Abstract
The possibility of ending the HIV epidemic in Europe is more tangible than ever. Decades of scientific innovation, community partnership, and public health advocacy have helped to transform HIV from an inevitably fatal diagnosis to one that can be effectively managed and prevented. Despite the progress that has been made, challenges remain that must now be addressed to eliminate HIV for everyone, everywhere. Progress can be secured through the heightened rollout of education and awareness, delivery of screening and prevention measures, and understanding the lived experiences of those living with HIV. A strong and consistent commitment from all stakeholders, with each of them playing their part, is now needed to maintain momentum in these areas. The Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 HIV testing, treatment, and viral suppression targets are all within reach. However, what got us here won’t get us to 2030, unless there is a change in direction. The decisions and actions we take today will determine whether we succeed in going the extra mile or fall short at the final hurdle.
HIV has been the focus of the career of Felipe Rogatto, Executive Director, Global Medical Affairs – HIV, Gilead Sciences Europe, and he has seen firsthand what can be achieved if a proactive community of researchers, clinicians, and other stakeholders work hand in hand with those impacted by HIV. Effective and well-tolerated antiretroviral therapies (ART) have helped to drastically reduce HIV-related deaths and improved both the quality of life and the life expectancy of people living with HIV. Simplified treatment regimens significantly reduced the burden for many people living with HIV, and the spread of therapies to prevent HIV transmission holds great promise for ending the spread of the virus. He has also watched as scientific evidence has been turned into effective campaigns, messages, or consensus statements, such as ‘Undetectable Equals Untransmissible’ (U=U), to help raise awareness and change perceptions of what it means to live with HIV.
There is no doubt that progress has been made. Much of the success we have seen in Europe has coalesced around strategies, targets, and milestones defined by organisations such as the UNAIDS and the WHO, which have helped to fuel high-level and united efforts to end the HIV epidemic.
The end of the epidemic is within reach. However, what got us here won’t get us to 2030, unless there is a change in direction. We must address challenges that remain if we are to go the extra mile and eliminate HIV for everyone, everywhere.
PROGRESS AGAINST UNAIDS GOALS IN EUROPE
In 2015, all countries in the UN, including those in the European Union (EU) and European Economic Area (EEA), committed to working toward the UN Sustainable Development Goals (SDG). One of these, Goal 3.3, aims to end AIDS by 2030.1
UNAIDS subsequently established the 90-90-90 targets, which sought to ensure that, by 2020, 90% of all people living with HIV would be diagnosed, 90% of those diagnosed would be receiving treatment, and 90% of those receiving treatment would have achieved viral suppression.2
Since the initial commitment to the SDGs, there has been a downward trend in the number of reported HIV diagnoses in EU/EEA countries that consistently provide data. By 2020, the region overall had reached two of the three 90-90-90 targets: 88% of people living with HIV were diagnosed, 93% of those diagnosed had started treatment, and 91% of those on treatment were virally suppressed.3
This was followed in 2021 by UNAIDS’ Global AIDS Strategy 2021–2025, which aims to “reduce the inequalities that drive the AIDS epidemic and put people at the centre of the HIV response”.4 As part of the strategy, UNAIDS extended goals relating to testing and care: by 2030, 95% of people living with HIV will know their HIV status, 95% of people who know they are living with HIV are on antiretroviral treatment, and 95% of people on treatment are virally suppressed.5
However, only a few countries are currently on track to reach this goal. In fact, 37 of the 49 countries in the WHO’s European region reported annual increases in HIV diagnoses in 2022.6 This included new record highs for some countries. Late diagnosis remains a persistent challenge, and figures indicate that the population of people living with undiagnosed HIV in Europe is also growing.6
URGENCY OF KEEPING HIV ON THE AGENDA
The bottom line is that, despite progress, the estimated number of new HIV infections in Europe remains concerning. In 2022 alone, there were around 18,000 people newly infected with HIV in the EU/EEA.7
We have achieved a lot, given where we started. People with HIV who have access to treatment have a life expectancy similar to those without the virus and, with an undetectable viral load, are unable to transmit the virus. But we cannot stop there or let progress to date create a perception that HIV is ‘resolved’.
The European Centre for Disease Prevention and Control’s (ECDC) February 2024 Evidence Brief highlighted that only two countries have achieved the first 95% target, nine countries the second 95% target, and 13 countries the third.7
In addition, the number of people acquiring HIV is rising in at least 28 countries globally,5 with Eastern Europe being one of several regions that is experiencing increasing numbers of new HIV infections.
