-formalised
example of how to
diffuse HIV prevention
through social
networks.”
“
10 HIV in the European Region: Using Evidence to Strengthen Policy and Programmes
individuals more vulnerable to police intervention. The relaxation of legal restrictions to the
provision of sterile needles and syringes increases their availability and accessibility, reducing
levels of risk behaviour, as well as potentially levels of police harassment among PWID (and
thus impact on epidemic spread). Interventions which bring about change in the legal environment seek to minimise effects of the criminalisation of drug users and of the prohibition of HIV
prevention interventions. The WHO notes that “the alignment of drug control measures with
public health goals is a priority”. If HIV risks are in part associated with the criminalization of
drug use per se, as is increasingly evidenced internationally, then decriminalizing drug use is
also a strategy to reduce such harm. Recommended interventions, which target changes in
criminal justice systems, include:
Key targets for
health interventions
for SWs, in
addition to HIV risk
reduction, include
reducing violence
and unwanted
pregnancies,
and improving
mental and
emotional health.
With the
growing
number of indoor
SWs across the
region, there is
a need to reach
off-street sex
workers, for instance
by conducting
outreach on-line,
contacting women
via websites and
circulating frequent
emails about
services.”
“
•
Police HIV prevention training and partnerships
•
Developing alternatives to prison programmes, including coerced or mandated entry to
drug treatment via community penalties and court orders
•
The provision of sterile injecting equipment in prisons (where evidence suggests positive
risk reduction effects)
•
The provision of OST in prisons, linked to improved drug treatment outcomes including
post release
•
Interventions enabling legal aid and legal rights literacy to protect against rights violations
(note that the HIV prevention impact of these has not been proven)
Preventing HIV among sex workers, their clients, and the sexual
partners of their clients
1. Attain universal access to comprehensive and evidence-informed HIV services which
are adapted to the specific health, welfare and protection needs of SW
Evidence shows that a larger HIV impact is obtained when services for SW address HIV/
STIs simultaneously with the broader social and health problems of SW. However, in some
countries, especially in the East, the focus of services has been on SWs who inject drugs
rather than targeting the health and welfare needs of all SWs more broadly. Key targets for
health interventions for SWs, in addition to HIV risk reduction, include reducing violence and
unwanted pregnancies, and improving mental and emotional health. Sexual health interventions throughout the region need to focus not only on sexual safety negotiations with clients of
SWs but also on promoting contraceptive use among the non-paying sex partners of SWs to
prevent unplanned pregnancy and unprotected sex. The mandatory approach to HIV testing
following SW arrest or detention must be stopped in favour of facilitating voluntary testing
alongside counselling. It is also important that drug and sexual health services are sufficiently
integrated to maximize their coverage potential. The vertical structure of health service provision, especially in the East of the region where SW and drug use are closely intertwined,
compounds the problem of targeting HIV prevention to all those potentially in need, as there
is often little linkage between drug treatment and sexual health services. In these contexts,
HIV prevention services for PWID and SWs need to be integrated, with cross referrals and
service linkages, where possible.
2. Change the nature and improve coverage of programmes for hard-to-reach , part time
and migrant SWs across the European Region
The heterogeneous nature of sex worker populations in the European Region requires
a context-specific and flexible intervention approach. Programme reach across the European Region is insufficient. Across the region, the Russian Federation, Slovenia, Spain and
Germany have the smallest number of specialised sex worker-targeted services (<0.2 per
1000 FSWs). The rapidly changing sex worker scene in the European Region accentuates
the need for innovative approaches to health service provision. With the increased use of the
internet and mobile phones to acquire clients, there has been a diversification of indoor sex
work and the increased involvement of women with migrant status (without legal residency
rights) in sex work. With the growing number of indoor SWs across the region, there is a
HIV in the European Region: Using Evidence to Strengthen Policy and Programmes 11
need to reach off-street sex workers; for instance, by conducting outreach on-line, contacting
women via websites and circulating frequent emails about services. The provision of translated materials and interpreters is a priority for short-term interventions, as a result of the
increase in migrant women, in the West. In countries where sex work is regulated, the benefits
of this are denied to migrant sex workers without legal residency rights who are not accorded
the same rights as non-migrants. While it is fundamental that HIV prevention interventions
specifically target SWs, including those not involved in drug use, this is harder to do among
those who may not define themselves as connected to the sex industry. One approach to
including this population is to incorporate HIV prevention interventions inside change strategies that simultaneously address the social welfare of sex workers and their social determinants of health, including disparities in employment opportunity for women, income and
access to welfare services.
