The annual surveillance report released recently by the European Centre for Disease Prevention and Control (ECDC) shows that the number and rate of new diagnoses of HIV is continuing to rise in eastern Europe, and is also rising sharply, though from a much lower base, in central Europe.
Meanwhile the annual number of new diagnoses is stable in western Europe, but continues to increase in gay men and other men who have sex with men (MSM) in most central and western European countries.
In eastern Europe the HIV epidemic is changing from being one concentrated in people who inject drugs (PWIDs) into one that is spreading into the general heterosexual population and especially into women. However because few men in that area report sex with other men, this increase in sexual transmission may incorporate, and conceal, an increasing MSM epidemic too.
In terms of absolute numbers of both new and cumulative diagnoses, the UK is the most badly-affected large country in the European Union and in western Europe. The UK’s rate of HIV per head of population is only exceeded by the small countries of Luxembourg, Latvia and Estonia: in the latter two cases, infection rates among large epidemics driven by drug injection are falling. Overall, annual diagnoses in the EU and the European Economic Area (which includes Norway and Iceland) appear overall to be stable or falling slightly.
In central Europe, HIV prevalence in a group of low-prevalence countries is rising sharply, with new infections concentrated almost entirely in MSM. The island of Malta is also experiencing a sudden increase in MSM cases.
The new ECDC surveillance report was released two weeks ago in time for World AIDS Day. In the past, European surveillance has been hampered by inconsistent surveillance methods and partial coverage. Notably, figures from Russia have been lacking, as Russia has no arrangement to report to the ECDC. This year, the Russian Federal Centre for the Prevention and Control of AIDS released limited figures to the ECDC that allow new and cumulative diagnoses and per capita rates of HIV to be compared across the whole World Health Organization (WHO) European Region, which encompasses 53 countries stretching from Ireland to Tajikistan and Iceland to Israel. Fifty-one countries reported figures last year, with only Uzbekistan and Turkmenistan failing to.
Last year (2014) 142,197 new diagnoses of HIV in the WHO European Region were notified to the ECDC, including 85,252 from Russia – 60% of the total. This brings the cumulative number ever diagnosed to 1,840,136 of which 907,607 are Russian – 49% of the total.
There were 29,992 new diagnoses in the WHO’s western region, which contains all the ‘old EU’ countries plus Switzerland, Norway and Iceland – 21% of all diagnoses in the WHO European Region. Only 4950 (3.5%) were diagnosed in the WHO’s central Europe region, which contains the former communist countries from Poland down to Bulgaria and Macedonia, plus Turkey, Israel and Cyprus. This means that three-quarters of HIV diagnoses (107,255) came from the WHO’s eastern region, which includes all the former Soviet Union countries; the majority of cases not from Russia were from Ukraine, with 15,796 cases last year; only 6% came from other countries.
Russia has now overtaken Ukraine as the country with the highest rate of new diagnoses in Europe. The ECDC 2014 report uses the number of new HIV cases per 100,000 people as its diagnosis rate, but it is perhaps easier to rate if they are stated as the number of people in the whole population among whom there was one diagnosis. In Russia, for instance, with 58.4 new diagnoses per 100,000 people, this means that there was one new HIV diagnosis for every 1712 people in 2014.
At the other end of the scale, in Serbia, the country with the lowest prevalence in the European region, there was one diagnosis for every 71,500 people.
Most of the former Soviet countries had more HIV diagnoses per head of population than countries in western Europe: only Azerbaijan and Lithuania had rates more typical of western Europe, and the region as a whole had one new diagnosis per 2314 people last year.
In western Europe, as noted above, the UK has the highest diagnosis rate (one case a year in every 10,500 people) apart from Luxembourg – it is not clear why that small country has one diagnosis per 8000 a year. The average rate in western Europe is 6.4 cases last year per 100,000 population, or one per 15,600, which is roughly the rate seen in Switzerland. In central Europe, it is less than half that, at one case per 38,500 people.
