Presentation by ECDC HIV expert Anastasia Pharris on epidemiological challenges for the HIV response in Europe. Presented at: 16th European AIDS Conference, 26 October 2017, Milan.

1. Epidemiological Challenges in Europe
Anastasia Pharris
European Centre for Disease Prevention and Control, Stockholm
EACS, Milan, 26 October 2017

2. Employed by ECDC
No conflicts of interest or disclosures

3. 2
Acknowledgements
Teymur Noori, ECDC
Annemarie Stengaard, WHO Regional Office for Europe

4. 3
• What is the epidemiology of HIV in the European
Region?
• Is the European response sufficient?
• What are our challenges and opportunities in the
decade ahead?

5. New HIV diagnoses in Europe, 2015
Source: ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015
<2 per 100 000
>50 per 100 000
20 to <50 per 100 000
10 to <20 per 100 000
2 to <10 per 100 000

6. WHO European Region
5
More than 150 000 new diagnoses
(17.6 per 100 000 population)
79% in the East
18% in the West
3% in the Centre

7. Reported routes of HIV transmission*, by
European sub-region, 2015
6
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Region West Centre East
Source: ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015
* Among those with known route of transmission
Heterosexual
Sex between
men
Injecting drug
use
Mother to child

8. Reported routes of HIV transmission*, by
European sub-region, 2015
7
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Region West Centre East
Source: ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015
* Among those with known route of transmission
Heterosexual
Sex between
men
Injecting drug
use
Mother to child

9. Estimated new HIV infections are decreasing globally
1,400,000
1,600,000
1,800,000
2,000,000
2,200,000
2,400,000
2,600,000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Numberofnewdiagnoses(global)
Year of diagnosis
Global
Source: ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015. UNAIDS/WHO global estimates.
Global

10. Estimated new HIV infections are decreasing globally,
but increasing in the WHO European Region
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
1,400,000
1,600,000
1,800,000
2,000,000
2,200,000
2,400,000
2,600,000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Numbernewdiagnoses(Europeanregion)
Numberofnewdiagnoses(global)
Year of diagnosis
Global
WHO
European
Region
Source: ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015. UNAIDS/WHO global estimates.

11. Estimated new HIV infections are decreasing globally,
but increasing in the WHO European Region
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
1,400,000
1,600,000
1,800,000
2,000,000
2,200,000
2,400,000
2,600,000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
WHO
European
Region
Global
East
West
Centre
Source: ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015. UNAIDS/WHO global estimates.

12. HIV diagnoses, Eastern Europe
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Numberofcases
Year of diagnosis
Heterosexual
+100%
Sex between men
+1000%
Injecting drug use
-38%
Source: ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015
IDU-driven epidemic, with increasing heterosexual transmission

13. HIV diagnoses, Central Europe
0
200
400
600
800
1000
1200
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Numberofcases
Year of diagnosis
Source: ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015
MSM/heterosexual-transmission driven epidemic
Heterosexual +83%
Sex between men
+300%
Injecting drug use +200%

14. Heterosexual
-41%
Injecting drug use
-50%
Sex between men
+7%
Source: ECDC/WHO (2015). HIV/AIDS Surveillance in Europe, 2014
Data is adjusted for reporting delay. Cases from Estonia and Poland excluded due to incomplete reporting on transmission mode during the
period; cases from Italy and Spain excluded due to increasing national coverage over the period.
Source: ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015
0
2000
4000
6000
8000
10000
12000
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
MSM are the only group where infections have increased, however….
HIV diagnoses, Western Europe

15. Proportion of HIV diagnoses among migrants,
EU/EEA, 2007-2015
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2007 2008 2009 2010 2011 2012 2013 2014 2015
Western Europe
Central and Eastern
Europe
Sub-Saharan Africa
South and Southeast
Asia
Other
Latin America and
Caribbean
Migrants play an important role in some European countries
37%

16. Where do migrants get infected with HIV
(prior to or after arrival to Europe)?
18%
Source: Rice BD, Elford J, Yin Z et al (2012). A new method to assign country of HIV infection among heterosexuals born abroad and diagnosed with HIV in the UK. AIDS
26 (15): 1961-6
7%
Clinic-based estimate CD4-based estimate
Source: Rice BD, Elford J, Yin Z et al (2012). A new method to assign country of HIV infection among heterosexuals born abroad and diagnosed
with HIV in the UK. AIDS 26 (15): 1961-6

17. Where do migrants get infected with HIV
(prior to or after arrival to the Europe)?
18%
Source: Rice BD, Elford J, Yin Z et al (2012). A new method to assign country of HIV infection among heterosexuals born abroad and diagnosed with HIV in the UK. AIDS
26 (15): 1961-6
24%
7%
Clinic-based estimate CD4-based estimate
46%
Source: Rice BD, Elford J, Yin Z et al (2012). A new method to assign country of HIV infection among heterosexuals born abroad and diagnosed
with HIV in the UK. AIDS 26 (15): 1961-6
Why is this important?
 Screening newly arrived migrants at point of entry is not
enough
 Some sub-populations of migrants are at-risk for HIV
acquisition many years after arrival to Europe
 Countries should develop and deliver targeted primary HIV
prevention programmes to migrant populations at risk

18. • What is the epidemiology of HIV in the
European Region?
• Is the European response sufficient?
• What are our challenges and opportunities in
the decade ahead?

