European HIV response "falling behind" as Eastern European epidemic grows

HIV diagnoses have increased by 80% in the European region since 2004, and three quarters of new HIV diagnoses in the European region are occurring in Eastern Europe, yet the scale and targeting of HIV prevention, testing and treatment in Eastern Europe are inadequate, a European meeting on standards of care for HIV and co-infections in Europe heard last week in Rome, Italy.

The meeting, organised by the European AIDS Clinical Society, preceded a high-level European Union Ministerial Meeting on HIV organised by the Italian Ministry of Health, designed to renew momentum on HIV among European Union policy makers ten years after the 2004 Dublin Declaration set out a framework for actions to tackle the growing epidemics in Eastern Europe and Central Asia.

Speaking at the High-Level Ministerial Meeting, Mark Sprenger of the European Centre for Disease Prevention and Control, said that the European region faced two distinct epidemics.

Despite the ambition of the Dublin Declaration to halt and reverse the spread of HIV in the European region, in Eastern Europe the rate of HIV diagnosis per 100,000 inhabitants has increased by 126% since 2004. The rate has remained stable in the European Union. The rate of increase has been greatest among heterosexuals, indicating that the epidemic among people who inject drugs is now resulting in onward transmission to sexual partners.

Although the rate of increase of HIV diagnoses has remained almost flat for the population as a whole in the European Union since 2004, this lack of increase disguises a major shift in the epidemic. Whereas HIV diagnoses among heterosexual men and women and people who inject drugs have gone down, new diagnoses among men who have sex with men have risen by 33% since 2004, with a particularly sharp increase seen in 2010 and 2011. “Men who have sex with men are the number one priority in the European Union,” he said.

He outlined five priorities for action in the European region to reverse the increase in HIV diagnoses.

The first priority is targeted prevention at an appropriate scale for key populations – men who have sex with men, people who inject drugs, migrants, prisoners and sex workers – he said. There is variable coverage of harm reduction interventions even within the European Union.

The second priority is greater coverage and frequency of HIV testing in order to reduce late diagnosis. Testing should be community-based and governments should look for innovative methods of expanding the uptake of testing, as well as targeting key populations rather than the general population. At present, uptake of HIV testing is consistently low across all key populations, he said.

The third priority is to scale up antiretroviral treatment coverage in Eastern Europe and to make antiretroviral therapy and care available to undocumented migrants throughout the European Union. National programmes need to improve rates of diagnosis and viral suppression in order to achieve the full impact of treatment as prevention. At present rates of diagnosis are still low, even in the best-performing countries.

The fourth priority is large-scale financing, especially for civil society delivery of key prevention and harm reduction services.

The fifth priority is strong political leadership, both at national and European level, in order to mobilise funding and change attitudes towards HIV.

The new target for HIV treatment scale up – 90% of all people living with HIV would know their status, 90% of those would be on treatment, and 90% of those would be virally suppressed – will be an important element of future efforts in the European region, but Martina Brostrom of UNAIDS told the meeting that many countries in the region – including some large countries in Western Europe – are falling behind some of the most successful countries in sub-Saharan Africa in their efforts to diagnose and treat HIV infection.

A survey of HIV expert physicians conducted by Dr Cristina Oprea of Victor Babes Hospital, Bucharest, Romania, found low estimated levels of HIV diagnosis in Eastern Europe, low levels of antiretroviral coverage and a high frequency of use of antiretroviral drugs no longer recommended by the World Health Organization (WHO). She expressed scepticism about the likelihood of achieving the 90 / 90 / 90 target in Eastern Europe and Central Asia, but revealed that Romania has already achieved treatment coverage above 60%, which compares favourably with many wealthier countries.

Professor Andrzej Horban of the Hospital for Infectious Diseases, Warsaw, Poland, agreed that in most central European countries it is possible to achieve the UNAIDS targets now, due in part to low HIV prevalence. It will be possible to achieve the targets in Central Asia in the near future, but in Eastern Europe – especially the Russian Federation – it will take time to achieve the goals due to lack of political will.

“The lack of political leadership in Eastern Europe is a real difference from sub-Saharan Africa,” said Prof. Manuel Battegay, President of the European AIDS Clinical Society (EACS).

Delegates expressed concern over the deep-seated political and social opposition to harm reduction for people who inject drugs, and the profound reluctance of Eastern European societies to tackle drug use as a public health problem rather than a criminal offence.

