HIV in Europe
Working Together for Optimal Testing and Earlier Care Copenhagen 2012 Conference
Proceedings of the Copenhagen 2012 Conference
HIV in Europe Copenhagen 2012 Conference 19 - 20 March 2012 University of Copenhagen
www.hivineurope.eu
Content Acronyms............................................................................................................................................. 5 HIV in Europe Steering Committee....................................................................................................... 6 HIV in Europe Copenhagen 2012 Conference – Organising Committee............................................... 7 HIV in Europe Copenhagen 2012 Conference Objectives..................................................................... 8 Executive Summary.............................................................................................................................. 9 2 Opening Plenary................................................................................................................................. 10 Welcome to HIV in Europe Copenhagen 2012; objectives and expected outcomes.................... 10 Welcome from the University of Copenhagen.............................................................................. 10 Keynote speech: Danish Acting Minister of Health....................................................................... 10 Keynote speech: the European Commission................................................................................ 11 Earlier HIV testing and care on the European agenda.................................................................. 11 The role of the ECDC in optimal testing and earlier care.............................................................. 12 The role of WHO in optimal testing and earlier care.................................................................... 12 Plenary 2: Access to Earlier Testing and Care.................................................................................... 15 Key issues for HIV testing in Europe.............................................................................................. 15 Challenges in earlier HIV testing and linkage to care among people who inject drugs................ 15 HIV testing guidelines in Europe and linkage to care: need for implementation: a Western Europe perspective...................................................................................................... 15 HIV testing and counselling in the EECA: the entry point for curbing the HIV epidemic.............. 16 Estimating HIV prevalence in European countries........................................................................ 16 Parallel Sessions 1–3. Testing Programmes and Strategies.............................................................. 17 Parallel Session 1. Lessons learned in novel HIV testing strategies and programmes.................. 17 Parallel session 2. HIV testing and the continuum of HIV care..................................................... 18 Parallel session 3. HIV testing among key populations................................................................. 18
Plenary 3. Late Presenters and the Undiagnosed............................................................................... 20 Characteristics of the epidemiology and temporal trends of late presenters in Europe.............. 20 Approaches to evaluating cost-effectiveness of HIV screening strategies.................................... 21 Plenary 4. Testing Strategies.............................................................................................................. 22 HIV diagnostics and testing: a US perspective.............................................................................. 22 A model of the MSM epidemic in the UK: understanding the impact of condom use and ART in influencing incidence........................................................................................... 22 The People Living with HIV Stigma Index: findings from Estonia.................................................. 22 The HIV-COBATEST Project: a survey of community-based testing services in Europe................. 22 Parallel Sessions 4–6. Challenges in Optimal Testing and Earlier Care............................................. 23 Parallel Session 4. Cost-effectiveness of HIV testing..................................................................... 23 Parallel Session 5. Characteristics of PLHIV who present late for care, and missed opportunities for earlier diagnosis............................................................................ 25 Parallel Session 6. New HIV testing diagnostic technologies........................................................ 27 Closing Plenary. HIV in Europe: the Way Forward............................................................................... 28 The impact and outcome of the European Parliament resolution of 20 November 2008, “HIV/AIDS: early diagnosis and early care,” for member states, with Italy as a case.................... 28 HIV testing and counselling services in Ukraine: what else should be done?............................... 28 Panel discussion............................................................................................................................ 28 Part 1. Moving east: what are the challenges?............................................................................. 28 Part 2. Political considerations: the way forward.......................................................................... 30 HIV in Europe Call to Action, 2012–2014...................................................................................... 31
The proceedings of the Copenhagen 2012 Conference were written by Misha Hoekstra, rapporteur
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Acronyms Ag/Ab
antigen/antibody
ART
antiretroviral treatment
CDC
Centers for Disease Control and Prevention (United States)
DG SANCO
Directorate-General for Health and Consumers (European Commission)
EATG
European AIDS Treatment Group
ECDC
European Centre for Disease Prevention and Control
EEA
European Economic Area (the EU plus Iceland, Liechtenstein and Norway)
EECA
Eastern Europe and central Asia
EFTA
European Free Trade Association (Iceland, Liechtenstein, Norway and Switzerland)
EMCDDA
European Monitoring Centre for Drugs and Drug Addiction
EU
European Union
GDP
gross domestic product
GP
general practitioner
IDU
injecting drug user
INSERM
National Institute of Health and Medical Research (France)
MSM
man who has sex with men / men who have sex with men
NHS
National Health Service (United Kingdom)
PLHIV
person/people living with HIV
QALY
quality-adjusted life year
UK
United Kingdom
UN
United Nations
US
United States
VCT
voluntary counselling and testing
WHO
World Health Organization
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HIV in Europe Steering Committee The Co-Chairs Ton Coenen Jens Lundgren
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Members Jordi Casabona
AIDS Action Europe, Executive Director, Aids Fonds and STI Aids Netherlands The Netherlands Professor & Chief Physician, University of Copenhagen & Rigshospitalet Director, Copenhagen HIV Programme, Denmark
John de Wit
Scientific Director, Center for HIV/STI Epidemiological Studies of Catalonia (CEEISCAT) Past Chair of the Board of Directors European AIDS Treatment Group (EATG), Greece Health Protection Agency, London, United Kingdom Head, Infectious Diseases & AIDS Units, Clinical Institute of Medicine & Dermatology, Hospital Clinic. Professor of Medicine, University of Barcelona, Spain Professor of Medicine, Imperial College School of Medicine. HIV Research Director, Chelsea & Westminster Hospital, UK Professor, Department of Infectious Diseases Belarus State Medical University Professor of International Health Systems, University of Copenhagen, Denmark Professor of Medicine, University of Bonn, and Head of an HIV outpatient clinic, Germany MD, PhD, Professor, Department of Medicine Karolinska University Hospital, Sweden Executive Director of “Center for Information and Counseling on Reproductive Health – Tanadgoma” Professor of Sociology, Utrecht University, The Netherlands
Observers Kevin Fenton Lali Khotenashvili Marita Van de Laar Jean-Elie Malkin Lucas Wiessing Vitaly Zhumagliev
Centers for Disease Control and Prevention (CDC), USA WHO Regional Office for Europe, Denmark European Centre for Disease Prevention and Control, Sweden UNAIDS RST/ECA, Russia European Monitoring Centre for Drugs and Drug Addiction, Portugal The Global Fund to Fight AIDS, Tuberculosis and Malaria, Switzerland
Nikos Dedes Valerie Delpech José Gatell
Brian Gazzard Igor Karpov Jeff V Lazarus Jürgen Rockstroh Anders Sönnerborg Nino Tsereteli
HIV in Europe Copenhagen 2012 Conference – Organising Committee SC members and observers Ferenc Bagyinszky Ferran Pujol Henrik Arildsen Luis Mendao Miriam Sabin Ulrich Marcus Vincent Douris Yusef Azad Jan Fouchard Klaus Legau Anna Zakowicz Maryna Zelenskaya Igor Sobolev Alexey Yakovlev
Hungarian Civil Liberties Union, Hungary HISPANOSIDA, Spain HIVEurope, Denmark EATG, Portugal UNAIDS, Switzerland Robert Koch Institute, Germany Sidaction, France National AIDS Trust, United Kingdom Danish National Board of Health, Denmark STOP AIDS, Denmark European AIDS Treatment Group, Belgium Minstry of Health, Ukraine Estonia PLWHA Network, Estonia Botkin Hospital of Infectious Diseases in St. Petersburg, Russia
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HIV in Europe Copenhagen 2012 Conference Objectives The main objectives of the HIV in Europe Copenhagen Conference 2012 were to:
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Provide an overview of European innovative initiatives and best practices on optimal testing and earlier care - how to bring people to testing?
