Prevention

Understanding the Epidemiological Dynamics of HIV Infection in MSM in Europe

Information taken from the ECDC: HIV/AIDS surveillance in Europe 2018 (2017 data). Copenhagen: WHO Regional Office for Europe; 2018 & the Review of HIV and Sexually Transmitted Infections among men who have sex with men (MSM) in Europe. (WP1 ESTICOM) RKI March 2017.

Why is understanding and using data around epidemiology and behaviour important for the work with MSM?

Data gives us a starting point to understand where the epidemic is within both the larger and regional contexts for the community/ies you work with.

Knowing levels of prevalence and incidence in the populations you are working with is key to knowing the needs of that community. It is also key is assessing the provision of services and ensuring that they are appropriate to, and meet the needs of, those population/s.

Understanding where the epidemic started in your region and how it has developed within the population ensures you are able to shape the services to the needs of the people infected and affected. It will affect which services are provided, and how changes in behaviours and incidence are reflected in service provision.

This approach is generally known as ‘evidence into practice’.

Contents

Historical trends in HIV incidence among MSM in Europe

HIV started to spread among gay and bisexual men in Europe at different time periods in different geographical regions.

In Northern and Western European countries (Scandinavian countries, UK, France, the Netherlands, Belgium, Western Germany, Switzerland, Austria) HIV started to spread largely unrecognized in metropolitan gay communities in the late 1970s and early 1980s, fueled by repeated importations from North America. Peak incidences were reached around 1985/1986, when the first diagnostic tests became widely available. Spontaneous and promoted behaviour changes, such as reductions in numbers of anal intercourse partners and increasing condom use, contributed to declining incidence of new HIV and STI infections in the late 1980s and early 1990s. However, incidence increased again in the late 1990s/ early 2000s.

In Southern Europe (Spain, Portugal, Italy), HIV initially spread mainly among IDUs, while transmission among gay and bisexual men increased gradually from the late 1990s onwards. In Eastern Europe, explosive HIV epidemics developed among IDUs from the mid-1990s, followed by increasing incidence of sexual transmission.

In Central and Eastern Europe HIV started to spread among MSM from the early 1990s, with incidence initially increasing slowly but then accelerating from the early 2000s onwards. In Eastern Europe heterosexual contact and IDU remain the main modes of HIV transmission, although the epidemic among MSM remains masked and often invisible because detailed information on mode of transmission is either unavailable or unreliable, due to high stigmatization of homosexual behaviour.

Overview: What does the most recent data tell us?

Sex between men remains the predominant mode of HIV transmission reported in the EU/EEA, accounting for 38% (9694) of all new HIV diagnoses in 2017 and half (50%) of diagnoses where the route of transmission was known.

Among those with known route of HIV transmission, sex between men was the most commonly reported and accounted for more than 60% of new HIV diagnoses in 10 countries (Austria, Croatia, the Czech Republic, Hungary, Ireland, the Netherlands, Poland, Slovakia, Slovenia and Spain)

The trend in reported HIV diagnoses declined slightly between 2008 and 2017. In the earlier part of this period, rates were 6.9 per 100,000, decreasing slightly to 6.5 in more recent years, and 6.2 in 2017. While the overall EU/EEA trend appears to have declined slightly during the last decade, contrasting trends are seen at national level.

Several countries, including Austria, Belgium, Denmark, Estonia, the Netherlands, Norway, Spain and the United Kingdom, have reported a decline in rates of new diagnosis in recent years, even after adjusting for reporting delay.

Conversely, since 2008, and taking reporting delay into account, rates of HIV diagnoses have more than doubled in Bulgaria, Cyprus and Lithuania, and have increased by over 50% in the Czech Republic, Hungary, Malta and Poland.

HIV diagnoses

In 2017, 25, 353 new HIV diagnoses were reported in the 30 countries of the EU/EEA, with a rate of 6.2 per 100, 000 when adjusted for reporting delay.

The highest rates were reported by Latvia (18.8; 371 cases) and Estonia (16.6; 219 cases), and the lowest by Slovakia (1.3; 70 cases) and Slovenia (1.9; 39 cases).