19. Sustainable Development Goals and
UNAIDS “Fast-track commitments”
Goals for Europe and Central Asia
√ To reduce new HIV infections to fewer than 63 080 by
2020
√ To reduce AIDS-related death
√ To eliminate HIV-related stigma and discrimination by 2020

20. Will we make it?
0
20000
40000
60000
80000
100000
120000
140000
160000
180000
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
NewHIVdiagnoses
Year
HIV Region 2020 target
HIV EU/EEA 2020 target

21. Fast Track Targets by 2020
73%
of all people living
with HIV
VIRALLY
SUPPRESSED
=
Target 1 Target 2 Target 3 Target 4
diagnosed with HIV
ON ART
living with HIV
DIAGNOSED
on ART
VIRALLY
SUPPRESSED

22. % PLHIV who are diagnosed
Source: ECDC. Thematic report: HIV continuum of care. Monitoring implementation of the Dublin Declaration
on Partnership to Fight HIV/AIDS in Europe and Central Asia: 2017 progress report. Stockholm: ECDC; 2017.
>90%
80-90%
<50%
60-69%
70-79%
No/incomplete
data
50-59%
Target 90%
West 84%
Centre 84%
East 57%

23. Source: ECDC/WHO Europe (2016). HIV/AIDS Surveillance in Europe, 2015
Testing: Too many people living with HIV are
diagnosed late
*CD4<350 at diagnosis
51%

24. Persons with CD4 cell count <350 mm3 at HIV
diagnosis, by European sub-region
0
10
20
30
40
50
60
70
2007 2008 2009 2010 2011 2012 2013 2014 2015
%diagnosedlate(CD4<350mm3)
Year of diagnosis
East
West
Centre
Source: ECDC/WHO Europe (2016). HIV/AIDS Surveillance in Europe, 2015

25. Fast Track Targets by 2020
73%
of all people living
with HIV
VIRALLY
SUPPRESSED
=
Target 1 Target 2 Target 3 Target 4
diagnosed with HIV
ON ART
living with HIV
DIAGNOSED
on ART
VIRALLY
SUPPRESSED

26. Proportion of diagnosed PLHIV on ART
Target 90%
Source: ECDC. Thematic report: HIV continuum of care. Monitoring implementation of the Dublin Declaration on Partnership to Fight
HIV/AIDS in Europe and Central Asia: 2017 progress report. Stockholm: ECDC; 2017; Pokrovskaya, HIV Glasgow, 2014
>90%
West 88%
Centre 69%
East 45%
80-89%
<50%
50-59%
60-69%
No/incomplete data
60-72%

27. Policies on ART initiation in European countries
2014 (n=48)
2015
Source: ECDC. HIV treatment and care. Stockholm: ECDC; 2017.
4
29
15
1028
8
1
0
5
10
15
20
25
30
35
40
45
50
2014 2016
Numberofcountries/ARTpolicy
200 cells/mm3
350 cells/mm3
500 cells/mm3
Initiation regardless
of CD4 count

28. Policies on ART initiation in European countries
2014 (n=48)
2015
Source: ECDC. HIV treatment and care. Stockholm: ECDC; 2017.
4
29
15
1028
8
1
0
5
10
15
20
25
30
35
40
45
50
2014 2016
Numberofcountries/ARTpolicy
200 cells/mm3
350 cells/mm3
500 cells/mm3
Initiation regardless
of CD4 count

29. Policies on ART initiation in European countries
2014 (n=48) and 2016 (n=47)
2015
Source: ECDC. HIV treatment and care. Stockholm: ECDC; 2017.
4
29
15
1028
8
1
0
5
10
15
20
25
30
35
40
45
50
2014 2016
Numberofcountries/ARTpolicy
200 cells/mm3
350 cells/mm3
500 cells/mm3
Initiation regardless
of CD4 count

30. Availability of ART for undocumented migrants, 2016
Source: ECDC. From Dublin to Rome: ten years of responding to HIV in Europe and Central Asia: Stockholm, ECDC; 2014
Source: ECDC. HIV and migrants. Monitoring implementation of the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia:
2017 progress report Stockholm: ECDC; 2017.