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Sustain and fuel the political discussion of the WHO Regional Office for Europe testing guidelines (2010), ECDC testing guidelines (2010) and ECDC-EMCDDA Guidance �Prevention and control of infections among people who inject drugs�(2011), the EU Communication on HIV/AIDS and EP Resolution adopted 1 Dec 2011 and their implementation at national levels
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Accompany the debate at European Union HIV/AIDS Civil Society Forum and Think Tank level on HIV testing
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Provide opportunities for multi-stakeholder dialogue to develop creative solutions to unresolved challenges in research and implementation of HIV policies and programmes to improve early diagnosis and care of HIV across Europe - which people are prevented from testing and treatment, which measures are needed to overcome theses problems, which are the incentives for policy makers and people undiagnosed to become more active?
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Discuss and take forward the strategy for implementation of changes based on the concrete outcomes of the projects and initiative.
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Inform leaders, including key policy makers and donors, as to increase their commitment to ensure that HIV infected patients enter care earlier in the course of their infection than is currently the case.
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Increase public awareness of the public health problems associated with late presentation for HIV care.
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Present data available on temporal trends of late presenters and the undiagnosed population and data on the cost-effectiveness of HIV testing demonstrating how scaling up HIV testing can contribute to more sustainable health systems.
9. Discuss HIV testing and linkage to care and testing among key populations and the role of new HIV testing diagnostic technologies
Executive Summary There were an estimated 2.3 million PLHIV in the WHO European Region in 2010, including 1.5 million in EECA. While the epidemic has stabilized in much of the western part of the region, the eastern part is home to the fastest growing epidemic in the world, with the vast majority of new infections occurring among Russian and Ukrainian IDUs and their partners. Although HIV testing in EECA is on the rise, the benefits of the expansion are minimal, since risk group members still constitute less than 1% of those tested. More than half the PLHIV in the European Region are still classified as late presenters. While ART has expanded in most countries, the scale-up in EECA lags far behind the increase in new infections, and poor access to ART in many countries contributes significantly to high levels of late presentation. Though the overall situation is better in Western Europe, there are many settings in the West where HIV test access, uptake and linkage to other services remain poor. The funding outlook for European HIV efforts is bleak, due in particular to the ongoing financial crisis in the euro zone, huge cutbacks in Global Fund grants, and the ineligibility of many EECA countries for future grants. The consequences for EECA are particularly dire, since the area has a concentrated HIV epidemic and the Global Fund has been financing 97% of the HIV efforts that target risk populations there. Political willingness to fund more HIV services, particularly for risk groups, is thus becoming more critical than ever. Countries also need to address the stigmatization of PLHIV and risk group members head-on, particularly in the East. Stigma Index studies continue to reveal an alarming degree of stigma and discrimination among PLHIV and risk groups in many countries – e.g. 50% of Moldovan PLHIV reported that health care workers violated their confidentiality, and 23% of female PLHIV in Belarus reported being subjected to compulsory sterilization. A draft guide to routine testing in response to indicator conditions was presented to participants for feedback. Thanks in large part to findings from the HIV Indicator Diseases Across Europe Study (HIDES), the list of conditions that should trigger an automatic HIV test now stands at more than 50. More generally, numerous studies demonstrated the cost-effectiveness and broad acceptance of routine testing for all health care clients in a wide variety of settings, including emergency departments and primary care clinics. As an aid to researchers and policy-makers, several presentations outlined improved models for making prevalence and cost-effectiveness estimates. Speakers also presented a wealth of evidence that buttresses the importance of targeting risk groups and the effectiveness of point-of-care testing and lowthreshold, community-based testing. There were also numerous studies attesting to the utility of rapid tests, including orally administered ones. Several presenters showed how acute HIV infection is driving the epidemic, underscoring the need for not only early testing generally, but also for expanding the use of RNA and Ag/Ab assays and technological innovation to narrow the detection window further. Finally, the conference featured a sometimes heated discussion of the role counselling should play in HIV testing, with some arguing that it should be de-emphasized as routine testing becomes more widespread, and others maintaining that counselling will serve as a critical adjunct to testing for the foreseeable future.
