Welcome to the December 2022 Sexual Health & HIV Policy EUROBulletin.

For our feature in this edition, we hear from Jaime Nadal, the representative for the United Nations Population Fund (UNFPA) in Ukraine. Jaime explains the life-saving work the UNFPA has been doing to support sexual and reproductive health services since the start of the war.

Despite the destruction of hospitals and other facilities, health professionals and community groups in Ukraine are continuing to provide sexual and reproductive health services. This dedication and determination was illustrated in a presentation to the HIV Glasgow conference. Delegates heard that the provision of PrEP (regular medication to prevent HIV infection) in Ukraine has been rapidly scaled up this year.

This edition also includes a hearing at the European Parliament highlighting the consequences of the abortion ban in Poland, which has led to the deaths of women denied life-saving care.

Other items to look out for in this edition include: new statistics on HIV in Europe; new European HIV guidelines; research news from HIV Glasgow; and an upcoming webinar on progestin-only contraceptives.

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Since the Russian invasion of Ukraine earlier this year, much of Ukraine’s health infrastructure has been destroyed. Health professionals continue to provide sexual and reproductive health services in a variety of settings and the United Nations Population Fund (UNFPA) has been working to maintain supplies and services.

Jaime Nadal, UNFPA representative in Ukraine, spoke to us about its life-saving work, supporting sexual and reproductive health services in a time of war.

Increasing numbers living with undiagnosed HIV

The new annual HIV report published by the World Health Organization (WHO) Regional Office for Europe and the European Centre for Disease Prevention and Control (ECDC) shows that since 2018 more people acquired HIV in the European region than were diagnosed.

In contrast, in the part of the region which is within the European Union/European Economic Area (EU/EEA), there were more diagnoses than HIV infections, indicating that the number of people living with undiagnosed HIV is decreasing in many of these countries. Even so, an estimated 1 in 8 people living with HIV in the EU/EEA remains undiagnosed.

In 2021, nearly 300 new HIV diagnoses were made every day across the region. This amounts to 106,508 newly diagnosed HIV infections. However, there was a sharp decline in reported numbers during 2020, the first year of the COVID-19 pandemic, and the number of new HIV diagnoses reported in the WHO European region in 2021 remained almost 25% lower than pre-pandemic levels.

Dr Andrea Ammon, ECDC Director, said, "We want to decrease the number of people living with undiagnosed HIV through early testing and rapid linkage to HIV treatment. Unfortunately, we see things moving in the opposite direction, with large numbers of people living with undiagnosed HIV.”

Lack of testing recommendations for indicator conditions

A new study looked at the recommendations for HIV testing in national guidelines for HIV indicator conditions. These include cervical cancer, hepatitis C and tuberculosis.

Fifteen countries participated and the authors found fewer than half of the relevant guidelines included HIV testing recommendations. They highlight that this means opportunities for timely HIV diagnosis are being missed.

PrEP access in central Europe

The number of people able to access PrEP (regular medication to prevent HIV infection) in most countries of central Europe still numbers in the tens to hundreds rather than thousands, and there are no signs of immediate improvements, the recent Standard of Care for HIV and Co-infections in Europe meeting heard.

Dr Bartosz Szetela, who runs the All Saints Sexual Health Clinic at Wrocław Medical University in Poland, said that the issue of inconsistent guidelines, access restrictions and lack of training for providers was particularly acute in central Europe.

Low-level HIV and viral load blips

A new European study has found that low-level HIV and viral load blips are important warning signals of non-adherence and emerging drug resistance.

Researchers in the EuResist network, a European research collaboration that studies HIV drug resistance, investigated the impact of viral blips and low-level viraemia in the largest population studied to date in a high-income setting. They identified 22,532 people who started treatment between 2005 and 2015 and had at least 12 months of follow-up after starting treatment, at HIV clinics in Germany, Spain, Italy, Luxembourg, Belgium and Portugal.

Viral blips were defined as a single viral load above 50. Low-level viraemia meant several viral loads between 51 and 199, at least 30 days apart.

The researchers found that the vast majority of people who experienced a viral blip or low-level viraemia went on to re-suppress HIV and did not experience virologic failure.

However, the research also found that viral load blips above 50 were associated with an increased risk of subsequent treatment failure and therefore they need to be taken seriously as signals of non-adherence and emerging drug resistance.

Research news from HIV Glasgow

The 2022 International Congress on Drug Therapy in HIV Infection (HIV Glasgow) took place as an in-person and online meeting in October and NAM aidsmap was the official scientific news reporter.

You can catch up on all the research news coverage online, as well as a summary bulletin in English, French, Italian, Portuguese, Russian and Spanish.