31. Fast Track Targets by 2020
73%
of all people living
with HIV
VIRALLY
SUPPRESSED
=
Target 1 Target 2 Target 3 Target 4
diagnosed with HIV
ON ART
living with HIV
DIAGNOSED
on ART
VIRALLY
SUPPRESSED

32. Estimated % PLHIV who are virally supressed
Source: ECDC. Thematic report: HIV continuum of care. Monitoring implementation of the Dublin Declaration on Partnership to Fight
HIV/AIDS in Europe and Central Asia: 2017 progress report. Stockholm: ECDC; 2017; Pokrovskaya, HIV Glasgow, 2014
>73%
65-72%
<30%
43-30%
44-54%
No/incomplete data
55-64%
Target needed 90%
UNAIDS target 73%
EU/EEA 65%
Non-EU 24%

33. • What is the epidemiology of HIV in the
European Region?
• Is the European response sufficient?
• What are our challenges and opportunities in
the decade ahead?

34. • What is the epidemiology of HIV in the
European Region?
• Is the European response sufficient?
• What are our challenges and opportunities in
the decade ahead?
…….Implementing what we already know works!

35. Despite decades of evidence, harm reduction
coverage remains low in parts of Europe
Opiate substitution
treatment coverage
Needle and syringe
programme coverage
Source: European Monitoring Centre for Drugs and Drug Addiction (2016), Drug-related infectious diseases in Europe. Update from the EMCDDA expert network, November 2016.
Publications Office of the European Union, Luxembourg.

36. Turning the tide?
Source: Brown et al, Eurosurveillance 2017
32% decrease in London infections linked to increased testing, immediate ART, PrEP

37. Implementation of community-based testing by
trained medical staff in Europe and Central Asia
Source: Dublin monitoring data 2016

38. Implementation of community-based testing by
non-medical staff in Europe and Central Asia
Source: Dublin monitoring data 2016

39. Implementation of home sampling in Europe and
Central Asia
Source: Dublin monitoring data 2016

40. Status of formal PrEP implementation in Europe
(as per October 2017)
ECDC. Evidence brief: Pre-exposure prophylaxis for HIV prevention in Europe. Stockholm: ECDC; 2016. (updated)

41. Hornet/ECDC survey on PrEP
(2017)

42. 0
5
10
15
20
25
30
Condom + Health
promotion
+ STI services + PEP + PrEP
NrofcountriesreportingCombination prevention cascade: European countries
with multiple interventions for MSM in place
Source: ECDC. The status of the HIV response in the European union/European Economic Area, 2016. Stockholm. ECDC: 2017.
Most European countries are not
implementing a comprehensive
approach to prevention for MSM

43. 2 out of 3 countries report that funds available for
HIV prevention are insufficient to reduce the
number of new HIV infections
Source: ECDC. The status of the HIV response in the European Union/European Economic Area, 2016. Stockholm. ECDC: 2017.

44. Using new technology to promote STI/HIV testing
European Testing Week

48. Mobile optimised HIV Test Finder

49. EU Test Finder stats
European HIV Testing Week 18-25 Nov 2016
Visits Page views
Friday 18-Nov 4 958 10 821
Saturday 19-Nov 20 640 39 600
Sunday 20-Nov 4 918 9 348
Monday 21-Nov 1 885 3 244
Tuesday 22-Nov 8 300 17 152
Wednesday 23-Nov 9 992 23 414
Thursday 24-Nov 6 463 12 875
Friday 25-Nov 8 458 18 218
Total: 65 614 134 672
63% 81%
Push messages sent
to millions of users in
55 countries in 40
languages
Banner ads displayed
to users in EU
countries (250K
impressions)

50. EU LGBT Survey; European Union Agency for Fundamental Rights (FRA); 2013
Proportion of gay male
respondents who state
that no medical
staff/health care
provider is aware that
they are gay.
Stigma

51. Factors that will affect our work in the coming
decade
• Political instability, austerity
• Health care system re-structuring
• Migration
• Aging cohort of PLHIV
• Changes in drug markets and patterns of use
• Mobile technology

52. Conclusions
• Europe, as a region, is lagging behind in its response to
the HIV epidemic and is not on track to reach the 2020
targets
• Effective interventions --frequent testing, immediate
linkage to care and ART initiation, PrEP-- are not being
applied at scale in many European countries.
• There is good news! Reduced incidence in MSM in
select countries, MTCT and IDU

53. Into the next decade…
• As HIV incidence declines in some populations and regions, it will be
concentrated in even harder to reach populations/places
• Uneven application of evidence-based prevention and treatment
policies may further exacerbate existing inequalities in HIV
incidence and outcomes across Europe
• We have sufficient tools to eliminate new HIV infections in Europe!