More men than women were diagnosed with HIV in 2017 (19, 032 and 6178, respectively), resulting in an overall male–female ratio of 3:1).

This ratio was highest in Croatia (20.2) and Slovenia (18.5) and was above 1 in all countries in the EU/EEA. The predominant mode of transmission in these countries was sex between men. The overall rate of new diagnoses in men was 9.0 per 100, 000 population and for women 2.8 per 100 000 population.

Men had higher age-specific rates than women in all age groups except among people under 15 years, where age-specific rates were similar. The highest overall age-specific rate of HIV diagnoses was observed among 25–29-year-olds (14.4 per 100, 000 population), largely because this age group has the highest age-specific rate for men at 22.2 per 100 000 population, while rates for women were highest in the 30–39 age group (6.9 per 100, 000 population).

The median age at diagnosis was lower for MSM (34 years) than for cases attributed to injecting drug use (37 years) or heterosexual transmission (39 years overall, 37 in women and 41 in men). The 30–39 age group accounted for most HIV diagnoses overall (32%) and in all transmission groups. Thirty-four per cent of cases attributed to sex between men are diagnosed before age 30, while half (48%) of HIV infections due to sex between men and women are diagnosed at 40 years or above, and nearly one quarter (24%) at 50 or above.

Sex between men remains the predominant mode of HIV transmission reported in the EU/EEA, accounting for 38% (9694) of all new HIV diagnoses in 2017 and half (50%) of diagnoses where the route of transmission was known.

Sex between men was the most commonly reported route of transmission among those for whom route of transmission was known, accounting for more than 60% of new HIV diagnoses in 10 countries (Austria, Croatia, the Czech Republic, Hungary, Ireland, the Netherlands, Poland, Slovakia, Slovenia and Spain)

Trends in HIV diagnoses

As reported by the ECDC and WHO Regional Office for Europe, the number of HIV diagnoses among MSM in the European region increased from 8,244 cases in 2006 to 10,849 cases in 2014. While fewer cases were reported in 2015 (10,274), a decrease in diagnoses is less evident when delays in reporting are accounted for. HIV diagnosis trends among MSM in Western Europe were largely stable between 2006 and 2015.

In contrast, trends in rates of new HIV diagnoses among MSM in Central Europe (Bulgaria, Croatia, Hungary, Romania and others) increased almost universally between 2006 and 2015, with particularly large increases in Cyprus in recent years. There is high variability in the completeness of reporting of transmission risk group for Poland and Turkey, and increases in these two countries may be due primarily to improved reporting of transmission category (and also in Turkey, due to increased rates of testing).

In some countries, such as Romania, HIV diagnoses among MSM may still be underreported due to the high stigma associated with homosexuality. In interpreting the increasing numbers of new diagnoses in Central European countries, it is important to consider that historically there has been a much higher proportion of undiagnosed HIV among MSM in Central compared to Western Europe (in part because the epidemic is younger in the former region). Therefore, improvements in testing uptake may partly explain increases in rates of new diagnoses.

While the overall rates of new HIV diagnoses among MSM were lower in many Eastern European countries (e.g.Turkmenistan, Uzbekistan, Tajikistan, Azerbaijan) compared to Central and Western European countries, rates generally increased between 2006 and 2015. In Eastern European countries overall, the officially reported number of new HIV diagnoses among MSM increased ten-fold from 80 in 2006 to 799 in 2015. This increase may be explained by improvements in ascertainment of transmission group, as well as improved targeting of testing by projects implemented and funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria. In other countries, however, such as Russia, the social recognition of MSM has deteriorated and underreporting and under-ascertainment of transmission among MSM is likely increasing.

The trend in reported HIV diagnoses for the period 2008–2017 has declined slightly in recent years. Rates in the earlier part of this period were 6.9 per 100, 000, decreasing slightly to 6.5 in more recent years, and 6.2 in 2017 (27, 055 cases when adjusted for reporting delay.

While the overall EU/EEA trend appears to have declined slightly during the last decade, trends at the national level are contrasting. Several countries, including Austria, Belgium, Denmark, Estonia, the Netherlands, Norway, Spain and the United Kingdom, have reported a decline in rates of new diagnoses, even after adjusting for reporting delay.