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Opening Plenary Monday, 19 March 2012
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Welcome to HIV in Europe Copenhagen 2012; objectives and expected outcomes Ton Coenen (co-chair, HIV in Europe) opened the conference by describing it as an inclusive platform for all efforts in the field of HIV testing in Europe, bringing together patient advocates, public health professionals, policymakers and representatives from the major public health bodies working in the region. He reminded the audience of the three objectives of the HIV in Europe initiative: 1. highlighting the rising number of PLHIV who do not know they are HIV-positive 2. identifying the barriers to optimal VCT and earlier HIV treatment and care 3. promoting the best public health practices for HIV testing, counselling and care in Europe. Jens Lundgren (co-chair, HIV in Europe) outlined the conference objectives: to introduce the latest innovations and best practices in the field, inform the discussion of HIV testing in the EU’s HIV/AIDS Civil Society Forum and Think Tank, and increase the public health commitment to optimal testing and earlier care. Dialogue among different stakeholders would be facilitated by the diversity of the 323 participants, who hail from 46 countries and comprise 37% community representatives, 25% clinicians and 15% policymakers.
To test PLHIV without linking them to care borders on the unethical. – Jens Lundgren, HIV in Europe
Welcome from the University of Copenhagen Ulla Wewer (University of Copenhagen) meditated on the word utopia. While it usually refers to unrealistic projects and ideas, it can also be a vision that inspires us to strive harder. HIV in Europe may have seemed a utopian initiative in 2007, but now its vision is being realized. Today, we must define a new vision for testing in Europe – and work to make it real.
Keynote speech: Danish Acting Minister of Health Pia Olsen Dyhr (Danish Minister of Health) asserted the importance of using evidence-based knowledge as the basis for political action. Yet she noted that, despite overwhelming evidence on the benefits of early testing and access to care, more than 50% of PLHIV in the European Region are diagnosed after treatment should have begun. She drew attention to the growing number of countries that have criminalized risk behaviours, decrying how these laws have stigmatized people and discouraged testing and contact tracing.
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We have to remove all legal and practical obstacles standing in the way of early diagnosis and access to treatment. And this should be a joint European and global effort. – Pia Olsen Dyhr, Danish Acting Minister of Health
Keynote speech: the European Commission Martin Seychell (DG SANCO) observed that in 2011, there were more than 27,000 new infections in EU and EEA countries, with more than 50,000 new cases registered in neighbouring lands. Since the first HIV in Europe conference, testing guidelines have been developed, surveillance improved and ART become accepted as a key prevention strategy. Access to services has improved some places but deteriorated elsewhere, while prevalence has skyrocketed in the East. Seychell championed the importance of political will to work with PLHIV and risk groups; to invest in testing, care and prevention infrastructure; and to address stigma and discrimination. The Commission’s 2009 HIV strategy emphasized prevention, targeting risk groups and high-prevalence areas. While money is critical, so are political debate and leadership, human rights, research, surveillance and the involvement of risk groups.
Only a coherent and integrated policy approach, backed up by a strong injection of political support, will enable us to reach a turning point in the epidemic in Europe. – Martin Seychell, DG SANCO
Earlier HIV testing and care on the European agenda Marisa Matias (European Parliament, Portugal) pointed with approval to the European Parliament’s 2008 resolution on early diagnosis and care and its 2011 resolution on responding to HIV in member states and neighbouring countries. However, due to the ongoing financial crisis in Europe, she anticipated large cuts in both health services and relevant programmes. Of course, health investment is particularly critical during times of financial crisis, especially in improving access to services. Tailoring strategies to specific populations and countries would help maximize the use of available funds. So would introducing more transparency to the regulation of drug prices, as a recently proposed directive would do. 12
The role of the ECDC in optimal testing and earlier care After urging participants to use social media to increase pressure on political actors, Marc Sprenger (ECDC) told them to address money as well as health. The ECDC can help make the case to finance ministers for increased investment in testing and earlier treatment, especially for key populations. It is developing methodology to help countries readily assess the cost-effectiveness of screening programmes. Sprenger said that politicians often ask, “Why should we spend all this money to treat drug addicts? Or migrants?” American clinical trials have demonstrated that ART reduces transmission. Now we need to develop corresponding European evidence – and then ensure that policymakers act upon it.
This is an important conference, and I hope you are all “twittering” about it. Are you? – Marc Sprenger, ECDC
The role of WHO in optimal testing and earlier care Guénaël R. Rodier (WHO Regional Office for Europe) showed how the expansion of ART in the European Region is not keeping pace with the rise in new infections. Too often, access to testing is not linked to care, particularly in EECA. He described the European Action Plan for HIV/AIDS 2012– 2015, which emphasizes health systems strengthening and using the HIV response to improve broader health outcomes. The plan’s 2015 target is to test more than 90% of risk group members and more than 95% of pregnant women and exposed infants in the region. To expand coverage, it will rely on partnership with civil society, provider-initiated testing, rapid testing and the use of non-professionals.
Discussion. Ton Coenen lauded the strong institutional partnerships in evidence during the morning´s presentations. Ricardo Leite (Portuguese Parliament), referring to the high incidence rates and financial crunch in his own country, asked international organizations not to overlook the great need for help in much of western Europe. Luis Mendao (Portuguese Activists’ Group for HIV Treatments (GAT)) mentioned that drug stockouts were interrupting ART in Portugal. Brian Gazzard (Chelsea Westminster Hospital, UK) asked policymakers to be proactive and address the imminent availability of generic drugs and the effectiveness of pre-exposure prophylaxis. Marisa Matias and Martin Seychell both stated that the issue is not the lack of money but the prioritization of available funds. Seychell added that spending patterns today are outdated, emphasizing infrastructure and acute care rather than prevention and health determinants. Jens Lundgren claimed that one couldn’t really argue about cost-effectiveness, for all the interventions being discussed are in fact dirt-cheap.
