Srdan Matic

Tuberculosis-HIV co-infection: Policy and epidemiology in 25 countries in the WHO European region.

The aims of this study were to collect and review tuberculosis (TB)–HIV data for Europe and to provide an overview of current health policies addressing co‐infection.

Optimal HIV testing and earlier care: the way forward in Europe

The articles in this supplement were developed from a recent pan‐European conference entitled ‘HIV in Europe 2007: Working together for optimal testing and earlier care’, which took place on 26–27 November in Brussels, Belgium. The conference, organized by a multidisciplinary group of experts representing advocacy, clinical and policy areas of the HIV field, was convened in an effort to gain a common understanding on the role of HIV testing and counselling in optimizing diagnosis and the need for earlier care. Key topics discussed at the conference and described in the following articles include: current barriers to HIV testing across Europe, trends in the epidemiology of HIV in the region, problems associated with undiagnosed infection and the psychosocial barriers impacting on testing. The supplement also provides a summary of the World Health Organizations recommendations for HIV testing in Europe and an outline of an indicator disease‐guided approach to HIV testing proposed by a committee of experts from the European AIDS Clinical Society (EACS). We hope that consideration of the issues discussed in this supplement will help to shift the HIV field closer towards our ultimate goal: provision of optimal HIV testing and earlier care across the whole of the European region.

HIV-related restrictions on entry, residence and stay in the WHO European Region: a survey.

BackgroundBack in 1987, the World Health Organization (WHO) concluded that the screening of international travellers was an ineffective way to prevent the spread of HIV. However, some countries still restrict the entrance and/or residency of foreigners with an HIV infection. HIV-related travel restrictions have serious implications for individual and public health, and violate internationally recognized human rights. In this study, we reviewed the current situation regarding HIV-related travel restrictions in the 53 countries of the WHO European Region.MethodsWe retrieved the country-specific information chiefly from the Global Database on HIV Related Travel Restrictions at hivtravel.org. We simplified and standardized the database information to enable us to create an overview and compare countries. Where data was outdated, unclear or contradictory, we contacted WHO HIV focal points in the countries or appropriate non-governmental organizations. The United States Bureau of Consular Affairs website was also used to confirm and complement these data.ResultsOur review revealed that there are no entry restrictions for people living with HIV in 51 countries in the WHO European Region. In 11 countries, foreigners living with HIV applying for long-term stays will not be granted a visa. These countries are: Andorra, Armenia, Cyprus (denies access for non-European Union citizens), Hungary, Kazakhstan, Moldova, the Russian Federation, Tajikistan, Turkmenistan, Ukraine and Uzbekistan. In Uzbekistan, an HIV-positive foreigner cannot even enter the country, and in Georgia, we were not able to determine whether there were any HIV-related travel restrictions due to a lack of information.ConclusionsIn 32% of the countries in the European Region, either there are some kind of HIV-related travel restrictions or we were unable to determine if such restrictions are in force. Most of these countries defend restrictions as being justified by public health concerns. However, there is no evidence that denying HIV-positive foreigners access to a country is effective in protecting public health. Governments should revise legislation on HIV-related travel restrictions. In the meantime, a joint effort is needed to draw attention to the continuing discrimination and stigmatization of people living with HIV that takes place in those European Region countries where such laws and policies are still in force.

Access to highly active antiretroviral therapy (HAART) for women and children in the WHO European Region 2002-2006.

Abstract Objective. To assess the level of access to highly active antiretroviral therapy (HAART) for women and children in the WHO European Region. Methods. Analysis of data from three national surveys of 53 WHO European Member States. The comparative level of access to HAART for women and children was assessed by comparing the percentage of reported HIV cases with the percentage of HAART recipients in women at the end of 2002 and 2006 and in children at the end of 2004 and 2006. Findings. Overall, the data suggest that there is equivalence of access to antiretroviral therapy by gender and age in Europe. However, in central and eastern Europe women were disproportionately more likely to receive HAART when compared with men in 2006, representing 29% of HIV cases when compared with 39% of HAART recipients in central Europe, and 34% of HIV cases when compared with 42% of HAART recipients in eastern Europe. In comparison with adults, children (<15 years of age) were over-represented among HAART recipients when compared with HIV cases in eastern Europe, accounting for 1% of HIV cases and 9% of people on HAART in 2004 and 1% of HIV cases and 8% HAART recipients in 2006. Conclusion. Access to HAART remains inequitable in terms of gender in central and eastern Europe, favouring women over men, and in terms of age in eastern Europe, favouring children over adults. Despite high and increasing coverage with HAART in many European countries, countries must address how to further increase the number of people on treatment while ensuring equitable access for all population groups in need.

