Update on HIV in Western Europe

A reduction in the proportion of people with HIV who are undiagnosed will be primarily achieved through expansion in coverage and frequency of HIV testing. Even in Western Europe, where ART is widely and generally freely available to all those diagnosed and in need, HIV testing rates vary substantially from 1.9 (Greece) to 119.5 (San Marino) tests performed per 1000 population (where data are collected and excluding unlinked anonymous testing and testing of blood donations) [6]. As a large proportion of transmissions are thought to originate from individuals who are not yet diagnosed [23, 24], earlier and more frequent testing is paramount to benefit, both on an individual- and population-level. In particular, the HIV in Europe Initiative (www.​hiveurope.​eu) has been successful in promoting optimal HIV testing and earlier care in Europe [25]. Delineation of persons presenting late for care have identified that many were in contact with the health system several times before being diagnosed and hence increased provided-initiated testing is likely to be helpful. The HIV Indicator Diseases across Europe Study (HIDES) was a result of the HIV in Europe 2007 Conference, with the aim to improve targeted testing for people most likely to be infected with HIV [26]. The study authors found that it would be cost-effective to offer an HIV test to anyone presenting with one of eight indicator conditions (sexually transmitted infection, lymphoma, cervical or anal cancer/dysplasia, herpes zoster, hepatitis B/C, mononucleosis-like illness, unexplained leukocytopenia/thrombocytopenia and seborrheic dermatitis/exanthema) [27•].

Although many European countries already have national guidelines for HIV testing [28], ECDC has also issued an evidence-based guidance for testing programmes to help inform recommendations and scale up testing further [29]. Access to testing however seems to vary widely across healthcare settings in Europe: although most countries offer HIV tests in HIV clinics, sexual health clinics, hospitals and antenatal settings, tests are less available through general practitioners, prisons and tuberculosis services [28]. HIV testing has also been found to be feasible in emergency departments, community-based centres and through use of laboratory-based testing of oral fluid, where each have their own benefits and difficulties in implementation [30‐33, 34•]. A systematic review assessing barriers to testing in Europe found that there are barriers concerning patients, healthcare providers and at the level of institutions, which include perceived low-risk, fear, accessibility, as well as lack of financial and human resources [35]. These need to be addressed to ensure earlier diagnosis and wide access to care to prevent excess morbidity and mortality. Nonetheless, there is momentum to normalise HIV testing, by means of routine testing such as wider use of opt-out testing, including use of rapid testing, self-sampling (where the sample is posted for the test to be performed), and self-testing (where the person both takes the sample and performs the test themselves) [36, 37].

Despite the aforementioned efforts to encourage earlier and more frequent HIV testing and targeting at-risk populations, late presentation (presentation with low CD4 count) is unfortunately not a rarity. A consensus definition has been agreed in order to identify the extent to which it occurs [38, 39]. A common definition of late presentation is important. The term “late” indeed is central, as guidelines across the continent agree that ART should be started before the CD4 count drops below the threshold of 350 cells/mm³. Conversely, “late” may not necessarily imply that the person has been infected for several years, since data from seroconverter cohorts suggest that for around 20 % of people, the CD4 count is below 350 cells/mm³ by one year from infection [40]. Among adult HIV diagnoses in the EU/EEA (European Union and European Economic Area) region reported to ECDC (56 % completeness in 2011), 49 % were reported as late presentations (CD4 count at diagnosis <350 cells/mm³) and 29 % were reported as advanced HIV disease (CD4 count at diagnosis <200 cells/mm³) [8]. A large cohort collaboration study found that late presentation in Europe has declined from 57.3 % in 2000 to 51.7 % in 2010/2011; however late presentation was found to be most prevalent in heterosexual males, Southern European countries (Greece, Israel, Italy, Portugal and Spain), and people originating from Africa, suggesting key populations and regions for priority interventions [41••].

Retention in care includes both linkage to care following a diagnosis and subsequent retention in care. In particular, a clear and established pathway for onward referral for patients who test HIV-positive is intrinsic to achieve good rates of integration into HIV care services for timely ART initiation and attaining viral suppression. Many of the barriers that limit access to and retention in care elsewhere have been reduced and even removed in healthcare systems in Western Europe. Care is generally free and focuses not only to treat HIV infection but also co-infections and co-morbidities, including addiction and psychiatric diseases [42]. There are a minority of settings of concern that do not provide universal access to HIV prevention, treatment and care. The recent change in legislation in Spain preventing illegal immigrants from accessing HIV care is one notable example [43]. However, most people on ART in centres across Western Europe experience continued complete viral control. The level of viral load is the main predictor of HIV transmission risk [44]. Therefore the higher the proportion of people with suppressed viral load, the less chance of transmission of both drug-susceptible and drug-resistant strains. Perhaps largely due to on-going high rates of suppression in Europe, prevalence of transmitted drug resistance has been maintained below 10 % [45].

As life expectancies have improved over time in people living with HIV, we are now used to seeing a situation in Western Europe where a large group of people seen in care are over the age of 50 [46, 47]. The proportion of newly diagnosed cases of HIV in people aged 50 and above has also been gradually increasing each year, up from 11.9 % in 2006 to 16.6 % in 2012 [6]. It will therefore be important to ensure that HIV care services are adapted so that the needs of older people living with HIV are met. A more integrated approach to managing care may be appropriate, which would involve working closer with primary care physicians to manage HIV-related conditions but also non-HIV-related conditions which occur more frequently with older age.

