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HIV and AIDS in Western and Central Europe

back to top Introduction

World Health Organisation geographical division of the European region.WHO geographical division of the European region

At the end of 2010 it was estimated that around 840,000 people were living with HIV in Western and Central Europe.1 The HIV epidemic is fairly stable as a whole, with the transmission rate having changed little since 2004.2 Although the number of people living with HIV and AIDS in the region is relatively small when compared to areas such as Asia and sub-Saharan Africa, HIV and AIDS in Western and Central Europe is still considered to be a major public health issue.3 4 On a localised level, recent evidence shows increasing rates of HIV transmission in a number of European countries, particularly among men who have sex with men (MSM).5 Additionally, the number of people living with HIV who are unaware of their status is alarmingly high and many people are diagnosed with HIV at a late stage, reducing the likelihood of treatment success.

More encouragingly, the total deaths due to AIDS in this region have significantly decreased since the introduction of combination antiretroviral treatment in the mid-1990s. Most Western and Central European countries benefit from wealthy economies, stable infrastructures and developed healthcare systems, and so the majority of people needing antiretroviral treatment are receiving it. Many people now consider HIV as a chronic disease, instead of a death sentence.

This page focuses on the countries in Western and Central Europe as defined by the World Health Organisation (WHO).6 Countries in Western Europe include: Andorra, Austria, Belgium, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, Monaco, Netherlands, Norway, Portugal, San Marino, Spain, Sweden, Switzerland, and the United Kingdom. Countries in Central Europe include: Albania, Bosnia & Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Hungary, Former Yugoslav Republic of Macedonia, Montenegro, Poland, Romania, Serbia, Slovakia, Slovenia and Turkey.

back to top HIV prevalence and transmission in Europe

Number of people living with HIV in 2007, UNAIDS estimatesEstimated adult HIV prevalence in 2009 (UNAIDS)7

Generally HIV and AIDS have affected Western Europe more than Central Europe. At an estimated 0.6 percent, Portugal has the highest HIV prevalence, followed by Switzerland, Spain and France.8 In 2010 the UK reported the highest number of new HIV diagnoses (6,654), where incidence had increased by more than 50 percent between 2000 and 2009.9 10 France had the second highest number of new diagnoses (3,952) followed by Germany (2,918).11 HIV prevalence in Central Europe has remained at a relatively low level: Croatia, Slovakia and Slovenia all have HIV prevalence figures under 0.1%.12

The people who are most vulnerable to HIV infection vary between countries, areas and communities within Western and Central Europe. However, generally in the region key populations at higher risk include IDUs and their sexual partners, MSM, transgender people, prisoners, sex workers and migrants.13 Laws that protect these key populations have been implemented in many countries in the region and can help to overcome some of the barriers that many at-risk groups face to accessing HIV services.14

There are some variations in how the epidemic has spread across the region, particularly in Central Europe, where the main transmission route differs between countries. For example, whilst more than half of all diagnoses were acquired from heterosexual sex in Romania, in contrast, over half of all cases were reported to be among MSM in Slovakia.15 In Western Europe the epidemic is more homogenised, with heterosexual transmission accounting for 40 percent of diagnoses, many of which are among people who became infected in regions where there is a generalised epidemic.16 A large amount of transmissions in Western Europe are among MSM, which accounted for 39 percent of new infections in 2010.

In both Western and Central Europe Injecting drug use (IDU) accounted for 4 percent of new HIV diagnoses in 2010.17 There has been a steady decline in new HIV infections among injecting drug users in Western and Central Europe since the beginning of the century,18 which could be explained by the increasing availability of harm reduction measures, such as needle exchanges. However, not all European countries are witnessing a decline; IDU is still an important factor in several countries, and there have been some large increases in particular localised areas.19 Poland has reached a prevalence of 18 percent in some areas among IDUs,20 and in Greece and Romania there have been significant increases in cases of HIV among this group.21 22  

back to top HIV testing in Europe

In most countries the total number of HIV tests increased between 2003 and 2008 and testing rates are highest in San Marino, Belarus and France.23 HIV testing policies vary between countries in Western and Central Europe. Most countries have HIV testing facilities in STD clinics, hospitals, drug treatment clinics and antenatal clinics.24 Some countries include general practitioners in their main testing strategy, whilst in other countries local doctors play a minor role or none at all, demonstrating a need to ensure coherence and define best practice across Western and Central Europe.25 Most countries provide routine testing for pregnant women and those presenting at STD clinics.26 Testing uptake increases with ‘opt-out’ policies – whereby a test is performed unless the patient asks not to have one.