3. Within the combination prevention strategy, enhance community-level interventions
to address underlying and contributory factors of SW’s HIV risk
There have been increased calls for applying a pragmatic ‘harm reduction’ approach to sex work
as more commonly applied in relation to drug use. A harm reduction framework for sex work
seeks to envisage how a variety of harms related to sex work might be relevant, directly or indirectly, to HIV prevention. One of the key concerns is violence. The data show that violence experienced by SWs in family, social and work relationships is contextualised by broader social and
structural violence feeding social stigma and discrimination. Other effects are reduced self-esteem and ability to negotiate safer practices for fear of further violence, increasing drug use to
manage the stress of violence or forced relocation of sex work to less familiar or safe areas.
The significance of violence in the everyday lives of SWs emphasises the need for envisaging
HIV prevention inside a social and structural intervention approach to reducing sex work risks
of which HIV is one. Community-level interventions may facilitate some of the social changes
required to improve social acceptance and protection of SW, including regarding the practices of
police and health care professionals. Therefore, in the short and medium-term, emphasis should
be given to community-level interventions, such as the development of managed street sex
work zones, which have shown positive effect in reducing incidences of violence and providing
a safer place to work. Managed street zones need consent of local communities, and need to
clearly assign responsibilities to authorities to manage the zone. A long-term SW strategy may
include the decriminalization of sex work across the region, since the evidence suggests that
such a change would positively impact HIV prevention, including indirectly through the reduction
in violence, incarceration rates and SWs’ mental health problems.
Preventing HIV among men who have sex with men, including their
female sexual partners
1. Scale-up HIV service models which improve reach and coverage of MSM with
high-impact interventions
Effective measures to estimate coverage of services by MSM are urgently needed in order to
monitor uptake of services. It is likely that coverage is highly variable across the region, with
the legislative and social environment impacting upon service use by MSM. Studies have
shown that paying for tests and other medical care is a major barrier to service uptake by MSM
and should therefore be discontinued. Equally, condoms should be made freely available in all
gay venues and known MSM meeting places and dedicated MSM-only test facilities may be
needed. Voluntary HIV testing and counseling may offer prevention benefits in non-infected
people. Evidence suggests that HIV testing can increase condom use for anal intercourse,
but for HIV-negative men is a more effective HIV prevention strategy when accompanied
by counselling on risk reduction. However, effective counselling is rare in contexts where
specialised services are scarce. For full health impact, it is essential that links are made with
other prevention services appropriate to the needs of MSM, particularly in the East where
many MSM seem poorly informed of HIV risks linked to certain practices. Condom promo-
The data show
that violence
experienced by
SWs in family,
social and work
relationships is
contextualized
by broader social
and structural
violence feeding
social stigma and
discrimination.
Condom
promotion must
be accompanied with
behaviour change
messaging, especially
on reducing rates
of partner change,
having fewer partners
and the avoidance of
multiple concurrent
partnerships.”
“
12 HIV in the European Region: Using Evidence to Strengthen Policy and Programmes
tion must be accompanied by behaviour change messaging, especially on reducing rates of
partner change, having fewer partners and the avoidance of multiple concurrent partnerships.
2. Recognize the heterogeneous nature of populations of MSM and their living situations,
and tailor interventions accordingly
One difficulty with the targeting of HIV prevention to MSM is that it tends to be based on interventions targeting homosexually-identified men. However, designated gay men’s services
and interventions may disproportionately fail to reach men of lower socioeconomic status,
men from minority cultures and male sex workers. In some settings, significant barriers to
service access exist for MSM with migrant status. In the former Soviet Union, HIV and STI
treatment requires official residency documents; such a requirement excludes migrant MSM.
