HIV testing and counselling

Entry point to prevention services

Knowledge of serostatus (whether a person is HIV positive) is the key entry point to prevention services in populations at risk, as well as to care and support for people living with HIV/AIDS. Knowing that one is HIV infected is a prerequisite to accessing HIV care. Testing strengthens prevention efforts, encourages infected people to avoid transmission to others and motivates those who are not infected to remain so through risk reduction strategies.

Counselling is also an essential component of public health prevention strategies for sexually transmitted infections (STI) and HIV/AIDS. It allows health care providers to communicate with their clients and to help them decide to change their behaviour. Testing and counselling can lead to a reduction in the number of sexual partners, increased condom use, fewer STIs and wider use of safe injecting practices.

Promoting testing and counselling is vital in the countries of eastern Europe, where these services are not currently widely available. Promotion efforts aim to increase access to information and appropriate health care services for the general population and particularly marginalized vulnerable groups.

Prevention

Much has been learned about HIV/AIDS prevention since the epidemic began in the European Region more than two decades ago. Experience shows that the proper polices and strategies can prevent, slow and reverse HIV epidemics, and deliver high-quality treatment, care and support, even in resource-limited settings. Effective responses to HIV epidemics have been achieved through the implementation of proven, evidence-based interventions.

Effective HIV prevention interventions include condom use, provision of clean injecting equipment, opioid substitution therapy, treatment of sexually transmitted infections, and HIV testing and counselling.

Treatment and care

In addition to prevention of HIV transmission, treatment and care for people living with HIV (PLHIV) has to be an integral part of a comprehensive and appropriate response to the epidemic.

Treatment and care for PLHIV, including antiretroviral treatment (ART), delays the progression of the disease, reduces disability, improves quality of life and increases life expectancy; thereby making HIV/AIDS a chronic disease rather than a death sentence. Above and beyond the advantages for individuals, access to ART also has a public health dimension. As part of a prevention plan, it can significantly reduce HIV transmission and affect the epidemic’s development.

At the 2001 meeting of the United Nations General Assembly Special Session on HIV/AIDS (UNGASS), countries made a unanimous commitment to address the question of access to evidence-based treatment for those in need, primarily highly active antiretroviral treatment (HAART). European countries continue to make significant progress in scaling up access to HIV/AIDS treatment and care and ART is now available in 52 of the 53 Member States in the WHO European Region.

There is an increasing trend in the extent of ART coverage among PLHIV in need of care: from 53% in 2004 to 63% in 2008 in 47 reporting countries. There are substantial differences in proportions of people on ART between sub-regions. Observing the five year period from 2004 to 2008, in the west 73%, 80%, 85%, 89% and 88% were receiving ART at the end of each year among those seen for care, while in the east the proportions were 3%, 5%, 8%, 15% and 24%, respectively. In central Europe, a stable proportion of PLHIV on ART among those seen for care is observed: 73%, 71%, 76%, 82% and 75% respectively. The divergence might be explained by timely differences in the epidemic onset within the Region, as well as by other factors, like low access to treatment for IDUs in the eastern part of the Region, etc. Inequity of access to treatment for this particular population group in eastern Europe presents a serious barrier for public health interventions.

As part of the global commitment to provide universal access to HIV/AIDS treatment and care, WHO/Europe assists the Member States in moving towards this goal, by supporting Member States in policy making, planning and implementing effective and evidence-based interventions WHO/Europe promotes a comprehensive approach in treatment and care for PLHIV. This includes not only specific ART, but addressing other health needs of PLHIV including: management of other infections and morbidities (TB, hepatitis B and hepatitis C), management of drug dependence, treatment of opportunistic infections, palliative care, sexual and reproductive health, prevention of HIV mother-to-child transmission, immunization of PLHIV and post-exposure prophylaxis.

HIV and other infections

European framework to decrease the burden of tuberculosis (TB) and HIV coinfection

TB and HIV/AIDS are global public health problems with considerable mutual interaction. Globally, TB is a leading killer of people living with HIV/AIDS (PLWHA). In high-prevalence countries, HIV is the most potent driver of the TB epidemic. While TB incidence is declining in central and western countries in the WHO European Region, a high burden persists in the eastern countries. TB/HIV morbidity and mortality are expected to accelerate significantly in the Region.