In western and central Europe the only group in which diagnoses are consistently increasing is MSM. In the EU/EEA in 2014 13,393 diagnoses in MSM were notified in the EU/EEA. However this is certainly an underestimate, due to reporting delays. In 2013 13,514 diagnoses were reported in the EU/EEA, and 14,138 in the WHO western and central regions.
Increases in HIV diagnoses
The rate of new diagnoses in western Europe has stayed the same for the last decade, with a possible slight decline since 2013. This conceals big shifts in who is acquiring HIV, however. The proportion of infections via heterosexual sex has declined by 44% since 2005, from nearly half to a third of the total; infections diagnosed in people born in sub-Saharan Africa have gone down by 50%.
Conversely, infections due to sex between men has risen from 30 to 42% of all infections, and in 19 countries from the UK to Serbia, MSM now represent more than half of the newly-diagnosed. Diagnoses in MSM have increased in almost every European country apart from the Netherlands, Portugal, Slovenia and Switzerland, where rates have stabilised or somewhat declined. In the UK the annual number of diagnoses has increased by 15% relative to 2005.
In the central European countries ranging from Poland to the Balkans, HIV is still less common than elsewhere but diagnoses are increasing faster than anywhere else. The annual number of new diagnoses has more than doubled (up 117%) since 2005. The countries where new diagnoses have more than doubled are Malta, Bulgaria, Poland, Hungary and Slovakia.
In MSM, new diagnoses in the central area have more than tripled (up 218%), and have increased exponentially in some countries: relative to 2005 they have increased more than threefold in Israel, Spain, Hungary and the Czech Republic; four- to sevenfold in Romania, Slovakia, Poland and Italy; tenfold in Turkey, Ukraine and Kazakhstan; and more than 20-fold in Bulgaria and Belarus. These exponential increases may, in some countries like Spain and Italy, be partly due to better surveillance, in others like Poland may be due to an increase in testing, and in others may be due to more men being willing to identify themselves as gay.
However many countries only officially claim a tiny handful of their HIV diagnoses as being due to sex between men. Russia reports no MSM figures separately to the ECDC, but men are only classed as MSM if they volunteer the information and Russia is seeing a worrying combination of a considerable increase in infections in non-drug-injecting men, while at the same time the already small proportion of infections ascribed to MSM has shrunk further.
In the eastern European region annual diagnoses in general have more than doubled since 2005. Diagnoses have gone up 141% in Russia and nearly 60% in the rest of the region, and in women by 74%. Within Russia, figures obtained separately by Aidsmap show that after a peak of 88,000 cases, most of them among people who inject drugs, in 2001, cases fell to an annual total of about 33,000 in 2003-2005. But they then started increasing again and are set to exceed the 2001 figure in 2015, with a 7% annual rate of increase in the last decade.
Most new cases in eastern Europe are now due to heterosexual sex; in Russia no less than 79% of new diagnoses in 2014 were ascribed to transmission via sex between men and women. Although as noted above, some cases may be due to unrecognised male/male sex, increased incidence and prevalence in women regionally and in Russia is a sign that heterosexual sex is indeed now the primary mode of transmission and that in some areas of Russia at least HIV is in danger of becoming a generalised epidemic.
In the ECDC report, in eastern Europe apart from Russia, cases in women increased by 74% in the last decade whereas in men the increase was 49%. Within Russia, HIV prevalence in women in their 20s now matches that in men, at 1.1% of the adult population (15-49); in adults aged 30-34, it is now 1.4% in women and 2.5% in men.
Diagnoses have also gone up sixfold in people who inject drugs (PWIDs) in central Europe, but this is almost entirely due to a localised and sudden mini-epidemic among PWIDs in Romania 2011 and 2013, which is now being contained; this also happened in Greece, which for WHO purposes is classed as being in western Europe. Since 2005, the number of new diagnoses in PWIDs has declined by 56% in western Europe, 28% in eastern Europe and 17% specifically in Russia. This is the main reason HIV epidemics in some eastern European countries are not increasing further or starting to decline: in Ukraine, HIV prevalence and incidence have stabilised while in Estonia, the small Baltic country that has seen the EU’s worst epidemic, new diagnoses have halved since 2005.