Conversely, since 2008, and taking reporting delay into account, rates of HIV diagnoses have more than doubled in Bulgaria, Cyprus and Lithuania, and have increased by over 50% in the Czech Republic, Hungary, Malta and Poland.

Reporting delay affects some countries more than others: decreases in the rates of new HIV diagnoses may therefore be overestimated and increases in rates underestimated.

HIV diagnoses among people born outside of the reporting country comprised 44% of all new diagnoses in 2008, decreasing slightly to 37% in 2013 and increasing to 41% in 2017. New diagnoses among people originating from sub-Saharan Africa decreased from 24% of all new diagnoses in 2008 to 18% in 2017, while new diagnoses among people originating from other countries in central and eastern Europe increased from 4% to 6% of all new diagnoses. The proportion of people originating from other regions has remained stable.

The proportion of all HIV diagnoses attributed to sex between men increased from 34% of cases in 2008 to 41% in 2014 and 2015, then decreased to 37% in 2017.

The number of HIV diagnoses reported among MSM in countries reporting consistently increased from 7369 cases in 2008 and peaked at 8297 in 2013. Although fewer cases were reported in 2017 (6294), reporting delay probably plays a partial role in this decline. Most of the decline appears to be due to fewer diagnoses among MSM in Belgium, Greece, the Netherlands, Spain and the United Kingdom. Increases were observed in many EU/EEA countries between 2008 and 2017, with substantial increases noted in Bulgaria, Cyprus, Ireland, Malta, Poland and Romania in recent years.

Cases attributed to MSM born outside of the reporting country increased over the period, declining slightly between 2015 and 2017 but not to the same extent as observed in EU/EEA-native MSM

90-90-90: Why is understanding the continuum of care important?

We now have overwhelming evidence via research such as the Partner Studies that getting people tested, and if positive onto effective treatments, not only affects their disease progression but also means they cannot pass on HIV to sexual partners or via the Mother to Child route (there is insufficient evidence to show that it is effective with intravenous drug use as of August 2019).

So getting people tested, onto treatments and virally suppressed is a major part of a combination prevention approach, which has led to the adoption of the 90-90-90 targets.

What are the targets?

The treatment targets

90% diagnosed: Diagnosis is dependant on testing technologies, now improving with rapid tests, and self-sampling and self-testing kits.

90% on treatment: Treatment is dependant on economics and access to treatments – costs of effective first-line treatments and use of effective generics and ability to access treatment regimes.

90% virally suppressed (= 73% of all PLHIV will have a durable viral suppression): Viral suppression is dependant on effective treatment, treatment adherence and support for it and access to viral load testing.

When this three-part target is achieved, at least 73% of all people living with HIV worldwide will be virally suppressed – a two- to three-fold increase over current rough estimates of viral suppression. Modelling suggests that achieving these targets by 2020 will enable the world to end the AIDS epidemic by 2030, which in turn will generate profound health and economic benefits.

HIV treatment is a critical tool towards ending the AIDS epidemic, but it is not the only one.

While taking action to maximize the prevention effects of HIV treatment, urgent efforts are similarly needed to scale up other core prevention strategies, including elimination of mother-to-child transmission, condom programming, pre-exposure antiretroviral prophylaxis, voluntary medical male circumcision in priority countries, harm reduction services for people who inject drugs, and focused prevention programming for other key populations. To put in place a comprehensive response to end the epidemic, concerted efforts will be needed to eliminate stigma, discrimination and social exclusion.

HIV treatment averts AIDS-related deaths: Whereas someone who acquired HIV in the pre-treatment era could expect to live only 12.5 years, a young person in industrialized countries who becomes infected today can expect to live a near-normal lifespan (or an additional five decades) with the use of lifelong, uninterrupted HIV treatment. A rapidly expanding body of evidence indicates that comparable results are achievable in resource-limited settings.

HIV treatment prevents new HIV infections: Among prevention interventions evaluated to date in randomized, controlled trials, HIV treatment has demonstrated by far the most substantial effect on HIV incidence.