HIV testing and late diagnosis

HIV/AIDS prevention poster from Switzerland. HIV/AIDS prevention poster from Switzerland.

Since the introduction of combination antiretroviral therapy in the mid-1990s there has been a significant decline in AIDS-related mortality in Western and Central Europe.27 Most people living with HIV in these regions have access to combination therapy, which reduces their chances of acquiring AIDS-related illnesses. With the roll-out of ARVs there was a general expectation that the widespread availability of antiretroviral therapy would act as an incentive for individuals to get tested for HIV, as once diagnosed the drugs will help them stay healthy for longer.28

However, in Western and Central Europe, rates of late diagnosis have either remained at high levels or have increased.29 As a result, many people are unaware that they are living with HIV. For example, in the UK just over a quarter of people living with HIV are unaware that they are infected.30 and in Poland estimates are as high as 50 percent.31 Worrying evidence from across Western and Central Europe suggests that opportunities to diagnose HIV infections are often missed, particularly in healthcare settings.32 In some European countries, testing among injecting drug users is particularly low and according to the EU drugs agency (EMCDDA) an estimated 30-50% of HIV infected injecting drug users, in Europe, are unaware of their positive HIV status.33

Late diagnosis of HIV has serious implications for both the individual and public health. If a person is diagnosed at a late stage they are more likely to develop an AIDS-related illness, are less likely to respond to antiretroviral treatment and are at an increased risk of mortality. As people are more likely to take precautions to prevent transmission if they know they are infected with the virus, late or no diagnosis can increase the risk that HIV will be transmitted, which has wider public health implications.34 35

Although testing uptake is high in France, (around half of the French population have had an HIV test), an estimated 40 percent of new HIV diagnoses are diagnosed late. This is because people who are most at risk of late diagnosis are those who are least likely to be reached by testing programmes – for example marginalised groups such as migrants, people living in low prevalence areas and older, heterosexual men with stable partners.36 37 As these groups are typically missed, or not thought of as ‘high-risk’ for HIV infection, they are not targeted by testing programmes, and so are at a greater risk of being diagnosed late.38 39 However, there are some positive developments; In the European Union, the proportion of men who have sex with men with a late HIV diagnosis decreased from 25 percent in 2000 to 10 percent in 2006.40

back to top HIV prevention in Europe

After the first AIDS diagnoses were reported in Europe at the beginning of the 1980s, HIV prevention programmes and campaigns were set up.41 Some of these programmes have been successful, especially in reducing the incidence of mother-to-child transmission of HIV (PMTCT), preventing HIV transmission in healthcare settings, and, in many cases, reducing HIV transmission among injecting drug users. However, the overall number of new HIV infections in Western and Central Europe is still high and there are signs of increasing transmission among MSM.

Specific prevention efforts and challenges

Many countries in Europe address the needs of key populations who are more at risk of HIV. However, there is also a need to address the barriers that people face both in wider access to healthcare and specifically HIV services. These could include stigma within society, the criminalization of some people’s behaviour and discriminatory rules and regulations within and outside of the healthcare system.42

Preventing mother-to-child transmission (PMTCT)

In most of Western and Central Europe the number of HIV infections that result from mother-to-child transmission have been significantly reduced as most countries routinely test all pregnant women for HIV. If a woman tests positive she will have access to antiretroviral drugs beginning at week twenty-eight of pregnancy,43 which significantly reduces the chances of HIV transmission from mother to child. HIV-positive women are also encouraged to avoid breastfeeding, as this too can transmit HIV. As a result of these PMTCT initiatives, in 2010, Western and Central Europe had only 250 cases of mother-to child transmission of HIV44 - a relatively small number compared to many other parts of the world.

Preventing HIV transmission in healthcare settings

HIV prevention initiatives have also been successful in reducing HIV infections within healthcare settings. The risk of HIV-infected blood donations entering the blood supply in Western and Central European countries is low, as all blood donations are screened for HIV and those who think they may be at risk of HIV infection are discouraged from donating blood.45 The widespread adoption of universal precautions has also lowered the risk of exposure to HIV for healthcare workers in medical settings.

Harm reduction measures

The contents of a needle exchange pack The contents of a needle exchange pack

Europe was the first continent to introduce harm reduction measures in the 1980s after a number of IDUs were infected with hepatitis B and hepatitis C through sharing injecting equipment. The need for harm reduction programmes was greatly intensified when an increasing number of IDUs were becoming infected with HIV.