Late diagnosis, AIDS cases and deaths
Late diagnoses are more common in the east than the rest of Europe. In 2014, 58% of diagnoses in countries in eastern Europe that reported CD4 counts at diagnosis (which excludes Russia), were in people with CD4 counts below 350 cells/mm3, compared with 47% in the European Union/European Economic Area, although the proportion diagnosed very late, with CD4 counts below the AIDS-defining limit of 200 cells/mm3, was 20% both in the EU and in eastern Europe. Meanwhile a third of people in the EU in 2014 were diagnosed with a CD4 count over 500 cells/mm3, compared with one in five in eastern Europe.
Are these rising rates of HIV accompanied by rising rates of AIDS-related illness and death, or is treatment starting to make a difference? The answer is in the east, not yet. Between 2005 and 2014 AIDS diagnoses increased by 143% in the whole region and increased in every country except Estonia. In the region, one person for every 9346 in the general population was diagnosed with AIDS – a higher rate than HIV diagnoses in any western European country apart from Luxembourg. In Armenia, Kyrgyzstan, Moldova and the EU country of Lithuania, AIDS cases increased three- to fourfold, in Azerbaijan tenfold and in the WHO 53’s farthest-east outpost of Tajikistan, AIDS cases have increased dramatically with a 40-fold increase in a decade. In these countries, the AIDS toll from needle-driven infections that peaked in the early 2000s is starting to become apparent.
Deaths from AIDS have increased by 55% in the eastern region since 2005 though, in a rare piece of good news, they have begun to decline since 2012.
In the centre, AIDS diagnoses also increased, by 25%, though numerically they were few and largely among heterosexuals, not reflecting the more recent increase in MSM cases of HIV.
By contrast, in the western European region, thanks to more prompt diagnosis and wider treatment, AIDS and AIDS-related deaths continue to decline and are becoming quite rare. Only one case of AIDS was diagnosed per 125,000 people in 2014 – a 69% decrease since 2005, and 13 times lower than the rate in the east. In eastern Europe excluding Russia, 3941 people had their deaths ascribed to AIDS in 2014: in western Europe, it was only 736 – five times fewer.
The increases of HIV in the east may not be quite as stark as the ECDC report seems to show. The number of HIV tests performed in the eastern European countries that report tests – which excludes Russia – doubled in the last decade at the same time as diagnoses did. In central Europe, however, new diagnoses also doubled despite an increase in testing of only 26% – so in this region there is no doubt that HIV infections are increasing.
Migration – and conclusions
One pattern that the ECDC draws attention to is the changes in cases among migrants, at least in the EU. In 2014 37% of cases on average in EU/EEA countries were in people not born in the country they were diagnosed, and more than 50% in Iceland, the UK (53%),Norway, Ireland, France and Sweden.
Only 16% of HIV diagnoses were in people from sub-Saharan Africa, however: the ECDC comment that HIV diagnoses are now more common in people from countries without generalised epidemics and especially from other countries in the European region. The ECDC comment that an increasing number of cases, especially in heterosexual transmission, may be “linked to periodic migration from neighbouring countries.”
The other notable pattern, of course, is the continued increase in, and spread of, cases in MSM. The ECDC note that in western Europe “there has been sustained increase in HIV diagnoses among both native and foreign-born MSM. MSM account for the largest number of new HIV diagnoses and are the only population in the EU and EEA where HIV cases continue to increase at an alarming rate.”
European Centre for Disease Prevention and Control. Surveillance report: HIV/AIDS Surveillance in Europe 2014. ISBN 978-92-9193-731-8. Doi 10.2900/29461. 2015. Download the report here.