“The greatest political challenge we face is drug use rather than HIV or TB” said Dr Fiona Mulcahy of St James’s Hospital, Dublin, Vice-President of EACS.

“The Russian scientific community are talking about the scale of the problem; this indicates high-level political awareness that HIV represents a major challenge for Russia,” said Martin Donoghoe, director of WHO Europe’s HIV and hepatitis programme.

“It’s important that scientists continue to provide scientific backing for evidence-based policy making in the European region,” he said

Prof. Jens Lundgren of the University of Copenhagen, Denmark, who has led a physician training programme in Eastern Europe on behalf of EACS, said that a public health approach to treatment – as recommended by WHO Europe – was needed in Eastern Europe. Regimen simplification is the key to rapid scale up of treatment in Eastern Europe. Too many potential regimens make it more difficult for physicians to learn how to use antiretroviral therapy, increase costs and make it difficult to achieve economies of scale in purchasing, he told the meeting.

Developing an integrated system of harm reduction, drug substitution treatment and HIV care is also essential. At present these programmes are separated in Eastern Europe, meaning that many drug users never receive the offer of an HIV test, cannot access drug substitution therapy and are not linked to HIV care due to lack of communication and formal linkages between programmes. Less than 5% of drug users are able to obtain drug substitution therapy in Russia, Ukraine, Belarus and Central Asia, and coverage of needle and syringe programmes is extremely low.

“We need to remember that it took a number of years to gain acceptance for harm reduction practices in Western Europe, so we need to be persistent in expert dialogue,” said Martin Donoghoe of WHO Europe.

The meeting also compared treatment cascades – the proportion of people diagnosed, linked to care, retained in care, started on antiretroviral treatment and virally suppressed – between countries and regions. The best performance is seen in Western Europe – Denmark, France, the United Kingdom and the Netherlands, where between 52 and 60% of all people living with HIV are estimated to have suppressed viral load. The new UNAIDS target implies a viral suppression rate of 73%, which can be achieved only through improvements in HIV testing rates and frequency.

In Central and Eastern Europe estimated suppression rates are much lower: 19% in Estonia, 20% in Georgia and 25% in Russia. Low rates of diagnosis, retention in care and treatment initiation each contribute to these low rates of viral suppression.

“In order to retain people in the cascade of care, you need to establish the cascade of care first,” said Tamas Berezcky of European AIDS Treatment Group. He pointed to the lack of efforts to diagnose and link to care people who inject drugs, and very low coverage of antiretroviral therapy in Eastern Europe, as fundamental weaknesses.

A lack of integration of HIV and tuberculosis (TB) treatment services is also contributing to a huge burden of TB among people with HIV in Eastern Europe, and a high frequency of multidrug-resistant TB (MDR-TB). Treatment practices in the region such as hospitalisation during the two-month intensive induction period of TB treatment – which increases the risk of nosocomial TB exposure – and lack of access to a full formulary of drugs for empiric TB treatment in people with suspected drug resistance, are the cause of the high MDR-TB burden, said Daria Podlekareva of the University of Copenhagen. Recent research led by the University of Copenhagen found that less than half of patients with HIV and suspected TB who received empiric treatment were prescribed four active TB drugs, as recommended by the World Health Organization. Death rates among people with HIV diagnosed with TB in Eastern Europe are more than twice as high as those in Western Europe or Latin America, largely as a consequence of lack of diagnosis, lack of antiretroviral therapy and the high burden of MDR-TB.

The meeting also discussed barriers to hepatitis C treatment among people with HIV and hepatitis C virus (HCV) co-infection in the European region. Low levels of HCV diagnosis mean that many people learn of their infection after the onset of serious liver disease. Despite recommendations from the European AIDS Clinical Society and the European Association for the Study of the Liver (EASL) for treatment of patients with advanced liver disease (stages F3 and F4), access to new direct-acting antivirals is limited on the grounds of cost and slow decision-making regarding reimbursement.

“We need you to stand publicly with us, on the basis of public health and patient care, and let the payers take care of the cost. Politics needs to control business,” said Luis Mendão of European AIDS Treatment Group. “We need to follow Joep Lange’s lead as a clinician activist in HIV treatment access, to fight for access to hepatitis C treatment for all,” said Dr Annemarie Wensing of University Medical Center, Utrecht, the Netherlands.