54. Thank you!
Dublin Declaration advisory group
Irene Rueckerl (Austria), Florence Lot, Daniela Rojas Castro, Richard Stranz (France), Gesa Kupfer (Germany), Derval Igoe (Ireland), Lella Cosmaro (Italy), Silke
David, Eline Op De Coul (Netherlands), Arild Johan Myrberg (Norway), Olivia Castillo (Spain), Maria Axelsson (Sweden), Valerie Delpech, Alison Brown, Cary
James, Brian Rice (United Kingdom), Velina Pendalovska (European Commission), Klaudia Palczak and Dagmar Hedrich (EMCDDA), Taavi Erkkola, Kim Marsh
(UNAIDS) and Annemarie Steengard (WHO Regional Office for Europe).
Dublin Declaration focal points in Europe and Central Asia
Roland Bani (Albania), Montse Gessé (Andorra), Samvel Grigoryan (Armenia), Irene Rueckerl, Bernhard Benka, Robert Zangerle (Austria), Esmira
Almammadova (Azerbaijan), Inna Karabakh (Belarus), Andre Sasse, Dominique Van Beckhoven (Belgium), Šerifa Godinjak (Bosnia and Herzegovina), Tonka
Varleva (Bulgaria), Jasmina Pavlic (Croatia), Ioannis Demetriades (Cyprus), Veronika Šikolová, Hana Janatova (Czech Republic), Jan Fouchard (Denmark), Kristi
Rüütel, Liilia Lõhmus, Anna-Liisa Pääsukene (Estonia), Henrikki Brummer-Korvenkontio (Finland), Bernard Faliu (France), Tamar Kikvidze (Georgia), Gesa
Kupfer, Ulrich Marcus, (Germany), Vasileia Konte, Chryssoula Botsi, Jenny Kremastinou, Theodoros Papadimitriou (Greece), Katalin Szalay (Hungary), Guðrún
Sigmundsdóttir (Iceland), Derval Igoe (Ireland), Daniel Chemtob (Israel), Maria Grazia Pompa, Anna Caraglia, Barbara Suligoi, Laura Camoni, Stefania
D’Amato, Anna Maria Luzi, Anna Colucci, Marco Floridia, Alessandra Cerioli, Lella Cosmaro, Massimo Oldrini, Laura Rancilio, Maria Stagnitta, Michele
Breveglieri, Margherita Errico (Italy), Irina Ivanovna Petrenko (Kazakhstan), Laura Shehu, Pashk Buzhala, Bajram Maxhuni (Kosovo*), Dzhainagul Baiyzbekova
(Kyrgyzstan), Šarlote Konova (Latvia), Irma Caplinskiene (Lithuania), Patrick Hoffman (Luxembourg), Jackie Maistre Melillo (Malta), Violeta Teutu (Moldova),
Aleksandra Marjanovic (Montenegro), Silke David (Netherlands), Arild Johan Myrberg (Norway), Iwona Wawer, Piotr Wysocki, Adam Adamus (Poland),
Antonio Diniz, Teresa Melo (Portugal), Mariana Mardarescu (Romania), Danijela Simic, Sladjana Baros (Serbia), Peter Truska (Slovakia), Irena Klavs (Slovenia),
Olivia Castillo (Spain), Maria Axelsson (Sweden), Stefan Enggist, Axel Schmidt (Switzerland), Muratboky Beknazarov (Tajikistan), Nurcan Ersöz (Turkey),
Valerie Delpech (United Kingdom), Igor Kuzin (Ukraine) and Zulfiya Abdurakhimova (Uzbekistan).
HIV Surveillance focal points in the EU/EEA
Daniela Schmid, Alexander Spina (Austria), Andre Sasse (Belgium), Tonka Varleva (Bulgaria), Tatjana Nemeth Blazic (Croatia); Maria Koliou (Cyprus), Marek
Maly (Czech Republic); Susan Cowan (Denmark), Kristi Ruutel (Estonia), Kirsi Liitsola (Finland), Florence Lot (France), Barbara Gunsenheimer-Bartmeyer
(Germany), Georgios Nikolopoulos and Dimitra Paraskeva (Greece), Maria Dudas (Hungary), Gudrun Sigmundsdottir and Haraldur Briem (Iceland), Kate
O’Donnell and Derval Igoe (Ireland), Barbara Suligoi (Italy), Šarlote Konova (Latvia), Saulius Čaplinskas and Irma Čaplinskienė (Lithuania), : Jean-Claude Schmit
(Luxembourg), Jackie Maistre Melillo and Tanya Melillo (Malta), Eline Op de Coul (Netherlands), Hans Blystad (Norway), Magdalena Rosinska (Poland),
Helena Cortes Martins (Portugal), Mariana Mardarescu (Romania), Peter Truska (Slovakia), Irena Klavs (Slovenia), Asuncion Diaz (Spain), Maria Axelsson
(Sweden), Valerie Delpech (United Kingdom).