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The HIV epidemic in western Europe can be characterized as an endemic disease that is concentrated among the high-risk populations of men who have sex with men (MSM) and injection drug users. The disease’s spread across the continent first appeared in northern nations such as Denmark and in France, but later made its way to Spain and Portugal, which now remains the only western European nation in which AIDS incidence has not decreased, says Francoise Hamers, MD, MPH, EuroHIV project leader of Institut de Veille Sanitaire in Saint-Maurice Cedex, France.
Both North America and Europe have benefited from the great advances in HIV treatment, but HIV prevalence in the United States is twice that of Europe. "These differences could be explained, at least in part, because HIV/AIDS is increasingly affecting poor, marginalized populations and because, compared with western Europe, the U.S. has a much greater proportion of poor, marginalized groups," Hamers says. "For example, the U.S. is the OECD country with the highest poverty index and with the worst inequality index."
While Spain, Italy, and France have among the greatest numbers of people living with HIV/AIDS in western Europe, Portugal’s adult HIV prevalence rate is among the highest at 0.74%. There are an estimated 36,000 people living with HIV/AIDS in Portugal, compared with 130,000 in France, 120,000 in Spain, and 95,000 in Italy. However, Spain’s HIV prevalence is 0.58%, France’s HIV prevalence is 0.44%, and Italy’s HIV prevalence is 0.35%, according to statistics collected by UNAIDS of Geneva, Switzerland.
In northern Europe, the epidemic’s impact has been much smaller. In Denmark, for instance, the number of people living with HIV/AIDS is estimated to be about 4,300, while the prevalence rate is 0.17%. Germany’s number of people living with HIV infection is estimated to be 37,000, and the prevalence rate is 0.10%.
Another difference between the northern and southern countries of western Europe is in how the disease is transmitted.
"In northern Europe, including Scandinavian countries and the United Kingdom, traditionally the main route of transmission has been homosexual men, while in South Europe, mainly Spain, France, Portugal, and Italy, the epidemic traditionally is driven by the injection-drug-using population," says Jordi Casabona, MD, MPH, scientific director of the Center for Epidemiological Studies on HIV/AIDS, Catalan Health Department in Barcelona, Spain. Casabona also is a co-chair of the XIV International AIDS Conference, which will be held July 7-12, 2002, in Barcelona.
Initially, Portugal’s HIV epidemic was driven through sexual transmission, but in the past two years it has progressed increasingly through injection drug use (IDU) transmission, Casabona says. IDU transmission is faster because people in IDU communities will expose themselves to the risk of HIV infection many times in a single day, he notes.
In the 1980s, the HIV prevalence among the IDU population in the United Kingdom was very low, while at the same time in southern Europe the prevalence among injection drug users was greater than 60%, Casabona says. Since Spain and other southern European countries introduced needle-exchange programs in the late 1980s, this prevalence rate has dropped. For example, Spain’s prevalence rate has declined from about 60% before needle-exchange programs to about 30%-40% prevalence, Casabona says. "Now Spain has one of the largest needle-exchange programs in Europe," Casabona adds. "In Spain, the administrations are very supportive of harm reduction approaches, which is not the case in the United States, by the way."
Injection drug users in Spain are offered first a methadone treatment program and then a needle-exchange program, and even some jails have needle-exchange programs and methadone maintenance, Casabona says. "The percentage of people who share needles has dropped from 30% in 1993 to 5% in the year 2000," Casabona says.
Needle-exchange programs are available in most western European countries, says Marie Jauffret-Roustide, a sociologist with the Institut de Veille Sanitaire. "But certain countries are more liberal than others," Jauffret-Roustide says. "For example, needle-exchange programs have existed in the Netherlands since 1984 and in Germany, the United Kingdom, and Switzerland since 1986." In southern Europe, needle-exchange programs were implemented later, with Italy first promoting a needle-exchange program in 1991, France in 1989, and Belgium in 1992, Jauffret-Roustide says. Also, needles and syringes could not be purchased without prescription in France until 1987.
In contrast, drug users have always had cheap and easy access to needles in Spain through pharmacies, but needle-exchange programs make it even easier, Casabona says.
Another reason for the lower rates of HIV prevalence among IDU populations of northern European countries is a cultural difference, Casabona says. "In northern Europe, people tend to share less in general, and in southern Europe, sharing was a cultural thing, so the behavior was different," Casabona says. "In Spain, the epidemic arrived at a time when the country was evolving a lot, so there were a lot of changes with the public health structure and the reaction to the epidemic was slower than in the UK or Holland," she adds.
At least one northern country, Sweden, still has not officially accepted needle-exchange programs, but for the most part the early attention to the potential spread of HIV through shared needles has resulted in lower prevalence of HIV infection among IDU populations of northern European countries, she says.
"This liberal policy toward drug users is certainly one of the causes of low rates of HIV contamination by drug users," Jauffret-Roustide says.
Western Europe, like North America, has benefited tremendously from the 1996 introduction of highly active antiretroviral therapy. AIDS deaths have decreased since 1996 at an average annual rate of 30% between 1997 and 2000, Hamers says. The incidence of AIDS had declined by 32% in 1997 and then 23% in 1998. However, the trend of decreasing AIDS incidence has begun to slow, with declines of about 11% in 1999 and 2000, Hamers says.
Tracking HIV cases is more difficult because while HIV reporting data exist in most European countries, such data do not exist at the national level in three of the most affected nations: France, Italy, and Spain, Hamers says. Countries that have nationwide HIV reporting data for at least two consecutive years show no clear trends regarding the overall rate of newly diagnosed HIV infection. In 2000, the overall HIV rate reported was 57.4 people with HIV infection per one million population, Hamers says. "The most marked trend is observed in the United Kingdom, where the number of newly diagnosed infections attributed to heterosexual contact has been increasing since the early 1980s," Hamers says. "This trend appears to be continuing in 2001."
A sizeable proportion of new HIV diagnoses in the United Kingdom are due to heterosexual transmission, and this is particularly true among people who moved there from sub-Saharan Africa and other nations where the epidemic is generalized, Hamers explains.
As in North America, the western European response to the HIV epidemic has resulted in very little mother-to-child HIV transmission. "In western Europe, prevention of mother-to-child transmission of HIV through screening of HIV and the use of antiretroviral therapy in pregnant women has been a public health success," Hamers says. "Overall, the number of AIDS cases through mother-to-child transmission has decreased from 300 in 1995 to less than 100 in 1998 and after." The only exception to this trend has been the United Kingdom, where the testing of pregnant women has not been widely promoted until recently, Hamers says.
In Spain, more than 90% of pregnant women are screened for HIV, and both the transmission rates and the prevalence rates for HIV are very low, Casabona says. While Spain’s response to HIV treatment is exemplary, with the nation’s universal health system paying for all antiretroviral treatment for those who are infected, the nation’s prevention efforts have encountered some obstacles. "Like other southern European countries, such as Italy, condom promotion has not been easy," Casabona says. "So condom promotion here is probably more difficult in comparison with northern European countries."
While the Spanish and Catalan governments have conducted several prevention campaigns aimed at reducing sexual transmission of HIV, there have been negative reactions to these efforts from the Catholic church and some sectors of civil society, Casabona says. "Catholic groups advocate abstinence, and from a public health perspective, that may be one of our messages, but it’s not very effective," Casabona says. "A more effective intervention should be to put into place access to condoms for youths and condom prevention education, as well."
One recent government campaign has put condom machines in high schools, and this initiative has elicited a strong debate on political and religious levels. "Overall, it has been good because it promoted discussion about access to condoms for youths," Casabona says.