The European region needs to step up prevention and
treatment activities if it is to reach the UNAIDS target of 90% diagnosed, 90%
of those diagnosed on treatment and 90% of those on treatment with fully suppressed
viral load by 2020, the United Nations Secretary-General's Special Envoy on
HIV and AIDS in Eastern Europe and Central Asia told the opening session of the 15th European AIDS Conference in Barcelona on Wednesday.
The
90-90-90 target promoted by UNAIDS, if achieved, would result in 73% of
people living with HIV having undetectable viral load. Mathematical modelling
suggests that achieving this target by 2020 would end the AIDS epidemic by
2030.
“Europe is not done with AIDS and there is no room for
complacency”, Professor Kazatchkine told delegates.
“There isn’t one
Europe”, Professor Kazatchkine told a press conference on the opening day of
the conference. The World Health Organization (WHO) Europe region covers 53
countries, and “in fact, there are three Europes – Eastern Europe, Central
Europe and Western Europe – with different epidemics, different responses and
different levels of success.”
The Eastern European epidemic continues to grow, driven
largely by unchecked epidemics in people who inject drugs, but autonomous
epidemics are also emerging in heterosexual men and women through sexual
transmission in the region, Professor Kazatchkine warned. The high levels of
transmission make it unlikely that Eastern Europe will be in a position to
reach the 90-90-90 target by 2020, he said. Prevention services are not
accessible at sufficient scale and access to harm reduction remains very
limited. Very low levels of co-operation on the part of government towards
non-governmental organisations impedes the scale up of prevention activities.
In Central Europe, despite low prevalence, HIV incidence has
been rising gradually in many countries. The epidemic remains highly
concentrated among men who have sex with men and people who inject drugs, but
there is “limited willingness to pay” for programmes aimed at these vulnerable
groups among governments in the region, Professor Kazatchkine said. He reminded
delegates of the consequences of reducing HIV prevention services in the
region: after Global Fund funding for harm reduction was gradually withdrawn
from Romania when it joined the European Union in 2007, the country suddenly
went from a minimal epidemic to high incidence among people who
inject drugs in less than two years.
Although Western Europe appears to have everything needed to
mount a successful response to HIV, the overall level of new infections has
remained stable over the past decade. Despite universal health coverage,
excellent HIV care and high levels of social support, new infections have
increased among men who have sex with men over the past 10-15 years. Much more
intense efforts are needed in both prevention and treatment, but the 90-90-90
targets should be achievable for both Western and Central Europe, he predicted.
But, he told the conference, “If we do not intensify our
efforts in the next five years we will not be on the path to ending AIDS.”
“We need to look carefully at the weaknesses in the European
response. We are still missing many infections among men who have sex with men
and migrants from countries with generalised epidemics,” said Professor
Kazatchkine. In particular he expressed concern about testing frequency among
men who have sex with men: if a large proportion of new infections among men
who have sex with men are a consequence of acquiring HIV from partners who are
themselves recently infected, yearly testing may be too infrequent to pick up
recent infection and start treatment early enough to interrupt a chain of new
infections. “Self-testing will be one of the solutions,” Professor Kazatchkine
suggested.
A focus on the groups of people left behind will also be
necessary: people who inject drugs, migrants, sex workers and men who have sex
with men continue to lack access to testing, treatment and care in many
settings in the region, yet are the groups most affected by HIV.
Closing the treatment gap will also be necessary in order to
reach the 90-90-90 target, he said. At the moment the number of new HIV
diagnoses in many countries in Eastern Europe continues to exceed the number of
people who start treatment each year, which means that the treatment gap is
growing, not shrinking. The treatment
gap is made worse by national guidelines restricting treatment to people with
CD4 cell counts below 350 throughout Eastern Europe and Central Asia, and by
alarmingly poor rates of diagnosis and retention in care. The average treatment
cascade for the region as a whole shows that only 47% of people living with HIV
know that they have HIV. In the Russian Federation, the country with the largest
number of people living with HIV, only 12% of people living with HIV are on
treatment.
Late diagnosis continues to be a major challenge for
achieving high treatment coverage in Western Europe, especially among migrants
who often lack good access to health care. In Eastern Europe, treatment coverage
is around 35%, compared to a global average approaching 60%, Professor
Kazatchkine told a press conference. “People are very reluctant to go to
services because of stigma and discrimination, because of a lack of co-ordination
between TB and HIV services, and because of criminalisation of people who
inject drugs." Less than 10% of people who inject drugs who are living with HIV
are currently accessing treatment in Eastern Europe, Professor Kazatchkine
said.
Tamas Berezcky of the European AIDS Treatment Group said
that stigma and discrimination are the biggest barriers to testing and
treatment among men who have sex with men (MSM) in Central Europe, and stigma within
the community is an important barrier to seeking care. “If you look at how men
who have sex with men treat other MSM with HIV it’s very depressing,” he told
the press conference. He said that stigma is being reinforced by a lack of
information about HIV, including a lack of awareness regarding recent advances
in HIV treatment, the normal life expectancy of people who receive appropriate
antiretroviral treatment and the impact of treatment on transmission.
There is also insufficient focus on partnership with
community organisations, Professor Kazatchkine said. Tamás Berezcky called on scientists to join in
partnership with the community to achieve implementation.
The financial sustainability of the HIV response in Eastern
and Central Europe is also a serious concern following the withdrawal of Global
Fund support for HIV and TB programmes in the region. Global Fund support has
come to an end as a result of a decision to focus future funding on
lower-income countries, despite the political difficulties of funding the
necessary prevention and treatment services in Eastern Europe.