Male circumcision in HIV prevention: some implementation caveats*

Faculty of Medicine, Lund University, SwedenIn this issue of HIV Medicine, Mills et al. [1] provide ameta-analysis of three Africa-based randomized controlledtrials (RCTs) studying the effects of male circumcision inpreventing female-to-male transmission of HIV [3–5].Their analysis once again raises several critical concernsabout the advisability of widespread adoption of thepractice in HIV prevention. Chief among these concernsis the apparent difficulty in extrapolating the resultsoutside the trial environment, making male circumcisionparticularly problematic as a public health intervention inresource-poor settings. The World Health Organization hasemphasized [6] that male circumcision does not providecomplete protection against HIV infection and should notbe implemented at the cost of existing preventative be-haviours and strategies, such as correct, consistent condomuse. Policy recommendations on the use of this interven-tion should also take the following issues into account.To begin with, in a study comparing traditional andmedical circumcision in Bungoma, Kenya, Bailey andEgesah [7] documented high levels of complications whenmale circumcisions are performed in settings that do notreplicate the ideal, well-resourced environments used forthe three trials. Delayed healing is one major concern: noneof the cases observed directly by Bailey and Egesah hadhealed fully by day 30 after a traditional or medicalprocedure. And of the 1007 subjects interviewed, 24% hadstill not healed fully a mean of 47 days after a traditionalprocedure. This finding stands in stark contrast to theapproximately 1400 participants in the RCT of malecircumcision in Kisumu [5], all of whom had healed bytheir day 30 post-operative visit. The increase in healingtime associated with a lack of sterilized equipment andhygienic conditions may very well increase the risk ofexposure to HIV infection in sexually active men.Furthermore, in all three trials, the adult participantswere extremely well counselled, both before and after theprocedure, about the risks of HIV transmission if they wereto resume an active sex life too soon after surgery. Thetrials also made condoms freely available to all participantsand provided regular wound checks throughout a 4-weekpost-operative period. The checks served not only tomonitor healing but also to reinforce the necessity ofabstinence during this period. Failure to communicate theneed to abstain for a recommended 6 8 weeks after theprocedure could have a devastating effect on the efficacyof the intervention. Therefore, it is imperative that anylarge-scale male circumcision effort involves the distribu-tion of adequate condom supplies and the use of multiplecommunication channels to ensure that everyone con-cerned understands the importance of abstaining untilhealing is complete.The issue of post-operative abstinence also raises thequestion of the target age for this intervention. In the Baileyand Egesah study [7], the average sexual debut of Bungomamales was between the ages of 14 and 15; about half of the797 boys interviewed had had sex before they werecircumcised. Issues concerning child protection [8] andthe optimal age for circumcision (which would ideally beperformed before sexual debut) remain unresolved. Anotherclosely linked question is how to address voluntary consentin communities where circumcision is a cultural practice.It is clear that if the conditions of these three trials are tobe replicated on a large scale, the costs will greatly exceedthe 300 rand (US

HIV testing and counselling policies and practices in Europe: lessons learned, ways forward.

50) per procedure spent in 2005 in theSouth African trial [3]. That amount did not cover theexpense of establishing the primary care facilities, nor thestaff and equipment necessary for thorough pre- and post-procedure counselling and wound checks. As it stands, theaverage annual per capita spending on health in sub-Saharan countries is currently US

HIV/AIDS in Europe: moving from death sentence to chronic disease management.

45 [9]. While circumci-sion is of course a one-time procedure, these economicconsiderations nevertheless undercut the notion that amass male circumcision intervention will be ‘inexpensive’,as the meta-analysis in this issue suggests [1].If the immediate solution to the lack of funding andprimary care resources is a donor-driven vertical interven-tion, then other questions arise. How long can such outsidesupport be maintained? What effect will it have on localownership and sustainability of prevention efforts? Sawires

Access to highly active antiretroviral therapy (HAART) for injecting drug users in the WHO European Region 2002-2004

The increasing rate of reported HIV cases in many European countries demonstrates that HIV is still an important public health issue in the World Health Organization (WHO) European Region. In 2006, Eastern European countries reported a rate of newly reported HIV cases that was nearly three times that reported in the West and over 20 times that reported in the Centre of Europe. While the incidence of AIDS has continued to decline in Western and Central Europe, it is increasing in Eastern Europe* [1]. However, the above data concern only reported HIV cases; undiagnosed cases should also be taken into consideration when discussing the extent of the HIV/AIDS epidemic and related trends. In the European Union (EU), the overall level of undiagnosed cases is estimated at 30%, and in some places almost 60% [2,3], and in some non-EU countries half of all injecting drug users (IDUs) – a population that is a driving force of the epidemic there – were unaware of their status when they tested positive in prevalence studies [4].