2013 HIV/AIDS Surveillance in Europe European Centre for Disease Prevention and Control, Stockholm WHO Regional Office for Europe, Copenhagen

European Union and European Economic Area (EU/EEA) 1

HIV diagnoses in the EU/EEA, 2013 Reporting countries/Number of countries30/31 Number of HIV diagnoses Rate per population5.7 Percentage age years10.9 Male-to-female ratio3.3 Transmission mode (%) Sex between men42 Heterosexual 32 Injecting drug use5 Mother to child transmission <1<1 Unknown 20 Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013

New HIV diagnoses, 2013, EU/EEA Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 > to <20 2 to <10 < 2 Not included or not reporting Lichtenstein Luxembourg Malta Non-visible countries Rate per population

Male-to-female ratio, new HIV diagnoses, by country, EU/EEA, 2013 (n= ) Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013

HIV diagnoses in females, 2013, EU/EEA > to <20 2 to <10 < 2 Not included or not reporting Lichtenstein Luxembourg Malta Non-visible countries Rate per female population Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013

> to <20 2 to <10 < 2 Not included or not reporting Lichtenstein Luxembourg Malta Non-visible countries HIV diagnoses in males, 2013, EU/EEA Rate per male population

Proportion of HIV diagnoses, by route of transmission, 2013, EU/EEA Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013

8 Proportion of HIV diagnoses, males, by route of transmission, 2013, EU/EEA Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013

9 Proportion of HIV diagnoses, females, by route of transmission, 2013, EU/EEA Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013

Percentage of new HIV diagnoses, per age group and transmission mode, EU/EEA, 2013 (n=22 472) Injecting drug use Heterosexual (from generalised epidemic countries) Heterosexual (excluding persons from generalised epidemic countries) Sex between men Data from persons <15, other/unknown transmission, mother-to-child transmission, transfusion-related transmission, and nosocomial transmission not shown here. Data from Estonia and Poland excluded. Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013

> 5 3 to <5 1 to <3 < 1 Not included or not reporting Lichtenstein Luxembourg Malta Non-visible countries HIV diagnoses attributed to sex between men, 2013, EU/EEA Rate per male population Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013

* Out of all reported HIV diagnoses with known mode of HIV transmission; No cases reported from Iceland in 2013 Percentage of new HIV diagnoses* acquired through sex between men, EU/EEA, 2013 (n=23 416) Percentage

Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 > 5 3 to <5 1 to <3 < 1 Not included or not reporting Lichtenstein Luxembourg Malta Non-visible countries HIV diagnoses acquired through injecting drug use, 2013, EU/EEA Rate per population

Proportion HIV diagnoses among migrants *, by country of report, EU/EEA, 2013 (n= ) Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 * Among cases with known region of origin; There were no cases reported among migrants in Croatia, Latvia or Poland Percentage

Rate of reported HIV diagnoses, by year of diagnosis, in the EU/EEA, 1984–2013 Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013

HIV diagnoses, by mode of transmission, , EU/EEA Injecting drug use Heterosexual (from generalised epidemic countries) Heterosexual ( excluding persons from generalised epidemic countries) Sex between men Unknown Mother-to-child transmission Data is adjusted for reporting delay. Cases from Estonia and Poland excluded due to incomplete reporting on transmission mode during the period; cases from Italy and Spain excluded due to increasing national coverage over the period. Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013

> 50% 40 to 50% 30 to <40% < 30% Not included or not reporting Lichtenstein Luxembourg Malta Non-visible countries Proportion of HIV cases diagnosed late (CD4<350 cells/mm 3 ), 2013, EU/EEA *Among cases with CD4 count at diagnosis reported

Proportion of HIV cases with CD4 cell count <350/mm 3 and <200/mm 3 at diagnosis, by mode of transmission, EU/EEA, 2013 (n=17 526) 18 Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 Percentage

Percentage of reported cases with a CD4 cell count <350/mm 3 and <200/mm 3 at diagnosis, by age category, EU/EEA, 2013 (n=17 526) 19 Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 Percentage

