A study assessing 29 European countries’ HIV policies and services has highlighted best practice and areas for improvement, with widespread differences between European countries. Overall, the countries rated as having the best response to HIV were Luxembourg, Malta, Switzerland, Finland and the Netherlands, while the United Kingdom came in ninth.
The states judged to have the poorest response were Romania, Greece and Italy.
The study was conducted by Health Consumer Powerhouse, a Brussels-based think-tank. It assessed the situation in the 27 European Union states, plus Switzerland and Norway.
For most indicators, information was drawn from interviews with experts from the ministry of health, national bodies and NGOs in each country, as well as a survey completed by over 800 patients and patient advocates. However, if statistics were available from the World Health Organization or an international project such as EuroHIV, this source was preferred.
The authors say that they did not just look at official policy but also actual outcomes, with the input of experts and patient advocates often providing a ‘reality check’.
Prevention
The researchers consider prevention a priority area, and assessed it in terms of the availability of:
- post-exposure prophylaxis
- harm reduction for injecting drug users
- antenatal HIV testing
- rapid testing
- female condoms
- sex education in schools
- harm reduction in prisons
- sexually transmitted infection screening for people with HIV.
In addition, countries in which prostitution was legalised and regulated scored higher than countries which criminalised it.
The highest scoring countries were Switzerland, Finland, Luxembourg, Germany and Norway.
Two countries with very high HIV prevalence rates, Italy (0.4%) and Latvia (0.8%), scored very badly on prevention. Others with low ratings were Lithuania, Romania, Hungary and Slovenia.
The services which were available in the largest number of countries were harm reduction for drug users and sex education in schools. However, most countries scored badly in terms of prostitution and the availability of female condoms.
Access
The indicators of access to treatment and care included the availability of drug resistance testing, lipodystrophy treatments and sperm washing. (The availability of all licensed antiretroviral drugs was not assessed.) Data were also collected on access to healthcare for migrants.
In addition, the researchers asked about the percentage of patients starting treatment late (at a CD4 count below 200 cells/mm3), but this information was only available in a few countries. Similarly, the researchers say that they would have liked to collect data on the proportion of people with HIV with access to antiretroviral therapy, but not enough countries had reliable data.
Given that the cost of making these services available depends on the number of people to care for, it may be relevant to look specifically at the 11 countries with an estimated HIV prevalence above 0.2%. In this group, the highest scoring countries were Luxembourg, the United Kingdom, Belgium and France. Among the lower prevalence countries, Slovakia and Malta also scored highly.
Romania scored badly on each issue assessed, and other low performers included Sweden, Hungary and Bulgaria.
One issue of particular interest is whether the healthcare available to undocumented migrants and other marginalised people is equivalent to that offered to others. For this indicator, higher prevalence countries which performed well were France, Luxembourg, Portugal, and Spain. Countries scoring particularly badly were Austria, Bulgaria, Cyprus, Denmark, Germany, Romania and Sweden.
Outcomes
Data on a number of outcomes was collected, including:
- proportion of TB patients tested for HIV
- deaths due to AIDS
- HIV infections diagnosed in new born babies
- proportion of people taking treatment who have an undetectable viral load.
Although many would consider the last indicator to be one of the most important, only a few countries had data available for it. Moreover, the authors note that estimates of the life expectancy of people with HIV in different countries are not available, and therefore could not be included.
It’s important to note that a number of these indicators are strongly influenced by the underlying prevalence of HIV infection in a country. For example, the number of infections in babies is a function both of prevalence and of the effectiveness of prevention interventions.
As a result, the countries which score the highest all have a relatively low HIV prevalence: Malta, Lithuania, Slovenia, the Netherlands, Slovakia and Hungary. On the other hand, countries with poor ratings tend to have a higher prevalence: Italy, France, Portugal, Germany and Estonia.
Involvement and rights
The study evaluated a number of issues including:
- the perceived prevalence of discrimination in housing, employment, schools and healthcare
- criminalisation of HIV exposure and transmission
- whether there is a national organisation for people living with HIV
- the ‘three ones’ principles (each country should have one action framework, one coordinating body and one monitoring and evaluation system for HIV).
Countries which performed well on these topics included Luxembourg, Latvia, Slovenia, France, and Ireland.
Greece’s ratings in this category were especially low, and other countries which scored poorly were Cyprus, Lithuania, Portugal, and Slovakia.
A number of countries which were otherwise judged favourably were scored down for laws which either made sexual exposure to HIV a criminal offence, or which treated the transmission of HIV differently to the transmission of other serious infections. For example, this was the case for Switzerland, Denmark, and Germany.
Most countries were rated badly for discrimination in general, for refusal of care by healthcare workers (e.g. dentists and surgeons) and for limited rights to receive healthcare in other European states.
Assessment of the United Kingdom
The project ranked the UK in ninth place overall. Looking only at the higher prevalence countries, it ranks third (after Luxembourg and Switzerland).
The UK scored very well for access to care, and quite well for prevention.
The UK was marked down on discrimination – this was not judged on whether legal protections exist, but on whether discrimination was perceived to occur.
Moreover, the UK scored badly because sex education is not a compulsory part of the national curriculum (although the current government has proposed to change this).
The UK also scored poorly on regular screening of people with HIV for sexually transmitted infections and hepatitis. This may surprise some people as British HIV Association sexual health guidelines state that there should be a sexual history taken every six months; an annual offer of a full sexual health screen; and hepatitis screening at baseline, followed by annual screening for those with exposure risks. However, the study’s lead author, Beatriz Cebolla told aidsmap.com that the low rating was because the majority of patients and patient advocates surveyed said that in practice screening only happens if a patient takes the initiative.
Conclusion
Johan Hjertqvist of Health Consumer Powerhouse commented: “There is a general lack of leadership in HIV management. Alarmingly enough, no government seems to know the true number of HIV-infected inhabitants. The main conclusion of this very first HIV Index is that there is still a lot to do.”