In terms of reaching the target group, the internet is increasingly utilised to reach MSM with
HIV communication, however, internet access is not equally distributed across countries, or
across demographic groups within countries. It is generally less accessible to many in the
East, especially in less affluent areas. In terms of social inclusion of MSM, the shift towards
recognizing MSM in the West—for instance, through the legalization of civil partnerships
between men—are important in that they contribute to an enabling context for health and citizenship, including potentially for HIV prevention. Community-level interventions may facilitate
some of the social changes required to enable the wider social acceptance of homosexuality,
including regarding the day-to-day practices of health, welfare and regulatory institutions, and
especially the practices of police and health care professionals.
3. Attain legislative equality and full social inclusion of MSM, by promoting legal and
societal change to decriminalise and de-stigmatise homosexuality
The legal situation facing MSM, and the social regulation of homosexuality, varies across the
region. There is a clear pattern of increased restrictiveness in the East compared to the West. In
part, this is because membership of the European Union requires the repeal of anti-homosexuality legislation, and the Treaty of Amsterdam requires its Member States to
enact anti-discrimination legislation. Nineteen countries display every feature of an
enabling environment in terms of legislation, social inclusion and acceptance, and the
recognition of civil partnership or marriage. Turkmenistan and Uzbekistan do not, and
sex between two consenting male adults remains illegal. In Turkmenistan and Uzbekistan criminal codes state that sex between men is punishable by imprisonment. Legal
change is a prerequisite to the formulation of MSM-supportive, non-discriminatory and
protective policies, as well as increases the validity of surveillance data. Access to
mainstream sexual health provision for MSM can be impeded by staff hostility borne
out of the dual stigma of homosexuality and HIV, and patient fears concerning breaches
of confidentiality. Such concerns appear more acute in the East. For instance, social
stigma appears to act as a deterrent to timely HIV testing, and levels of HIV testing are
lower in the Centre and East. Governments should therefore act to:
•
•
Remove legal prohibitions on sex between men
Set up a mechanism to prosecute police involved in harassment, assault or
extortion of MSM
•
Require police to enforce the laws against assault for MSM on equal terms with
the rest of the population
•
Provide legal recognition and protection of same sex relationships.
Preventing HIV through the strategic use of antiretrovirals
1. Maximise the coverage of ART in people living with HIV to enhance HIV prevention
effect
Antiretroviral therapy (ART) was introduced in 1996. The increasing use of effective ART regimens in the region since then has resulted in fewer people developing AIDS, and an increase
HIV in the European Region: Using Evidence to Strengthen Policy and Programmes 13
in the recovery of people diagnosed with an AIDS-defining illness. With the exception of
the East, declines in the number of AIDS cases have been recorded among both men and
women. Access to ART varies across the region, with data between 2002 – 2006 suggesting
that access to ART was inequitable in terms of gender in the Centre and the East, favouring
women over men, and in terms of age in the East, favouring children over adults. In addition,
key populations at high risk have disproportionally lower access to HIV treatment: in 2010,
62% of the reported people living with HIV acquired HIV infection through injecting drug use,
whereas only 22% of those receiving ART were people who injected drugs. Importantly, ART
can reduce viral load to undetectable levels. Strong evidence supports the efficacy of ART
in preventing heterosexual HIV transmission. The highest priority must be to increase the
number of people infected with HIV to receive ART, for both clinical and prevention benefits,
while ensuring equitable access for all key populations in need.
2. Assess the potential impacts of pre-exposure prophylaxis in HIV negative key
populations
In addition, there is a need to assess the potential impacts of using ART as a prophylaxis
in sero-negative people among key populations in the the European Regionan Region. A
landmark multi-country, randomized, placebo-controlled trial outside the European Region
in sero-negative MSM and transgender women who have sex with men, reported a 44%
HIV incidence reduction linked to pre-exposure prophylaxis (PREP). While these findings are
encouraging, the potential limitations of this strategy to curb MSM-linked transmission needs
to be considered, including side effects such as renal insufficiency, the potential emergence
of drug resistance, long-term treatment effectiveness, behavioural risk compensation, medication-use fatigue, and the high cost. Given the absolute risk reduction of 2.26 percentage
points reported in the study, about 44 individuals would have to receive pre-exposure prophylaxis to prevent one infection (it has been estimated that in the United States, preventing
one infection over a 1-year period would cost almost US$500,000, an amount about 20
times higher than providing ART to one person for a year). More research and consultation is
needed in the European context.