Today, harm reduction programmes such as needle exchanges and opioid substitution, operate and are legal in most Western and Central European countries.46 It is thought that these measures have succeeded in reducing the number of new HIV infections among IDUs.47  

Even though most countries in Western Europe have made it a national public health objective to reduce drug-related harm, coverage is still not sufficient to make every injection a safe one. In Sweden for example, there are only two needle syringe programmes serving only 5 percent of the total number of IDUs in the country.48 The WHO recommends that in Europe HIV services for IDUs should be integrated into existing general services for people who inject dugs, in order to ensure coverage.49 However, HIV prevention appears to be becoming less of a concern in drugs policy in Europe, possibly due to the overall drop in infections, combined with funding constraints during the economic decline.50

Some European countries are still battling with their HIV epidemics among injecting drug users; in Portugal the estimated adult HIV prevalence among IDUs is between 12-20.5 percent and in Spain some estimates are as high as 40 percent.51 In Estonia, the number of new IDU-related HIV infections almost tripled between 2008 and 2009.52

Preventing HIV transmission among men who have sex with men (MSM)

Designers Against AIDS slogan launched in March 2012 Designers Against AIDS slogan, promoting condom use

In most Western and Central European countries MSM make up a significant proportion of new HIV cases. Worrying trends show that since the mid-1990s, some countries have seen an increase in diagnoses among this group.53 54 The number of men who have sex with men newly diagnosed with HIV infection increased from 7601 in 2004 to 9541 in 2009.55 The UK witnessed the largest rise, with an increase of 91 percent between 2000 and 200656 and a figure that has since increased yearly to 3080 in 2010.57

It has been suggested that the increase in HIV diagnoses among MSM is linked to an increase in high-risk behaviour. In the 1980s HIV prevention campaigns successfully alerted people to the dangers of HIV, which accounted for a decline in the frequency of high-risk behaviours.58 In the 1990s the introduction of combination antiretroviral treatment turned HIV from a death sentence into a chronic disease, and it is thought that this may have created a sense of complacency and an increase in high-risk sexual activity.59 Françoise Barré-Sinoussi, the virologist who co-discovered HIV as the cause of AIDS, claims

“...some people in my country, France, and other Western countries have become complacent – they see HIV/AIDS as a chronic disease – not as one that can kill.”60

A study in Turkey showed that only 36.7 percent of MSM reported using a condom the last time they had anal sex with a male partner,61 and in London the percentage of MSM reporting unprotected anal sex rose from 30 percent to 42 percent over a four-year period.62 Similarly, surveys from Germany have reported an increase in unsafe sexual contact among MSM since 1996, after a previous ten years of declining occurrence of high-risk sexual behaviour.63 In Denmark also, a 2006 survey revealed an increase in the incidence of unsafe sex from the results of previous years.64

Preventing heterosexual HIV transmission

HIV prevention billboard in Switzerland An HIV prevention billboard in Switzerland

Heterosexual transmission accounts for 40 percent of HIV cases in Western Europe and 24 percent in Central Europe.65 Part of the European region World Health Organisation’s Action Plan for HIV and AIDS is to ensure that comprehensive and age-appropriate sex education is rolled out throughout the region, so that individuals understand the importance of using condoms to protect against HIV.66 Partners of people at higher risk such as injecting drug users also thought to be especially at risk of infection through sexual contact. For serodiscordant couples, where one partner is HIV positive and the other negative, ARV treatment as prevention where an HIV-positive person starts treatment early to help prevent transmission, is recommended by the WHO for use in Western and Central Europe.67

Migrant groups and HIV prevention

It can be especially difficult to target migrant groups with prevention messages, as migrant communities or individuals tend to be among the most marginalised people in society.68 Studies have shown that language problems, legal barriers, policies that prevent migrants working and social marginalisation make it difficult for migrants to be reached by HIV prevention initiatives.69 Moreover, there are often tensions between EU and national policies around equal rights to health, which can help migrants to access healthcare, and those related to illegal residence status, which can act as a barrier to accessing healthcare.70

A number of European countries are taking measures to increase awareness of HIV among their migrant populations. Many countries offer voluntary counselling and testing and provide health information leaflets (in a number of foreign languages) to all immigrants upon arrival.71

“i found out about my status wen i came to this country as i was supposed to go for all blood tests…to my surprise the results came back positive, i was so worried and confused…i haven’t told my family for fear of the stigma surrounding HIV in the African people. i have learned to deal and accept my condition im now on meds as my cd4 count was very low, but i refuse to let disease take control of my life” Charles, living in the UK72