Public hearing on the abortion ban in Poland

The European Parliament hosted a public hearing in November on the 'Consequences of the de facto abortion ban in Poland'.

It was hosted jointly by the Committee on Women’s Rights and Gender Equality (FEMM) and the Committee on Civil Liberties, Justice and Home Affairs (LIBE) on the second anniversary of Poland's decision to ban abortion in almost all circumstances.

Members of the European Parliament (MEPs) heard from Barbara Skrobol, a family member of Izabela Sajbor, the first person known to have died as a result of the ban. Sajbor died of septic shock last year when she was 22 weeks pregnant. The foetus she was carrying was inviable, but doctors waited for the foetus's heart to stop before treating Sajbor's infection symptoms.

Robert Biedroń, chairing the hearing, said the Polish law was barbaric and tantamount to a violation of human rights. He said there were at least six documented cases of women who had died as a result of the law, and that there were more cases going unrecorded.

He also highlighted the plight of women fleeing Ukraine, including victims of sexual violence, who find themselves unable to access abortion services in Poland.

MEPs hold talks in Poland on SRHR

A delegation from the European Parliament's Committee on Women’s Rights and Gender Equality travelled to Warsaw in November to hold meetings on women’s rights and sexual and reproductive health and rights (SRHR).

The delegation of MEPs met with representatives of civil society, the Ministry of Health and others to discuss SRHR in Poland, including in the context of the war in Ukraine and the needs of refugees.

Fred Matić MEP, who led the delegation, said: “We have received very worrying messages at our meetings: civil society and the opposition are deeply concerned about the current situation in Poland where women’s health and lives are endangered...The Committee on Women’s Rights and Gender Equality will continue its dialogue with Poland, but our requests will not be changed and women’s rights have to be at the forefront when speaking of the situation on the ground.”

A group of MEPs have also written to the Polish government in support of the right to peaceful demonstration, following the indictment of women’s rights protesters.

New European HIV guidelines

The European AIDS Clinical Society (EACS) has published the new edition of its EACS Guidelines (version 11.1, October 2022).

Changes have been made to every section in this update and a summary of changes is available. There are updated guidelines on COVID-19, tuberculosis and hepatitis D virus co-infections. The writing committee has also chosen to emphasise person-centred language throughout, moving away from the use of 'PLWH' to refer to people living with HIV.

The guidelines are available online and as an app. Translated versions will also be made available.

EACS plans new standards of care project

The World AIDS Day message from EACS strikes a reflective note, looking back on a year dominated by the invasion of Ukraine, the monkeypox epidemic and the threat of global recession.

It also acknowledges the gap between countries in the region, with some on track to achieve the goal of zero HIV transmissions, but others struggling with HIV prevention, testing and care.

In 2023, EACS plans to begin a new project with ECDC and the Centre of Excellence for Health, Immunity and Infections (CHIP) to define 'standards of care for HIV in Europe', which it hopes will support benchmarking and improvements across the region.

Disruption during COVID-19

The WHO Regional Office for Europe has published a review of publications and data that assessed the disruption of HIV, sexually transmitted infections‎ and viral hepatitis services as a result of the COVID-19‎ pandemic in the region.

It finds large variations across countries, but highlights that testing and HIV prevention services were most affected, with HIV treatment services more resilient.

A separate study has found that the number of babies born in Europe dropped 14%, nine months after the peak of the COVID-19 pandemic. The researchers say they believe, “couples’ fears of a health and social crisis at the time of the first wave of COVID-19 contributed to the decrease in live births nine months later.”

Updates on monkeypox

The most recent joint ECDC-WHO Europe surveillance bulletin, based on data up to 6 December, reports 25,573 cases of monkeypox in the European region since the current outbreak began. The highest numbers have been reported in Spain (7408), France (4110), the UK (3730), and Germany (3673).

Compared to the peak of reported cases in July, there has been a decrease of 98.8% in the weekly number of newly reported cases and, when the latest update was published, 17 countries in the region had not reported a case for more than 21 days. 

ECDC and WHO recognise multiple factors are likely to have contributed to the decline in cases, including efforts in risk communication and community engagement as well as increasing immunity in the most affected population groups due to natural immunity and vaccination.

Scaling up equitable access to PrEP

In November, the European Parliament’s Intergroup on LGBTI Rights, in partnership with UNAIDS, AIDS Action Europe, Aidsfonds, European AIDS Treatment Group, and the European Public Health Alliance, organised a policy dialogue on measures to be taken to scale up equitable access to oral PrEP for HIV as part of HIV prevention combination strategies.