Contributing to HIV prevention by improving surveillance and
research
1. Establish mechanisms for repeated measures of HIV prevalence and risk, as well as
the collection and use of routine monitoring data to estimate programme coverage
Among PWID, HIV prevalence and behavioural studies need to be conducted in Turkey and
Ireland where outdated evidence and HIV case reports suggests high prevalence of HIV. No
surveys were identified in Iceland or Turkmenistan for PWID. In the context of economic decline
across the region and the recent HIV outbreak in Greece and Romania, vigilance in monitoring
HIV case reports as well as HIV prevalence/behavioural surveys (where they are currently none)
are required. Routine data on the delivery of the three core interventions NSP, OST and ART,
are of chief importance, and whether they are provided as a combination package to PWID.
Among SW, HIV prevalence and behavioural studies need to be implemented in Portugal and
Turkey and improved in Estonia and Netherlands. This is particularly important given the lack
of routine HIV/STI epidemiological data in relation to sex work in the European Region. The
European Centre for Disease Control highlighted the limited scope of behavioural surveillance among SWs in EU countries usually collected through one-off surveys rather than on
going or repeated surveillance at a national level. There was also little consistency in the type
of indicators collected on SWs making comparisons difficult to draw. The routine collation
of reported HIV or STI testing at SW services would facilitate an estimate of the effective
coverage of services in relation to HIV prevention taking into account the need for consultation and protection of privacy. Routinely monitoring condom use with clients and non-paying
Strong evidence
supports the
efficacy of ART
in preventing
heterosexual HIV
transmission.
14 HIV in the European Region: Using Evidence to Strengthen Policy and Programmes
partners would also give an insight into sexual risk behaviours, as the high prevalence of
gonorrhoea underscores the persistent sexual vulnerability of SWs.
Regarding male sex workers (MSW), studies were found in only six countries across the
region, and all these studies found high prevalence of HIV in MSW (>5%). Portugal, Switzerland, Denmark, Ireland, Greece, France and Luxembourg also report an above average
number of HIV cases among MSM and should consider implementing HIV prevalence
studies among MSW. Slovakia, Poland, Luxemburg, and Italy—countries of HIV prevalence
in MSM above 5%—need to implement repeated studies for monitoring HIV prevalence and
risk behaviours.
2. Develop a centralised portal for the synthesis of surveillance and survey data to enable
cross region comparisons
At present there is no centralised portal for the collation and synthesis of HIV prevalence data
at the the European Regional level, a former responsibility of EuroHIV. The development and
maintenance of monitoring activities at a national level could be aided by the European wide
central collation of core data on HIV prevalence and risk behaviours. The extent of surveillance among PWID in EU countries is likely an indirect consequence of the central collation
system operated for HIV prevalence among PWID by the European Monitoring Centre for
Drugs and Drug Addiction, EMCDDA. Data on directly measured HIV prevalence among
vulnerable populations of PWID, SW and MSM should be collated centrally. Consideration
should also be given to collecting risk behaviours data centrally, as well as data from other
populations at risk, including migrants.
It is also
fundamental
that HIV prevention
responses integrate
sexual health and
drug-related health,
and that surveillance
systems are
broadened towards
such ancillary health
indicators.”
“
3. Include monitoring indicators of how the social and structural context mediate HIV
Surveillance systems in the European Region are poorly oriented to capturing indicators of risk
environment. They therefore need to give more importance to tracking the main risk factors
governing vulnerability and HIV exposure of PWID, SW and MSM, and relating these data to the
legislative and policy context. This means for instance, monitoring the prevalence of violence
among SWs and MSM, and the prevalence and contexts of policing practices, including extrajudicial practices, which may violate the human rights of PWID as well as potentially impact upon
their HIV risk reduction capacity.
4. Know the size of key populations at high risk
All countries within the region should regularly assess and estimate the sizes of the three
main key populations at high risk, and the plausibility of the estimates generated should be
assessed robustly by a range of stakeholders including civil society groups from within the
populations of interest. This should be undertaken at least every 10 years. It is also fundamental that HIV prevention responses integrate sexual health and drug-related health, and
that surveillance systems are broadened towards such ancillary health indicators.