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Plenary 2: Access to Earlier Testing and Care Key issues for HIV testing in Europe Martin Donoghoe (WHO Europe) said that in 2010, the European Region had an estimated 2.3 million PLHIV, including 1.5 million in EECA. The EECA epidemic remains the fastest-growing one in the world, with ART covering only 23% of those in need – less than half the coverage in sub-Saharan Africa. IDUs form the majority of PLHIV in EECA but comprise less than a quarter of those on ART. In the West, MSM are the largest infected group, making up nearly 40% of PLHIV. Testing is expanding, but the increase isn’t necessarily an improvement – e.g. Kyrgyzstan tested 360,000 people in 2009, yet fewer than 2500 belonged to risk groups. More than 50% of European Region PLHIV are late presenters, and AIDS-related deaths are concentrated in this group. Donoghoe also ran through the Regional Office policy framework on VCT, which WHO considers a public health and human rights imperative. Challenges in earlier HIV testing and linkage to care among people who inject drugs Roland Simon (EMCDDA) noted that while EU data on testing delay among IDUs is limited and hard to compare among countries, proxy data suggests it has plateaued overall. The ECDC and EMCDDA recommend that IDUs be offered HIV tests once or twice a year. And how else can IDU testing improve? Simon suggested that countries provide point-of-care testing, ideally with rapid tests; address the stigmatization of IDUs; improve referrals; combine testing with low-threshold drug services; cover testing costs; and target the IDUs likeliest to test late, e.g. older male migrants. HIV testing guidelines in Europe and linkage to care: need for implementation: a Western Europe perspective Valerie Delpech (UK Health Protection Agency) discussed the need to implement uniform testing guidelines and make testing routine. While consent and confidentiality remain essential, the emphasis on pretest counselling can make scaling up difficult in many places, as has been the experience in the West. Delpech advocates for normalising the testing for HIV as part of routine care – reducing it to a straightforward exchange of information and giving further pre-test counselling only if needed. Post-test counseling for those who are diagnosed remains important. Rapid testing would also help normalize testing and reduce stigma in many settings, including community settings and general practices. The new indicator disease guidelines should help make many more professionals comfortable about testing. In the UK, pilot projects have found that such routine testing is broadly accepted and effective in a range of medical settings, though offer rates vary considerably among providers. Finally, Delpech presented data showing that, once diagnosed and on treatment, the proportion of individuals who are infective is very low and it is likely that most infectious people are undiagnosed. This means that serosorting among purportedly negative persons is a poor strategy and needs to be discouraged.
Testing should include a short pre-test discussion providing information about the test. In-depth pre-test counselling (including a sexual risk assessment) is not necessary, but should be made available to individuals who require it. We need to normalise testing and make certain it is offered routinely in a wide range of medical settings, ensuring the offer is voluntary and confidential. –Valerie Delpech, UK Health Protection Agency
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HIV testing and counselling in the EECA: the entry point for curbing the HIV epidemic Nino Tsereteli (EHRN) said that nearly 90% of new European Region infections are in Russia and Ukraine, largely among IDUs and their partners. While HIV testing in EECA has increased in health care settings, risk group members still make up less than 1% of those tested. In Ukraine, an estimated 75% of PLHIV don’t know they’re infected. Barriers to timely testing include mandatory testing policies, repressive legislation, stigmatization and residency requirements. In Belarus, more than 40% of PLHIV reported that health workers had violated their confidentiality and more than 15% had been refused medical care due to their serostatus. In Kyrgyzstan, 90% of sex workers reported sexual violence and 100% police extortion. EECA doctors lack the time for proper counselling, which Tsereteli said is best offered by psychologists, social workers or peer counsellors. She also advocated expanding low-threshold, community-based testing and using rapid tests. Estimating HIV prevalence in European countries Ard van Sighem (ECDC) emphasized the importance of good HIV prevalence estimates and described three methods for obtaining them. The first method uses prevalence surveys and estimates of risk group sizes; it is impractical for countries with limited prevalence data. The ECDC is exploring ways to improve the other two approaches, which rely on case report data. In the second method, historical incidence curves are reverse-calculated from observed AIDS cases. It is hard, however, to estimate the time delays that ART introduces, and therefore HIV diagnoses are used after 1996 instead of AIDS cases. The third method uses the relation between CD4 counts and AIDS. While it is particularly useful for countries without a lot of historical data, it still needs further testing.
The “hard-to-reach community” is a myth. My community’s not hard to reach … for me. The people who are hard to reach are the people with the money. – Julian Hows, GNP+
Parallel Sessions 1–3. Testing Programmes and Strategies Parallel Session 1. Lessons learned in novel HIV testing strategies and programmes Michael Rayment (Chelsea and Westminster NHS Foundation Trust, UK) described how efforts to provide routine HIV testing in a London emergency department succeeded in providing modest coverage: 12% of eligible patients were offered tests, with 60% uptake. However, maintaining this coverage level required sustained attention, most effectively via in-house training, computer prompts and a newsletter (PS1/01: Routine HIV testing in the emergency department: tough lessons in sustainability). Dominique Costagliola (French National Institute of Health and Medical Research (INSERM)) presented findings from a similar effort using rapid tests in Parisian emergency wards, with a 6% offer rate to eligible patients and 70% uptake (PS1/02 Routine HIV Screening in 6 emergency departments in the Paris area). Fiona Burns (University College London) reported on a study in which a health advisor approached people in a London acute medical admissions unit and offered them a rapid test in conjunction with an educational video. Fifty-three percent of eligible patients could not be approached or were deemed inappropriate for testing; half the remaining patients accepted the offer, and the cost per screening was calculated to be €25 (PS1/03 Acceptability, feasibility and costs of universal offer of rapid point of care testing for HIV in an acute admissions unit: results of the RAPID project). Wendy Majewska (St. George’s Healthcare NHS Trust, UK) detailed the development of a slide-based training resource for doctors working outside of genitourinary medicine. Designed to be integrated into regular departmental training, the resource has proved a popular tool that has increased testing offers and earlier diagnosis (PS1/04 Increasing HIV testing in non-GUM settings: a new training resource). Axel J. Schmidt (London School of Hygiene and Tropical Medicine) presented results of the European MSM Internet Survey (EMIS). This large online survey, covering 38 countries, showed that MSM who engaged in risk behaviour (serodiscordant unprotected anal intercourse in the last 12 months) were half as likely to have been tested for HIV in the same time frame. Associations were also found between recent HIV testing and having a new steady partner, being 25–39 years old, being out or living in larger cities. Schmidt concluded that tailoring HIV testing to MSM at higher risk is an unmet prevention need (PS1/05 Individual level and country level predictors for recent HIV testing and late HIV diagnoses among MSM in Europe: aspects to consider when planning interventions to increase HIV testing). Claudia Carvalho (University of Porto) focused on EMIS findings for Portuguese MSM. Associations with testing were quite similar to those for European MSM as a whole; other parameters predicting higher uptake included having syphilis, being born in Brazil, having had sex abroad, and having sex at clubs or other “sex venues” (PS1/06 HIV testing among Portuguese MSM: results from the EMIS Study).