> 5 3 to <5 1 to <3 < 1 Not included or not reporting Lichtenstein Luxembourg Malta Non-visible countries AIDS cases reported, 2013, EU/EEA Rate per population Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013

21 Most common AIDS-indicative diseases by transmission mode, EU/EEA, 2013 Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013

22 Conclusions (1) HIV infection is of major public health importance in the EU/EEA, with no clear signs of overall decrease. During the past decade ( ) there have been important epidemiological changes in HIV diagnoses in the EU/EEA:  Sex between men accounted for the majority of cases diagnosed in 2013 and cases in this group increased by 33%;  Heterosexual cases declined, driven by a 61% decline among those from countries with generalised HIV epidemics  Still, 35% of HIV diagnoses in 2013 were among people originating from outside the reporting country  HIV cases attributed to injecting drug use declined by 36%, with an increase since 2011 in two countries due to localised outbreaks Nearly half (47%) of newly reported cases were diagnosed late, with a CD4 cell count <350/mm 3.

Conclusions (2) Evidence-based HIV prevention interventions tailored to the local epidemiological context and targeted at those most at risk should be sustained and scaled-up. Programmes for men who have sex with men should be a cornerstone of HIV prevention in all EU/EEA countries Given the high proportion of HIV cases among migrants in many EU/EEA countries, migrant sensitive prevention services is crucial Keeping harm reduction levels high will continue to prevent HIV among people who inject drugs Expansion of HIV counselling and testing will ensure early diagnosis and access to treatment; this will reduce the number of late presenters and improve treatment outcomes. 23

24 WHO European Region

Characteristics of HIV diagnoses reported in the WHO European Region, the EU/EEA, and by geographical area, Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013; data for Russia which were published by the Russian Federal Scientific and Methodological Center for Prevention and Control of AIDS. No data received from Lichtenstein, Turkmenistan or Uzbekistan. *Figures including Russia are presented for the WHO Region and East in (brackets) Geographical areas WHO European Region* WestCentreEast* Reporting countries/Number of countries50/53 (51/53)23/2315/1513/15 (14/15) Number of HIV diagnoses ( ) ( ) Rate per population7.8 (15.7) (41.2) Percentage age years10.2%10.3%14.4%9.5% Male-to-female ratio2.2 (1.7) (1.4) Transmission mode Men who have sex with men23.6% (10.1%)43.1%30.1%2% (0.8%) Heterosexual 46.1% (30.6%)33.6%24.8%62.7% (30.0%) Injecting drug use16.2% (21.3%)4.1%5.9%30.6% (26.3%) Mother to child transmission 0.9% (0.6%) 0.7%1.1% 1.1% (0.6%) Unknown 13% (37.3%)18.2%37.9%3.6% (42.2%)

26 Rate of new HIV diagnoses, EU/EEA and WHO European Region, 1984–2013 Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013

27 Cumulative number of new HIV diagnoses in the EU/EEA and other countries of the WHO European Region, 1984–2013 Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 Data from Russia not included

Rates of new HIV diagnoses, by geographical area and year of diagnosis, WHO European Region, 2004– Cases from Russia, Turkmenistan and Uzbekistan excluded due to inconsistent reporting during the period Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013

New HIV diagnoses, by transmission mode and year of diagnosis, WHO European Region, 2004– Cases from Russia, Turkmenistan and Uzbekistan excluded due to inconsistent reporting during the period; cases from Estonia, Poland and Turkey excluded due to incomplete reporting on transmission mode during the period; cases from Italy and Spain excluded due to increasing national coverage over the period. Data are not adjusted for reporting delays and numbers of cases reported for recent years are likely to increase in future reports. Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013

Rate of AIDS cases per population, by geographical area and year of diagnosis, Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 Cases from Sweden, Russia, Turkmenistan and Uzbekistan excluded due to inconsistent reporting during the period

New HIV diagnoses, 2013 Rate per population 31 Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 No data received from Liechtenstein, Russia, Turkmenistan and Uzbekistan.