5. Conduct a systematic assessment of the robustness of methods used to monitor HIV
risk in vulnerable populations over time
The review found that systems for collating HIV diagnoses need to increase the completeness and accuracy of risk factor data they collect. Subcategories of exposure among those
exposed heterosexually should be considered, for example in the case of sexual partners
of PWID. There is also a need to better monitor migrant status in HIV diagnoses reporting
systems. Increased monitoring of the accessibility of HIV prevention responses to migrant
PWID, SWs and MSM is also needed. Data on the coverage of combination interventions
is not routinely or systematically collected in the region, and this should be changed, given
the importance of access to a combination of proven HIV interventions. HIV related surveillance activities should be conducted in full consultation with affected populations, and with
appropriate rights protections in place. There are unrealised opportunities to collate surveillance data on indicators of HIV prevention intervention coverage, as outlined in 3rd generation
HIV in the European Region: Using Evidence to Strengthen Policy and Programmes 15
surveillance guidelines. The collection and collation of data on the coverage of combination
interventions is especially important.
6. Develop empirically-informed models of social and structural HIV prevention
The review identified structural indicators relating to criminalisation, low income, and gender
inequality as important. But how these factors may directly or indirectly mediate pathways
of risk towards HIV transmission is often unclear, as well as situation dependent. Wealth,
for example, does not have a straightforward relationship to HIV. Gender inequality is
reproduced non-linearly through situation specific interactions occurring simultaneously at
the structural level (for example, via laws or policy), at the level of the community or household (for example, through social norms, values and networks), and through individual and
interpersonal actions (for example, through risk negotiation and behaviour). A risk factor for
HIV such as physical violence, for instance, may act as a proximal indicator of structurally
determined social marginalisation indirectly mediated through a combination of gender and
material inequalities. Clearly, HIV is an outcome of multiple contributing factors interacting
together. There is therefore a need for an iterative and mixed-methods research approach, in
which qualitative evidence helps to map risk environment pathways, which are further elaborated through multi-level epidemiology. Future social epidemiological research investigating
HIV vulnerability in the region should address the criminalisation of vulnerable populations;
drug use and sexual practices; the experience of social stigma and discrimination; migration;
gender inequalities; and material inequalities; among others. Epidemiological and intervention studies of HIV among vulnerable populations need to better systematically delineate how
micro-and macro-environmental factors combine to increase or reduce HIV risk.
Clearly, HIV is
an outcome
of multiple
contributing
factors interacting
together.
Directing the response to where the
need and returns are largest
The synthesis of case report and HIV prevalence data suggest that the allocation of HIV prevention
resources should concentrate upon bolstering and expanding combination prevention responses
targeting PWID and their sexual partners in the East of the European Region, introducing prevention responses among MSM in the East and Centre, and reinvigorating prevention responses
among MSM in the West. With relatively low HIV prevalence in female sex workers, but strong
associations between injecting drug use and sex work, and high heterosexually acquired HIV
infections especially in the East, sex workers remain an important target population. In the West,
efforts need to be directed particularly towards male and transgender SWs (their risk linked to the
higher HIV prevalence among MSM, the main client group of male SWs).
The review of the HIV epidemics and responses in the European Region points to important
differences in the region, which must be used to inform targeting of the response. It suggests
that levels of risk behaviour among vulnerable populations are highest in the East. While the
frequency of reported needle or syringe sharing is highly variable across PWID in the European
Region, there are instances of particularly high levels of sharing in the East. Among SWs, the
systematic review showed that condom use with clients was consistently higher in the West than
East or Centre. Among MSM, the highest rates of condom use during anal sex emanate from
studies in the West, with rates around 15% higher than those reported in the East. Reports of
unprotected anal intercourse are also higher in the East than West or Centre. Most PWID across
the region report inconsistent condom use with their regular partners, with a substantial minority
reporting inconsistent condom use with their casual partners. HIV prevention interventions need
to give priority to targeting the intersection of sex work and injecting drug use. The uptake
of HIV testing needs to be increased but simultaneously increasing access to treatment and
reducing stigma associated HIV positivity and the removal of structural barriers to employment
and discrimination for those diagnosed.