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Parallel session 2. HIV testing and the continuum of HIV care Valerie Delpech (UK Health Protection Agency) reviewed clinical outcome data for adults diagnosed with HIV in the UK, showing that access to HIV care there is excellent and the standard of care high. In 2010, 50% of the new diagnoses were late presenters, and 28% had advanced disease. Late presenters were 10 times as likely to die within in a year as those diagnosed earlier (PS2/01 Quality of care and clinical outcome of persons diagnosed with HIV in the UK).
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Michael Meulbroek (Projecte dels NOMS: Hispanosida, Spain), Maria José Campos (Checkpoint LX, Portugal) and Jean-Yves Le Talec (University of Toulouse) presented on the successful implementation of the checkpoint model for MSM in Barcelona, Lisbon and Paris, respectively. These testing programmes are notably effective because they provide rapid tests, are communitybased, offer counselling and facilitate immediate linkage to medical care (PS2/02 BCN Checkpoint: high efficiency in HIV detection and linkage to care; PS2/03 CheckpointLX: MSM HIV testing and linkage to care in Lisbon; and PS2/04 Checkpoint: rapid HIV screening in a community setting for a strong link to care). Elena Grigoryeva (Belarusian PLHIV Community) reported on the results of the Stigma Index survey in Belarus. It found that PLHIV regularly encounter stigma and discrimination, and that internalized stigma is common, particularly among women. Among the respondents, 47% had been advised by health care providers not to have children, and 23% of the female respondents had been forced to undergo sterilization (PS2/05 PLHIV-related stigma in Belarus: impacts on quality of care and health outcomes). Zoya Shabarova (AIDS Healthcare Foundation (AHF) Global Immunity, Netherlands) said that in response to the poor access that key populations have to HIV services in eastern Europe, AHF and its partners initiated projects in 2009 to provide free rapid testing and linkage to care in four countries. While linkage to care was lower than for corresponding western European initiatives, it was still twice as high as with clinically based testing in the four countries (PS2/06 Scaling-up community HIV rapid testing and linkage to care in Estonia, Lithuania, Russia and Ukraine: results and lessons learned). Parallel session 3. HIV testing among key populations Oksana Savenko (International HIV/AIDS Alliance in Ukraine) sketched out Ukraine’s HIV test response to a burgeoning epidemic in which only 25% of PLHIV knew their serostatus. Most effective in increasing testing uptake among risk groups has proved to be the development of a comprehensive package of services; simultaneously testing for HIV, syphilis and hepatitis B and C; the introduction of 15 mobile testing vans; compulsory VCT training for specialists who work with risk groups; and publishing the location of testing points online (PS3/01 Ukraine’s experience in scaling up HIV testing and further referral of high-risk populations to health care institutions). Nino Tsereteli (EHRN) related the results of surveys in Georgia among MSM and female sex workers, both repeated after three years. Among MSM, awareness of testing availability rose from 33% to 59%, thanks to continuous informational outreach – yet the increase in knowledge did not translate to any increase in testing uptake (PS3/02 Effectiveness of continuous prevention interventions for HIV testing uptake among high-risk populations in Tbilisi, Georgia).
Lazare Manirankunda (Institute of Tropical Medicine, Belgium) presented a study of HIV testing among migrants from sub-Saharan Africa, which found that they required targeted outreach to encourage prevention and testing. It also found that their health care providers did not want to initiate testing with them. Major reasons included a lack of information on HIV in this group, worries about stigmatizing patients, language barriers and fears of testing undocumented migrants. A provider-initiated counselling and testing tool created for use with the migrants made providers much more comfortable in suggesting tests (PS3/03 Translating research results into promotion of HIV testing among sub-Saharan African migrants in Flanders). Assel Terlikbayeva (Global Health Research Center of Central Asia, Kazakhstan) discussed a respondent-driven survey of MSM in Kazakhstan, where they comprise a hidden community of unknown prevalence. The survey found high levels of risk behaviour and rights violations and uncovered a strong need for anonymous, community-based rapid testing and other HIV services. (PS3/04 Using community-based rapid HIV screening among MSM in a behavioural serosurveillance survey, Almaty, 2010). Marta Vasylyev (Lviv Regional AIDS Center, Ukraine) said that while the gender balance among IDUs in Lviv Region is nearly even, only a quarter of those tested are female. A mobile clinic was developed to target female IDUs. Of those who agreed to be tested, 91% stated they were chiefly attracted by other offerings, such as free gynaecological checkups, femidoms and lipstick (PS3/05 Development of gender-oriented services to increase the uptake of VCT among female drug users in Lviv Region, Ukraine). Massimo Mirandola (Hospital Trust of Verona) presented the results of a biobehavioural survey of MSM in Barcelona, Bratislava, Bucharest, Ljubljana, Prague and Verona. HIV test-seeking behaviour was most pronounced among MSM who were older, identified as gay (especially if living with a male partner), lived in cities, were better educated or had been exposed to prevention programmes (PS3/06 Sociodemographic factors predicting HIV test-seeking behaviour among MSM in 6 EU cities: results from the SIALON European Project, 2008-2010).