Interim findings from the PARTNER study indicate that among 767 serodiscordant couples, no case of HIV transmission occurred when the person living with HIV had suppressed virus – after an estimated 40 000 instances of sexual intercourse. As a prevention tool, HIV treatment should be seen as a critical component of a combination of evidence-based approaches (known as ‘combination prevention’).
Further evidence can be found at http://www.aidsmap.com/Zero-transmissions-mean-zero-risk-PARTNER-2-study-results-announced/page/3311249/

HIV treatment saves money: Early initiation of treatment enhances both health and economic gains. According to another modelling exercise, investments in HIV treatment scale-up generate returns more than two-fold greater when averted medical costs, averted orphan care and labour productivity gains are taken into account. Nor will it be necessary to wait decades to see the economic benefits of early investments in rapid treatment scale-up. In some countries, savings from investments in HIV treatment scale-up would be immediately felt. Actual costs savings would emerge somewhat later in countries with high HIV prevalence.

Conclusions

HIV surveillance data for 2017 contribute to demonstrating important changes in the epidemiology of HIV in EU/EEA countries over the past decade. Rates of AIDS
and AIDS-related deaths in the EU/EEA as a whole have decreased significantly over the past decade, reflecting greater access to treatment and better case management, and sustained progress towards the SDG of ending the AIDS epidemic and decreasing AIDS-related deaths.

There is a clear decline in the rate of new HIV diagnoses per 100, 000 population, with an adjusted rate of 6.2 reported in 2017. While the notification rate is lower than in previous years, it is expected to be revised upwards in future reporting cycles due to reporting delay, which is common for HIV generally and for certain countries in the EU/EEA in particular.

Despite the evidence of some progress in reducing the number of new HIV diagnoses in the EU/EEA overall, rates continue to increase in about one-third of EU/EEA countries.

There appears to be evidence of a true decrease in HIV diagnoses among MSM in select EU/EEA countries that seems to be driving the overall decline observed in the EU/EEA. This is significant because MSM still account for the largest number of new HIV diagnoses in the EU/EEA; until recently, this was the only population in the EU/EEA in which HIV cases were increasing during most of the last decade. The decline at EU/EEA level is driven by substantial declines in specific EU/EEA countries – Austria, Belgium, Denmark, Estonia, the Netherlands, Norway, Spain and the United Kingdom.

Reasons for the decrease may include successful programmes to offer more frequent and targeted HIV testing to promote earlier diagnosis, rapid linkage to care and immediate initiation of ART for those found to be positive, which results in higher rates of viral suppression and a decline in HIV incidence.

A trend toward earlier diagnosis is evident in the mean CD4 count data at diagnosis, which has increased significantly over the last decade in all people diagnosed, including MSM; this indicates improvements in case ascertainment, which could be a result of more effective testing policies. In addition to more frequent testing and linkage to care, the use of formal and informal PrEP may also have played a role in the decline of HIV diagnoses observed in at least some of these settings. The positive trend described above is countered, however, by the prevailing situation in other EU/EEA countries where HIV continues to increase among MSM.

Overall in the EU/EEA and even in some settings with declines in rates among MSM, new HIV diagnoses in migrant MSM have not declined at the same rate as those who are not foreign-born. There is an urgent need for significant scaling up of more effective combination prevention programmes for this at-risk population. This includes promoting the uptake of regular, easy-to-access HIV testing, accompanied by immediate linkage to care and treatment for those found positive, and condoms, peer support and possible PrEP for some populations of high-risk HIV-negative men.

Information contained in this module was correct at April 2019 and taken from europa.eu.

You can find associated information and links to service providers at:

Now that you have read the information, please think about a few issues:

  • How has the epidemic changed in the Eastern regions of the EU?
  • What is the general trend in the Western areas of the EU and what is this linked to? How could this be further enhanced?
  • How could you increase your use of data to inform the work you carry out?
  • How could you use data to initiate new initiatives?
  • What do you think the next 90-90-90 type initiative could be?
  • What makes it complicated to compare data?

Next module: Using Health Promotion Models to aid behaviour change

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