Stakeholders discussed the challenges faced by people most affected by HIV in accessing PrEP and strategies to overcome these. These included providing training to healthcare providers, ensuring transparency of drug pricing, and listening to the voices of affected communities.

Impact of the fall of Roe v Wade

The International Conference on Family Planning was held in Thailand in November, and Global Health Now reports that the impact of the fall of Roe v Wade featured heavily.

Roe v Wade was a landmark case which assured the constitutional right to abortion in the US. It was overturned by a ruling in the US Supreme Court earlier this year, rolling back abortion rights despite the American public being overwhelmingly against a ban on abortion.

Last month's conference was an opportunity for advocates and researchers to discuss the impact of the decision outside the US, with some reporting an emboldening of anti-choice campaigners.

Beth Schlachter, the International Planned Parenthood Foundation’s interim director of global advocacy, warned that the same people who oppose abortion rights are also targeting contraception, saying, “If we don’t look at contraception and abortion as an issue of power, then we’re going to be missing the larger picture and we’re fighting the wrong battle.”

Schlachter suggested moving past labels and focusing on values-based narratives around wellbeing and care, to try to find common ground and a way forward.

Call for short films on sexual and reproductive health

The WHO Health for All Film Festival has a special prize dedicated to sexual and reproductive health and rights.

Films can cover a variety of topics, including contraception, prevention of sexually transmitted infections, and sexual and reproductive rights. They can be documentaries, fiction or animation films, of three to eight minutes.

The closing date for submission is 31 January 2023.

Webinar on HIV research and pregnancy

The Choice Agenda is an international forum for advocacy on prevention research hosted by AVAC.

On Wednesday 14 December at 1500 CET, The Choice Agenda is hosting a webinar called, ‘More than vessels: Pregnant people deserve inclusion in HIV prevention clinical and implementation research’.

Webinars are recorded and made available on The Choice Agenda webpage. The November webinar was on ‘Addressing PEP neglect in HIV prevention research, programming and uptake’.

Webinar on overcoming challenges with progestin-only contraceptives

The European Society of Contraception and Reproductive Health (ESC) is hosting a webinar on Wednesday 21 December at 1600 CET on 'Overcoming challenges of progestin-only contraceptives'.

Speakers include Giovanni Grandi on the management of irregular bleeding and Farah Chaudhry on tips, tricks and troubleshooting for implant removals.

Monkeypox to be known as mpox

The World Health Organization has announced it will start using 'mpox' as the new name for monkeypox. Both names will be used for the next year while the term 'monkeypox' is phased out.

The move comes following consultations, after concerns were raised about the name and the racist and stigmatising language observed around it.

Denmark | The Danish Health Data Agency has recorded an increase of about 27% in the number of emergency contraception pills sold in the past five years: from 107,000 in 2017 to 136,000 in 2021, reflecting an increasing awareness of this method of preventing pregnancy.

England | Six months into the roll-out of routine opt-out testing in 33 emergency departments in England, more than 800 people living with HIV or hepatitis and not receiving treatment have been diagnosed.

France | Free condoms will be available in pharmacies for anyone under 25 from next year, President Emmanuel Macron announced last week, in a move aimed to fight a rise in sexually transmitted infections.

Germany | Early data from a demonstration project in which people took HIV medication in the form of injectable cabotegravir and rilpivirine, show that patient dissatisfaction with taking antiretroviral therapy halved after six months.

Ireland | New data from the Irish Family Planning Association show that its early abortion service is working well, but it warns that legal barriers, such as the mandatory waiting period, continue to cause harms.

Italy | In an interview with AIDS Action Europe, Leila Cosmaro of LILA Milano discusses a pilot campaign to raise awareness of HIV self-testing in Italy. Over half the people who ordered a test kit in response to the campaign had not taken an HIV test before.

Poland | Three leading women’s rights defenders, part of the Polish Women's Strike against the country's near-total ban on abortion care, have been indicted by prosecutors (charged) for organising protests and are facing up to eight years in prison.

Spain | Half of people with HIV are aged over 50. A study in Spain found that while they are equally considered ‘older people with HIV’, long-term HIV survivors and people with HIV who are aged over 65 have markedly different characteristics and needs compared to other sub-groups.

Switzerland | A scoring system that can identify which older people with HIV have a poorer prognosis is just as accurate in Swiss people with HIV as in the French population in which it was developed, a new study found. The system could help in prioritising clinical interventions, as well as highlighting preventive measures.

Ukraine | More than half the people on PrEP in Ukraine started it this year, and the country is hoping to further develop its PrEP services. This is a remarkable achievement in a country where HIV clinics have been damaged or destroyed, much of the population is on the move, and many medical staff have been redeployed or relocated due to the war.