Plenary 3. Late Presenters and the Undiagnosed Tuesday, 20 March 2012 Characteristics of the epidemiology and temporal trends of late presenters in Europe Joanne Reekie (University College London) outlined factors associated with late presentation in Europe, drawing on data from a database of 270,000 people from 35 European countries. While the sample was not representative (e.g. it included only one cohort from Eastern Europe), it does provide a good general picture, with 54% presenting late, 33% with advanced disease and 14% with AIDS since the beginning of 2000. Late presentation was more common in southern Europe; heterosexual males were twice as likely to present late as MSM; and people of African origin were much more likely to present late than those born in Europe. Late presentation also increased with age. Overall, late presentation in the sample declined from 57% in 2000 to 49% in 2009, and presentation with advanced disease from 37% to 27%.
Approaches to evaluating cost-effectiveness of HIV screening strategies Olivia Wu (University of Glasgow) provided a status report on the first half of an ECDC project on the cost-effectiveness of HIV screening interventions: a systematic review and critical assessment of different analytic approaches. Starting in April 2012, the project will also develop models and tools to support such analysis across the EU. Cost-effectiveness is quite country-specific, and most analyses have focused on either universal screening or antenatal screening. The most critical input parameter in most models is the prevalence of undiagnosed PLHIV in the population of interest; access to care and the cost of tests and counselling are key secondary factors. Recommending specific models will doubtless prove challenging, as the desire for comparable results will need to be balanced with the desire for flexibility. Indicator condition-guided HIV testing: presenting the HIV in Europe draft guidance document What diagnoses or clinical scenarios should automatically trigger an HIV test? Keith Radcliffe (International Union Against Sexually Transmitted Infections (IUSTI)) presented the three categories detailed in new HIV in Europe draft guidelines for indicator condition-guided testing. 1. AIDS-defining conditions (25 or so). Not only is a positive diagnosis highly probable with one of these conditions, but correct management includes early initiation of ART – which makes a failure to diagnose HIV tantamount to substandard care. 2. Conditions with high HIV prevalence (greater than 0.1%, the CDC threshold). This category includes conditions for which there is published evidence (e.g. STIs, lymphoma, herpes zoster and pregnancy) and those for which expert opinion deems prevalence over 0.1% likely. 3. Conditions where failure to diagnose HIV infection may have severe health consequences (e.g. before initiating immunosuppressive treatment for cancer or transplants). Implementation of the guide will include integration into clinical guidelines and provider training.
The great success story in HIV screening is that of antenatal testing. Once it was made a routine, universal, opt-out process, it worked very well indeed. Patients don’t like to feel that they’re being singled out – and physicians don’t like to single people out. – Keith Radcliffe, IUSTI
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Plenary 4. Testing Strategies
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HIV diagnostics and testing: a US perspective Bernard M. Branson (CDC) reviewed the history of HIV testing in the US. By 2011, an estimated 80% of PLHIV had been diagnosed, though only 28% had achieved viral suppression through ART. Adoption of more sensitive screening technologies has proceeded slowly, largely due to regulatory obstacles, but the window between infection and detection has narrowed from 56 days to 10 days (RNA assays) and 15 days (Ag/Ab combination assays). Acute infection is driving the epidemic; since the acute phase, 2–4 weeks after infection, is by far the most infectious, narrowing the detection window is critical in reducing onward transmission. The costs and logistics of RNA assays have unfortunately limited their use to date, but the development of Ag/Ab assays are making it possible to detect more acute infections. Today most US labs are reporting viral loads as well as CD4 counts. A model of the MSM epidemic in the UK: understanding the impact of condom use and ART in influencing incidence Andrew Phillips (University College London) explained how he and his colleagues developed a synthesis model to determine how three different interventions – condom promotion, early testing and the introduction of ART at diagnosis (regardless of CD4 count) – would affect the MSM epidemic in the UK. They adjusted a stochastic transmission model to achieve a good fit with historical data. Their model suggests that most new infections come from undiagnosed MSM, more than half during acute infection. It also shows that condom use has limited the increase in incidence today, and that a combination of more testing and ART at diagnosis would have prevented the rise in infected MSM that was seen after 2000. The model also enables estimation of the cost-effectiveness of such interventions. The People Living with HIV Stigma Index: findings from Estonia Jekaterina Voinova (Estonian Network of PLWH) summarized the findings of the peer-implemented Stigma Index in Estonia. The 300 PLHIV surveyed reported being subjected to high levels of psychological and physical violence due to their serostatus. Few of them believe in the confidentiality of their medical records. Only 63% of respondents said their HIV test was voluntary, and a third of them received no test counselling at all. Estonian health care providers advised many of the PLHIV not to have children, and some PLHIV were involuntarily sterilized. The Ministry of Social Affairs utilized Stigma Index results in creating HIV testing and referral guidelines, with an emphasis on counselling and rapid testing. In follow-up, the Estonian Network of PLWH is developing a peertraining programme to address internalized stigma, which is widespread among Estonian PLHIV, and a network of trusted medical specialists to reduce confidentiality breaches and improve care. The HIV-COBATEST Project: a survey of community-based testing services in Europe Michele Breveglieri (Veneto Regional Centre for Health Promotion, Italy) presented a survey of community-based VCT services (CBVCTs) and focal points in the EU and EFTA. While most countries have CBVCTs, the focal points do not always know about ones in their own countries/regions, and few focal points had a clear testing strategy. Respondents largely agreed with a proposed CBVCT definition, which describes services focused on offering VCT to specific risk groups with the involvement of group members. The service settings proved varied and somewhat difficult to compare. Most CBVCTs do not limit themselves to a single target group. Two-thirds reported that target groups were involved in conducting tests; 77% reported using blood-based rapid tests, and none saliva-based rapid tests.