...strong
associations
between injecting
drug use and sex
work and high
heterosexually
acquired HIV
infections especially
in the East, sex
workers remain an
important target
population.”
“
16 HIV in the European Region: Using Evidence to Strengthen Policy and Programmes
The review
highlights the need
for HIV prevention
programmes to
embrace social
and structural
interventions
which aim to bring
about a contextual
change in the
environments
which mediate
HIV risk.
The review highlights the need for HIV prevention programmes to embrace social and structural
interventions which aim to bring about a contextual change in the environments which mediate
HIV risk, with the objectives of removing barriers to HIV prevention and enabling social conditions
which protect against HIV vulnerability.
There are a number of intervention approaches which show promise. These include HIV
prevention focused interventions which aim to:
•
•
Create safer physical environments, for instance through safer injecting facilities, safer brothel
policies, managed sex work zones
Create safer social environments by diffusing changes in risk-related norms, values and
practices at the level of peer groups and social networks, and by anti-stigma interventions
•
Create safer legal environments by fostering legal change, avoiding the criminalisation of key
populations, minimising the HIV harms related to policing practices and by offering legal aid
or advocacy
•
Create ease of access to helping and health services by developing legal and human rights
literacy among key populations and creating public policies supportive of health service equity
•
Develop non-HIV and non-health focused structural and multi-sectoral initiatives which can
be theorised to have an indirect HIV prevention effect, including those linked to housing,
education, and social welfare.
Evidence assessing social and structural HIV prevention among vulnerable populations remains
embryonic, and creating this evidence is a key challenge for the future in order to ensure high
impact and cost-effective HIV responses in the European Region.
Annex: Additional figures
Annex Figure 1: Average HIV Case Reports Attributed to Injecting Drug Use Per Million,
European Region
Sources: ECDC and WHO Regional Office for Europe HIV/AIDS surveillance in Europe (2011) and Russian AIDS Centre
Report (2011).
HIV in the European Region: Using Evidence to Strengthen Policy and Programmes 17
Annex Figure 2:
Best Estimates of HIV Prevalence Among FSWs Across the European Region
Source: Literature review and estimates, main report.
Annex Figure 3:
Average HIV Case Reports Attributed to Sex Between Men Per Million
Sources: ECDC and WHO Regional Office for Europe HIV/AIDS surveillance in Europe (2011) and Russian AIDS Centre
Report (2011).
18 HIV in the European Region: Using Evidence to Strengthen Policy and Programmes
Annex Figure 4:
Monitoring of HIV Prevalence or Behaviours among MSM, PWID and SW
Source: Literature review, main report.
Acknowledgements
This review and secondary analysis of data on HIV in vulnerable and key populations at high risk
in the European Region was carried out by the Centre for Research on Drugs and Health Behaviour of the London School of Hygiene and Tropical Medicine (LSHTM), United Kingdom. The
work draws extensively from data collected by the European Centre for Disease Prevention and
Control (ECDC), the Eurasian Harm Reduction Network (EHRN), the European Monitoring Centre
on Drugs and Drugs Addiction (EMCDDA), the WHO Regional Office for Europe, the International
Harm Reduction Association (now Harm Reduction International), the European Network for HIV/
STI Prevention and Health Promotion among Migrant Sex Workers (TAMPEP) and the European Men’s Internet Survey (EMIS). Substantial contributions were made by in-country experts
from the following organisations: Central Asia Regional HIV/AIDS Programme, United Nations
Development Programme (UNDP), United Nations Office on Drugs and Crime (UNODC), Republican AIDS Centre in Tajikistan, the Support Project in Kazakhstan, ICAP / Columbia University,
Mailman School of Public Health, US Centers for Disease Control and Prevention (CDC), Robert
Koch Institute and Institute of Public Health in Germany, National Institute for Public Health and
the Environment and the Schorer Foundation in the Netherlands, the National Institute for STI
and AIDS Control in the Netherlands (SOA Aids), and the University of Porto in Portugal. The
review was funded by the World Bank, grant number 7153690. The findings, interpretations, and
conclusions expressed in this Review are entirely those of the authors, and do not necessarily
represent the view of the World Bank, WHO, their Executive Directors, or the countries they
represent.
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