For most of Europe, HIV continues to disproportionately impact certain areas of the population. This includes individuals and their sexual partners who use intravenous drugs, men who have sex with men, people who are transgender, sex workers, prisoners, and migrants. Evidence also points towards people from these population groups facing challenges accessing services for HIV prevention, testing, diagnosis, treatment, and both short- and long-term care.3
Put simply, the challenge we face remains complex. That is why it is so urgent that HIV remains on policy and healthcare agendas in Europe.
PUTTING PEOPLE AT THE CENTRE OF THE CARE CASCADE
To help bring the number of new infections to zero, we must evolve our treatment and prevention strategies to meet the challenges of the epidemic today.
In its latest strategy, UNAIDS is unequivocal about the need for people-centred approaches, which prioritise the needs and choices of those living with HIV, placing them as partners alongside healthcare professionals (HCP) in their own care. These approaches are essential in responding to the needs of those most at risk of new infection as well as improving outcomes for those already living with HIV.
More people-centred strategies will be crucial if we hope to tackle pervasive health inequalities that undermine equitable access to the latest, innovative treatments. HCPs are in a unique position to support these efforts across the entirety of the care cascade, both for treatment and prevention.
EDUCATION AND AWARENESS
Sustaining efforts in education and awareness over time is essential. As we know, a lack of awareness and education fuels stigma and discrimination, which undermines the health, well-being, and lives of individuals living with or at risk of HIV.
In fact, across 42 countries globally with recent survey data, almost half (47%) of people harboured discriminatory attitudes towards people living with HIV,5 and these attitudes are found even within health facilities. Additionally, Stigma Index 2.0 studies conducted across 25 countries between 2020–2023 show that almost one-quarter of people living with HIV reported experiencing stigma when seeking non-HIV-related healthcare services in the previous year.8
Coordinated public policies and campaigns can have a major impact on education, awareness, and stigma. HCPs should consider how their voices and expertise can help to drive or amplify calls for more person-centred policies. Additionally, those involved in care discussions have an important educational role to play, which could help to reduce internalised stigma. There may also be opportunities to improve education or awareness through collaboration with colleagues who work in non-HIV-related healthcare settings or who provide community-based or community-led support.
Above all, we must listen to people’s direct, lived experiences. Properly recording and understanding the stigma and discriminatory experiences of those living with or at risk of HIV will be vital if we hope to develop ongoing strategies to address this.
PREVENTION EFFORTS
There are more options than ever before for reducing the risk of HIV transmission. From tried and tested non-biomedical interventions to oral or injectable prevention therapies. However, there are still challenges with ensuring consistent access to and use of these options.
For example, in its recent evidence brief the ECDC highlighted that despite increased pre-exposure prophylaxis (PrEP) availability and uptake across the region, the situation is not where it should be. In fact, nine countries in Europe have still not developed PrEP guidelines to date.7
Improving awareness, availability, and access to prevention therapies is critical for improving PrEP uptake. Alongside other stakeholders, HCPs can positively use their frontline insights and experience to advocate for more effective policies and strategies. After all, those involved in HIV-related care or research have a view of how the demographics of the epidemic are shifting and therefore where prevention efforts should focus.
As outlined above, prevention therapies hold important utility for ending the spread of the virus. It is estimated that PrEP is around 99% effective in reducing the risk of HIV transmission when used correctly.9 The rollout of long-acting prevention therapy options may also serve to further reduce any concerns around adherence moving forward. However, both biomedical and non-biomedical prevention efforts are crucial for preventing HIV, as well as ensuring timely testing and treatment to avert new infections. Within these prevention efforts, as with every area of the care continuum, the needs of diverse groups must be considered. We must ensure that a range of options remain available and that interventions are tailored and targeted to the unique needs of those most at risk.