Parallel Sessions 4–6. Challenges in Optimal Testing and Earlier Care Parallel Session 4. Cost-effectiveness of HIV testing Elena Pizzo (Imperial College Business School, UK) described a study examining the costeffectiveness of routine testing in four medical non-specialist settings in parts of London with high rates of undiagnosed infections: an emergency department, an acute care unit, an outpatient dermatology clinic and a primary care centre. Prevalence among those tested was 0.19%, and total cost per newly diagnosed patient was £19,000 (€23,000), not including cost savings due to early diagnoses or to reductions in onward transmission. With higher uptake the projected unit cost would drop significantly (PS4/01 Cost-effectiveness of HIV testing in non-traditional settings: the HINTS Study). Julian Perelman (Universidade NOVA de Lisboa) used a model to explore the likely impact of introducing routine HIV testing in Portugal, which has the second-highest incidence rate in the European Region. Introducing routine one-time testing would increase the undiscounted life expectancy of PLHIV by six months, to 36.6 life years, with a discounted incremental cost of €38,600/QALY. Using the WHO standard for national cost-effectiveness – three times the per-capita GDP/QALY – one-time testing would be cost-effective in the general population, and triennial testing in high-prevalence areas would be nearly so. The model did not include savings due to reduced onward transmission (PS4/02 Routine HIV screening in Portugal: clinical impact and costeffectiveness).
Cost-effectiveness does not imply affordability. – Julian Perelman, Universidade NOVA de Lisboa
Agathe León (University of Barcelona) compared the cost-effectiveness of two different testing strategies in Barcelona primary care centres. The first strategy tested everyone presenting with certain HIV indicator conditions (herpes zoster, seborrheic eczema, mononucleosis syndrome and lymphopaenia/ thrombopaenia); the second strategy, everyone visiting the same centres for other conditions. Costs were €129 per new HIV diagnosis for indicator conditions and €2001 for others (PS4/03 Comparison of indicator-condition versus universal-testing strategies for HIV detection in primary care centres).
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Oleksii Smirnov (International HIV/AIDS Alliance in Ukraine) described the results of a study screening 1450 street children aged 14–18 in four Ukrainian cities. Overall, HIV prevalence was 6.3% and syphilis prevalence 4.3%, with seasonal variations. The chief risk factors for HIV were unprotected sex with multiple partners and injecting drug use. The street children are particularly vulnerable because Ukrainian prevention programmes are restricted to adults, and HIV centres hesitate to process children without documentation or registered residency (PS4/04 Testing for HIV and syphilis among street children in four cities of Ukraine: screening results).
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Steven Derendinger (Swiss Federal Office of Public Health) presented a computer model of the HIV epidemic among Swiss MSM, using historical data to generate various future scenarios. While the test-and-treat approach – putting people on ART as soon as they test positive for HIV – would cut down on transmission, high infectiousness during the primary infection period would still
more than make up for it, even if PLHIV went on ART one month after infection. Behaviour change remains the most important way to reduce incidence (PS4/05 Is “Test and treat” the answer to the HIV epidemic among MSM in Switzerland?).
Parallel Session 5. Characteristics of PLHIV who present late for care, and missed opportunities for earlier diagnosis Tetiana Kiriazova (Future Without AIDS Foundation, Ukraine) described the factors associated with a delay in seeking care after HIV diagnosis in the Odessa Region. The main predictor of delay is a history of drug injecting. In 2010, IDUs enrolling in care had tested positive an average of more than 3 years before, while those infected sexually an average of 11 months before. For IDUs, the delay was less than 3 months in 1996. Men took almost twice as long to seek care as women (many of whom were diagnosed during antenatal care); urban IDUs took almost twice as much as rural ones, and younger IDUs substantially longer than older ones (PS5/01 Association of injection drug use and late enrolment in HIV medical care in Odessa Region, Ukraine). Karen Champenois (INSERM, France) said that one-third of French PLHIV are diagnosed at an advanced stage. Medical records of newly diagnosed patients revealed that 82% of the ones who had sought care for an HIV symptom in the 3 years before diagnosis had not been offered an HIV test; and that neither had 55% of MSM who told providers they were MSM. She recommended improving provider education and extending HIV testing to primary care (PS5/02 Missed opportunities for earlier HIV testing in newly diagnosed HIV patients in France). Nikoloz Chkhartishvili (Infectious Diseases, AIDS and Clinical Immunology Research Center, Georgia) said that despite universal access to ART, nearly half of all HIV patients in Georgia have AIDS at diagnosis. Multivariate regression showed that the factor associated most strongly with late diagnosis was referral for an HIV indicator condition such as prolonged fever or pneumonia; the average time from such a referral to diagnosis was 26 months. Other associated factors include increasing age, unemployment and a history of living abroad or of drug injecting. Routine testing for HIV indicator conditions is strongly recommended, especially for IDUs (PS5/03 Factors associated with late HIV diagnosis in Georgia). Axel Kok-Jensen (Statens Serum Institute, Denmark) examined how well the Danish health system has done on testing TB patients for HIV. Both are notifiable diseases in Denmark. Medical records show that HIV testing rose from 43% of TB diagnoses in 2007 to 63% in 2009; most tests were of people considered at risk. Of those tested for HIV, 6% tested positive; the overall coinfection rate among of people with TB is estimated to be 3–4%. Although national and individual hospital guidelines recommend routine HIV testing for all TB patients, hospitals have not been following their own guidelines (PS5/04 HIV testing among tuberculosis patients in Denmark increased through the period from 2007 to 2009). Murad Ruf (NHS Lambeth, UK) reminded participants that primary HIV infection is typically accompanied by two or three weeks of non-specific symptoms such as fever, myalgia and headaches. He presented a London study of 1045 patients presenting in general practices with glandular fever-like illness. GPs requested HIV tests for only 11%, thereby identifying 1 of 4 cases of primary HIV infection in the patient sample. Adding an HIV test to standard glandular fever-like illness test panel would be practical and cost-effective (PS5/05 Diagnosing HIV infection in patients presenting with glandular fever-like illness in primary care: are we missing primary HIV infection?).