HIV infection has had a large impact on MSM in Western Europe and it still remains the predominant mode of HIV transmission. Reported prevalence is high, ranging from 0.5 to 17.7 % [49]. The highest prevalences were found in France (17.7 %), Spain (13.1 %), Greece (12.7 %) and Germany (11.5 %). It is important to note here that these data were from various sources, mainly prevalence surveys, conducted in each country separately and may differ greatly by risk group definition, definition of a man who has sex with men, representativeness of the sample and sample size.

The UK, France, Netherlands, Germany, Denmark and Spain are examples of countries that have seen a gradual rise in the number of HIV diagnoses reported among MSM [8]. Studies published in the last few years have indicated that these rises are not just a result of higher testing rates and better surveillance systems, but are a result of an increase in transmission by condom-less sex [14, 50‐52, 53•]. In many of these new infections, the probable source is thought to be HIV-positive people who are not yet diagnosed. These observations have been seen despite high ART coverage in people with CD4 count <350 cells/mm³ [54].

Results from the European MSM Internet Survey (EMIS) found that men known to be HIV-positive were 2.4-fold more likely to report condom-less sex with a partner of discordant or unknown status (CLS-D) than HIV-negative and untested men [55]. The proportion of men who had CLS-D with any male partner in the preceding 12 months ranged from 25 to 41 %. The study also found that countries in the Central-West and West regions had the lowest levels of CLS-D whereas countries in the South-East regions had the highest levels. Similarly, condom-use at last anal intercourse with a male partner also ranged from 28 to 76 % over 35 countries in Europe, although around half the countries reported proportions between 40 and 60 % [49]. Despite the limitations of the uncertain representativeness of those sampled, and the potential for social desirability bias in reporting, these data seem to indicate that sexual risk behaviour among MSM varies considerably from country to country.

Migrants from countries with generalised HIV epidemics, mainly from sub-Saharan Africa, represent a large proportion of heterosexually-acquired HIV and AIDS case reports in Western Europe. Although there are large disparities due to former colonial links, healthcare systems and social structures, the general trend is such that countries with large migrant populations in the general population will have large numbers of migrants among those presenting with HIV [56]. The reported number of cases of HIV diagnoses in Western Europe originating from sub-Saharan Africa has nearly halved in the years between 2006 and 2012 (Fig. 1) [6]. In contrast, for example in the UK, there has been a rise in the proportion of diagnoses among people born abroad but who probably acquired their infection in the UK [57].

Of individuals infected through heterosexual contact and diagnosed in 2011, the proportion of reported cases in people originating from a country with a generalised epidemic varied from 5.6 % in Finland to 66.4 % in Ireland, which are much higher than levels seen in Central and Eastern European countries [6]. A major concern is that more than 60 % of migrants from generalised epidemic countries are considered to be late presenters [58] and many probably have a CD4 count below 350 cells/mm³ before arrival in Europe. As mentioned earlier, although many countries recognise that migrants and ethnic minorities are particularly vulnerable to HIV [59], testing and care are not universally available in all settings, particularly for those with uncertain or illegal migrant status.

The effect of migration from Eastern to Western Europe is unclear, but absolute numbers of European migrants diagnosed with HIV are small to date [56]. The exceptions are for countries with close borders to countries in the Eastern Europe and Central Asia region where the epidemic has around the turn of the millennium been mainly driven by injecting drug use, but more recently mixed with heterosexual and some MSM transmission [60, 61].

Across Western Europe, there have been low rates of new infections among PWID due to the wide implementation and success of harm-reduction policies and services [6]. Where data are available, it seems that all countries in Western Europe provide needle and syringe exchange programmes, opioid substitution treatment (OST) and ART for PWID, which is much higher than the average global coverage [62].

However, a number of European countries reported a rise in the number of new HIV diagnoses among PWID in 2011, most notably Greece and Romania [63•]. Both countries reported a ten-fold rise; in Greece, the number of HIV diagnoses increased from 22 cases in 2010 to 245 cases in 2011 and similarly in Romania, from nine cases in 2010 to 108 cases in 2011 [8]. Greece attributes the outbreak to the shortage of needle and syringe exchange programmes and long waiting times for access to OST prior to 2011 [64]. In Romania, evidence from behavioural surveillance surveys conducted in PWID suggested changes in drug-use patterns (amphetamine-type stimulants, associated with more frequent injections and increased sharing of injecting equipment, became more common than heroin) [64]. However similarly to the situation in Greece, access to harm reduction services also declined alongside due to the withdrawal of international programs and funding support [63•, 64]. These recent outbreaks of HIV transmission among PWID serve as a reminder that these policies are fragile and vulnerable in countries affected by economic constraints, and stress the need for continuing public health and preventative services.

PWID are at the highest risk of being co-infected with hepatitis C virus (HCV). Of patients in a Europe-wide cohort 78 % who were HCV-positive had acquired HIV-1 via injecting drug use and most likely acquired HCV through this route too [65]. For people with HCV, co-infection with HIV is known to be strongly associated with poorer prognosis with an increased risk of developing liver disease and HCV-related mortality [66]. Expanded access to HCV diagnosis and treatment will therefore be important in conjunction with harm-reduction and HIV-related programs to control the evolving epidemic.