32 New HIV diagnoses in females, 2013 Rate per female population Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 No data received from Liechtenstein, Russia, Turkmenistan and Uzbekistan.

33 New HIV diagnoses in males, 2013 Rate per male population Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 No data received from Liechtenstein, Russia, Turkmenistan and Uzbekistan.

34 New HIV diagnoses attributed to heterosexual transmission, 2013 Rate per population Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 No data received from Liechtenstein, Russia, Turkmenistan and Uzbekistan.

35 New HIV diagnoses attributed to injecting drug use, 2013 Rate per population Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 No data received from Liechtenstein, Russia, Turkmenistan and Uzbekistan.

36 New HIV diagnoses attributed to sex between men, 2013 Rate per male population Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 No data received from Liechtenstein, Russia, Turkmenistan and Uzbekistan.

37 AIDS cases diagnosed, 2013 Rate per population Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 No data received from Liechtenstein, Russia, Turkmenistan and Uzbekistan.

Geographical/epidemiological division of the WHO European Region 38 West Centre East Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013

39 WHO European Region: East

40 Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 Cases from Russia, Turkmenistan and Uzbekistan excluded due to inconsistent reporting during the period; cases from Estonia excluded due to incomplete reporting on transmission mode during the period New HIV diagnoses, by transmission mode and year of diagnosis, East,

41 Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 Most common AIDS-indicative diseases by transmission mode, East, 2013

42 WHO European Region: Centre

43 Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 New HIV diagnoses, by transmission mode and year of diagnosis, Centre, Cases from Poland and Turkey excluded due to incomplete reporting on transmission mode during the period

44 Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 Most common AIDS-indicative diseases by transmission mode, Centre, 2013

45 WHO European Region: West

46 Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 New HIV diagnoses, by transmission mode and year of diagnosis, West, Cases from Spain and Italy excluded due to increasing national coverage of reporting during the period. Data are not adjusted for reporting delay and numbers of cases reported for recent years are likely to increase in future reports.

47 Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 Most common AIDS-indicative diseases by transmission mode, West, 2013

Data limitations Data completeness  Data lacking from a small number of countries Reporting and testing  Reporting systems may differ across countries, and testing patterns are subject to change over time Data quality  Completeness remains low for select variables for some countries (transmission route, CD4 at diagnosis)  Under-reporting and reporting delays influence interpretation of the most recent trends 48

Conclusions (1) HIV infection remains of major public health importance in Europe, with continuing HIV transmission and an overall 80% increase in new HIV diagnoses in 2013 compared to 2004 Wide geographic variation in rates of new HIV diagnoses per population: 41.2 in the East; 6.3 in the West and 2.2 in the Centre Almost half (49%) of new HIV cases were diagnosed late (CD4<350/mm 3 ) and more than a quarter (27%) were diagnosed with advanced HIV infection (CD4<200/mm 3 ) New AIDS diagnoses increased three-fold in the East but continued to decrease in the West 49

Conclusions (2) Heterosexual transmission  Increasing and predominant in most countries in the East  A considerable proportion is diagnosed in people originating from countries with generalised epidemics in the West Injecting drug use  Continuing but decreasing transmission in many countries in the East  Low-level in the West and Centre, two recent outbreaks aside Men who have sex with men  Increasing and predominant in most countries in the West and Centre  Low but rapidly increasing in the East 50

Conclusions (3) Countries in the East  Evidence based policies targeting key populations, including harm reduction programmes and early access to treatment for people who inject drugs, should remain the cornerstone of the HIV response  Heterosexual transmission in couples where one partner is engaged in high- risk behaviour to be strengthened  Antiretroviral therapy should be used strategically to treat and prevent HIV transmission and reduce the growing number of AIDS cases. Countries in the Centre and West  Interventions to prevent, test and treat HIV among men who have sex with men remains the priority  Access to services for migrant populations must be ensured  Harm reduction programmes to prevent outbreaks among people who inject drugs need to be maintained or scaled-up 51

52 Full report and tables and can be downloaded at: and