SCREENING AND DIAGNOSIS
Health and community systems have become far better at offering HIV tests to people who may have been exposed to the virus, but further rapid increases in diagnoses and treatment provision are needed if we hope to achieve the first 95 across Europe. This could be challenging, particularly as recent estimates suggest that, across the EU in 2022, one in six people living with HIV avoided healthcare services because of a fear of being treated differently.6
Concerningly, Eastern Europe and Central Asia have seen a 20% increase in new HIV infections since 2010, and two in five (41%) people living with HIV in the region did not know their status in 2023.5 Many countries in the region still criminalise sex work, nondisclosure, exposure or transmission of HIV, and possessing small amounts of drugs for personal use, meaning that those most at risk of acquiring HIV are less likely to seek HIV and other health services. For example, around 30% of surveyed people who inject drugs in the Republic of Moldova said they avoided starting treatment due to stigma and discrimination.5
To improve uptake, we need to ensure multiple options are available, from self-testing, which has been found to be highly effective, including among people from at-risk populations,10 to facility- and community-based testing. Healthcare leaders should also assess whether existing opportunities for screening and diagnosis in healthcare settings are being missed. Systems vary significantly across Europe, but there are likely several settings where voluntary or opt-out testing could be piloted or introduced as standard, for example, as part of routine blood tests in emergency rooms or GP clinics. There could even be opportunities to include screening in non-HIV-related research and clinical trials.
TREATMENT, RETENTION IN CARE, AND LONG-TERM SUCCESS
When it comes to HIV treatment we have come a long way. The introduction of highly active antiretroviral treatments marked a significant turning point in the epidemic, and the health sector is continuing to innovate. Now that people living with HIV have access to multiple treatment options, it is important that we empower people to make informed choices about their own health. We know that suboptimal adherence can impact the risk of developing treatment-emergent resistance, and in one study, 71% of people living with HIV reported missing an ART dose once or more within the past month.11
Open, two-way communication between HCPs and people living with HIV can ensure that people have access to the appropriate medications for their own needs and lifestyles, supporting strong adherence to their regimen and durable viral suppression. HCPs must actively involve people living with HIV in treatment conversations as early as possible and provide clear and accessible information that contributes to optimal outcomes and adherence.
However, there is no one-size-fits-all approach, and these conversations must be adapted to the individual. For example, there are regional variations for perceived needs for HIV treatment, and newly diagnosed people may be more focused on learning and managing symptoms than on issues of long-term care and future treatment complications.12 The average age of people living with HIV is also rising. In some high-income countries (e.g., the UK), up to half of adults accessing HIV care are now aged 50 years or over, and around one in 11 are aged 65 years and over.13 By 2030, it is also estimated that close to 20% of people living with HIV will be aged over 70 years in France.14 This means an increasing number of people living with HIV may experience a growing number of comorbidities, such as hypertension or diabetes. In these instances, the quality of communication between people living with HIV and their HCPs, as well as between different HCPs co-managing the persons’ care needs, is critical.
There are other challenges too. UNAIDS highlights the potential risks for people who have received antiretroviral therapy and then stopped treatment. This puts their own health at risk, increases the risk of HIV transmission, and adds to the burden on health systems.14 We must provide the right support to enable people to stay on HIV treatment and, importantly, to ensure that those who have interrupted their treatment can be re-engaged.
LOOKING FORWARD
It has taken years of concerted efforts by people living with HIV, advocates, governments, policymakers, NGOs, researchers, and clinicians to transform the HIV epidemic into what it is today. The progress we celebrate now has been hard-won, but our work is not finished.
A strong and consistent commitment from all stakeholders, with each of them playing their part, is needed going forward. EU and national governments are a central driving force to ending the epidemic. They can ensure key enablers, like continuous and sustainable funding or access to innovative HIV therapies, are embedded in national policies, pathways, and strategies. This, alongside transparent data reporting, can help to drive accountability when it comes to tracking further progress.
Healthcare leaders and providers are the connection between governments and other stakeholders. They have a pivotal and multifaceted role to play. From making HIV testing a routine part of vulnerable populations’ healthcare to advocating for innovative therapies both in prevention and treatment, to providing safe spaces that encourage open interactions between people living with HIV and the individuals or organisations involved in their care. We must also actively support community organisations in reaching out to underserved populations, encouraging them to access and stay engaged with the healthcare system. This will only succeed if we play our part in ensuring all stakeholders have the knowledge needed to overcome HIV-related stigma and discrimination.
The UNAIDS 95-95-95 HIV testing, treatment, and viral suppression targets are within reach. However, we also know that there is still work to be done on key areas such as prevention, with current European figures estimating that combination prevention is only available to around 40–50% of target groups, a long way off the 95% goal.5 This underscores how important decisions and actions we take today will determine whether we succeed in going the extra mile or fall short at the final hurdle. It is time to act now both at EU and national levels to make Europe lead by example for the rest of the world.
IHQ-UNB-6479
October 2024