In recognition of the close interaction of the TB and HIV epidemics, the global Stop TB Partnership established the TB/HIV Working Group in 2001 to coordinate and promote interventions to decrease the burden of HIV-related TB (TB/HIV). The Working Group developed a global TB/HIV strategic framework, as well as implementation guidelines for adaptation in each WHO region.

In 2002, the WHO Regional Committee for Europe urged Member States to develop comprehensive, multisectoral, national HIV/AIDS strategic plans and programmes and to promote effective collaboration between TB and HIV prevention and control programmes.

WHO/Europe recently developed the European framework to decrease the burden of TB/HIV as the result of an extensive consultation process with those responsible for national HIV/AIDS and TB programmes and their partners.

The framework aims to guide countries in the Region in developing their national plans to reduce TB/HIV morbidity and mortality. It builds on strategies developed globally and in Europe for TB control and for HIV/AIDS prevention and care. It sets out the rationale for effective action to address TB/HIV, including the collaboration between national programmes for TB and HIV/AIDS. It identifies the populations at risk of TB and HIV, five strategic components and eight key operations. The main target audience comprises policy-makers in ministries (particularly health, justice and interior ministries), international agencies and nongovernmental organizations.

HIV and hepatitis coinfection

HIV epidemics in many European countries are driven by injecting drug users (IDU) or men who have sex with men (MSM). These populations also report a high prevalence of HIV/hepatitis coinfection due to the same mode of transmission of two viruses. In the absence of hepatitis treatment, mortality in people living with HIV/AIDS increases.

Liver cirrhosis and hepatocellular cancer due to hepatitis are among the top reasons of death among people living with HIV/AIDS.

The prevalence of hepatitis C virus infection in HIV-infected patients is particularly high in Europe and still rising, in contrast to the rest of the world, averaging 40% and reaching 50–90% in urban areas. Yet only a minority of HCV/HIV-coinfected patients are treated for hepatitis. Hepatitis B infection is more frequent and more severe in HIV-infected people and hepatitis D is also often found in patients with HCV, most commonly in IDU, and causes more severe liver disease than hepatitis B alone.

Harm reduction

Harm reduction is a set of policies, programmes, services and actions that aim to reduce the harm to individuals, communities and society related to drugs, including HIV infection. Harm reduction is key in the prevention of HIV infection among people who inject drugs (PWIDs) and their sexual partners.

Addressing HIV associated with injecting drug use is one of the key challenges in the health sector response to HIV, especially in the east of the WHO European Region.

A comprehensive package of interventions for the prevention, treatment and care of HIV among people who inject drugs has been endorsed widely, by WHO, UNAIDS, UNODC, the UN General Assembly, the Economic and Social Council, the UN Commission on Narcotic Drugs, the UNAIDS Programme Coordinating Board, the Global Fund and PEPFAR. The comprehensive package includes:

• Needle and syringe programmes
• Opioid substitution therapy and other evidence-based drug dependence treatment
• HIV testing and counselling
• Antiretroviral therapy
• Prevention and treatment of sexually transmitted infections
• Condom programmes for people who inject drugs and their sexual partners
• Targeted information, education and communication for people who inject drugs and their sexual partners
• Prevention, vaccination, diagnosis and treatment for viral hepatitis
• Prevention, diagnosis and treatment of tuberculosis.

The interventions included in the comprehensive package are commonly referred to as the harm reduction approach to injecting drug use. Harm reduction in response to drug use may also encompass other interventions; those included in the comprehensive package relate in particular to HIV and other co-infections. Countries should promote scaled-up access to harm reduction services including opioid substitution therapy for PWIDs. This would also provide entry points for antiretroviral treatment.

WHO/Europe actively promotes scaling-up comprehensive harm reduction services to effectively address the HIV epidemic among PWIDs and their sexual partners. During December 2009 – June 2012, the WHO/Europe HIV/AIDS, STIs and Viral hepatitis (HSV) programme carried out a range of specific activities to scale up access to high quality harm reduction, treatment and care for people who inject drugs in the WHO European Region. The activities were carried out as part of a grant agreement between WHO/Europe and the Executive Agency for Health and Consumers (EAHC), acting under powers delegated by the European Commission (EC).