Countries are working with non-governmental organisations and community representatives in an attempt to target specific at-risk groups.73 Interventions that involve migrant communities in their design and implementation or utilise peer support can be more effective. This is important in overcoming cultural factors that increase vulnerability, such as taboos or prejudice within migrant communities and ensuring that services are culturally sensitive.74 However, in Central Europe there are fewer HIV prevention programmes for migrants that involve users in their design.75 Successful initiatives of this kind include Réseau d’Associations Africaines et Caribéennes in France which promotes the HIV-related needs of migrant groups at a national level through bringing together 34 migrant and HIV NGOs.76

back to top HIV treatment

HIV treatment is widely available for people living with HIV in Western and Central Europe with 745,000 people in high-income European countries receiving it.77 This has meant that the number of people dying from AIDS has been significantly reduced. However, there are still a number of issues concerning antiretroviral treatment and people are still dying from AIDS in this region, with 9,900 AIDS-related deaths in 2010.78 The main causes of death among people living with HIV in Europe are TB and end-stage liver disease caused by viral hepatitis C.79 Reasons why people in Western and Central Europe still die from AIDS include:

  • A high number of late diagnoses. As mentioned earlier, there is still an unacceptably high number of people in Western and Central Europe who are diagnosed with HIV at a later stage. These people typically respond less well to treatment and are at an increased risk of early mortality.
  • Access to treatment and care for migrants. Studies have found that migrants are affected by cultural, socio-economic, linguistic, and administrative barriers to HIV treatment and care.80 These not only affect their access to testing, resulting in late diagnosis, but can also affect their access to antiretroviral treatment once diagnosed. For instance, policies which disperse migrants within a country can make it harder for people to adhere to treatment.81 Some countries, however, such as the UK, have implemented guidelines that aim to minimise any interruptions to the treatment and care received by migrants living with HIV.82 The guidelines were implemented in response to evidence of the adverse effects of rapid dispersal on HIV-positive asylum seekers.83
  • Drug resistance. As antiretroviral drugs have been available in Western and Central Europe for some time, there is a greater chance of transmission of HIV strains that are resistant to antiretroviral drugs. AIDS deaths due to drug resistance are not uncommon in the region. Fortunately due to the greater variety of potent antiretroviral drugs and close monitoring, there is evidence of a decline in transmitted drug resistance and the overall prevalence of drug resistance in a number of countries.84 85 86
  • Ageing and disease progression. Since the availability of combination antiretroviral treatment, Western and Central Europe have been among the first to witness a change in the natural course of HIV infection. Antiretroviral drugs are keeping people alive for longer, which means they not only have to contend with HIV-related illnesses, but also with illness associated with older age. Cardiovascular conditions and non-AIDS defining cancers are more prominent among people living with HIV in high-income areas.87

back to top Funding for HIV and AIDS

One of the priorities for the European Action Plan for HIV/AIDS 2012-2015 is to focus on funding, ensuring that services are cost-effective and sustainable.88 Since 2010, the economic downturn has affected the provision of healthcare in Europe. Several countries reported increases in HIV among IDUs, which may have been caused by budget cuts to harm reduction services.89 In Romania, where there has been a decrease in access to sterile syringes, the rate of new infections among IDUs rose suddenly from an average 3-5 per year, to 12 in 2010 and 62 in 2011. In Greece, cases went from around 16 annually to 190 in 2011. There have been reports in this country of drug users self-infecting with HIV in order to access benefits and to gain faster access to drug substitution programmes, which sometimes have waiting lists of up to three years.90 These incidents show the need to ensure that HIV services are safeguarded during economically challenging times.91 92  

back to top The way forward for Western and Central Europe

The shape of the HIV and AIDS epidemic in Western and Central Europe has changed significantly since AIDS was first discovered in the early 1980s. Remarkable progress has been made with regards to antiretroviral treatment and preventing transmission among certain groups. However, there is a danger that this progress has contributed to complacency. There are still a high number of new HIV diagnoses each year, a significant proportion of which are diagnosed at a late stage of infection.

In order to make any future progress in Western and Central Europe, the following issues need to be addressed:

  • Specific groups need to be targeted with prevention campaigns in order to maintain high levels of safer sex practices.93
  • The barriers that prevent migrant populations from accessing HIV testing, treatment and care need to be broken down.
  • HIV testing has to be promoted to increase the number of people who are aware of their status and to ensure early access to antiretroviral treatment.
  • Governments should ensure that HIV services within the healthcare system are safeguarded during the economic downturn.94

Finally, HIV/AIDS surveillance needs to be a priority in all European countries in order to allow for the sharing of best practice and to provide a greater understanding of the region’s epidemic.

Nominet Winner 2012

References back to top

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