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Percy Fernández Dávila (Centre for Epidemiological Studies on HIV/STIs in Catalonia) sketched a sociodemographic profile of Spanish MSM who have never been tested for HIV, based on analysis of the European MSM Internet Study (EMIS). Twenty-six percent of the 13,000 Spanish respondents in this self-selected survey had never been tested. Untested MSM were significantly more likely than tested MSM to live in a small city or town, be younger than 25, and be less educated or still in school. Other associations included being “out” to few or no people and being ignorant about HIV, STIs and post-exposure prophylaxis. Non-testers thus tend to be much harder to reach with HIV services (PS5/06 Profile and determinants of having never been tested for HIV among MSM in Spain). 26
Parallel Session 6. New HIV testing diagnostic technologies Michael Rayment (Chelsea and Westminster NHS Foundation Trust, UK) described the development of programmes using saliva-based tests in general clinical settings. Initially, the processing was fairly labour-intensive, and there were concerns about the extra training non-professionals require to administer and interpret rapid tests at point of care. Using automated laboratory-based analysis proved to be highly accurate, saved time and was much easier on field staff. In these routine optout settings, surveyed patients were in fact more accepting of saliva tests with a weeklong wait for results than finger-prick tests with immediate turnaround (PS6/01 Automated laboratory-based oral fluid HIV testing in HIV screening programmes: automatic for the people?). Cristina Agustí (Centre for Epidemiological Studies on HIV/STIs in Catalonia) discussed the findings from a survey of rapid testing among Spanish practitioners of family and community medicine, chiefly GPs. Seventy percent of respondents were aware of rapid HIV tests but unfamiliar with their use, and nearly 80% expressed willingness to offer them in their practices. The doctors identified a lack of time and training in both the use of the tests and associated counselling as the most common barriers to their utilization; cultural and linguistic barriers were also mentioned frequently, as was the need for informed consent (PS6/02 Acceptability of rapid HIV diagnosis technology among primary health care practitioners in Spain). Anne-Francoise Gennotte (Saint-Pierre University Hospital, Belgium) presented a study of 10 Belgian GPs who offered both rapid and standard tests to patients presenting with an indicator condition or identifying as members of a risk group. Patient uptake was high (94% for the standard test, 91% for the rapid test), but the GPs offered tests to only 41% of the qualifying patients. GPs’ most common reason for not testing was lack of time for counselling. However, in the course of a year, the time they needed to discuss and perform a test fell from 20 minutes to 7–10, and the GPs grew more comfortable offering tests and discussing risks and sexual practices (PS6/03 Feasibility and acceptability of HIV screening with the use of rapid tests by GPs in a Brussels area with a significant African community). Veronica Baractari (League of PLHIV from Moldova) discussed Stigma Index findings from Moldova. Late testing was common among PLHIV who had low incomes, had been in prison or were IDUs, MSM or sex workers. When asked why people subjected them to stigma and discrimination, most PLHIV cited ignorance of transmission, fear of infection or shame of infection; very few mentioned religious scruples or disapproval of behaviour or lifestyle. The setting where they experienced discrimination most often was medical institutions, and half reported that health workers had disclosed their serostatus without their consent. Since the index was finished, PLHIV have been meeting with health officials and developing training for health workers (PS6/04 The effects of stigma and discrimination on PLHIV’s access to testing and treatment and on their quality of life: results of the Stigma Index survey in Moldova). Virginie Supervie (INSERM) used the case of France to illustrate three methods of obtaining a good estimate of the prevalence of undiagnosed HIV cases in a country – its “hidden” epidemic. (See also Ard van Sighen’s presentation during the second plenary.) The direct method multiplies an
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undiagnosed prevalence estimate for each risk population by that population’s estimated size. The historical back-calculation estimates overall prevalence at a given time, then subtracts for HIV deaths and diagnoses. A newer back-calculation model using CD4 counts at diagnosis allows estimates of the time from infection to diagnosis. The three models provided similar estimates of 24,000 to 29,000 undiagnosed PLHIV in France (PS6/05 How to estimate the size of a hidden HIV epidemic: the case of France).
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Closing Plenary. HIV in Europe: the Way Forward The impact and outcome of the European Parliament resolution of 20 November 2008, “HIV/AIDS: early diagnosis and early care,” for member states, with Italy as a case Matteo Schwarz (Italian Network of HIV-Positive People) outlined the lessons learned in Italy during the process of creating a national consensus document and action plan on testing, in response to the 2008 European Parliament resolution on early HIV diagnosis and care. All major HIV stakeholders – patient groups, NGOs, academics and local health policymakers were involved. Consensus was difficult to achieve, but the stakeholders agreed to address the documents to providers rather than the public, and to have tests offered actively. The process unfolded quickly, thanks to concerted political outreach to local officials and to good scientific and practical briefings on the economic impact of early testing on local budgets. HIV testing and counselling services in Ukraine: what else should be done? Ihor Perehinets (WHO Ukraine) provided an overview of HIV testing and counselling in Ukraine, where adult prevalence is 0.71%. Thirty-six percent of IDUs and 38% of MSM know their serostatus, well under the 2013 target of 60% for these groups. Ukraine has good testing guidelines and numerous testing points, yet 30% of those who test positive do not register and thus cannot receive treatment. The gap between diagnosis and care is often years, exacerbated by poor access to ART. Despite an increasing number of tests – 3.3 million in 2011 – risk groups are greatly undertested. In point-of-care facilities, 85% of the budgets go to salaries and just 8% to client services. Ukraine has the key components needed for effective testing and counselling, but it needs to manage them, harmonize them and strengthen the linkage to care. Panel discussion. Nikos Dedes (EATG), Martin Donoghoe (WHO Europe), Brian Gazzard (Chelsea Westminster Hospital, UK), Elena Grigoryeva (Belarusian PLHIV Community), Jean-Elie Malkin (UNAIDS Europe and Central Asia) and Jürgen Rockstroh (Bonn University Clinic) Part 1. Moving east: what are the challenges? Elena Grigoryeva began by noting that poor access to testing, poor testing uptake and poor linkage to HIV services persist in much of both eastern and western Europe, as do stigma, discrimination and human rights violations. Key steps to take include making rapid testing universal, tailoring services to the needs of hard-to-reach populations and acting multisectorally. Raminta Stuikyte (EATG) observed that donor funding is a huge part of the picture in the East, where countries are only now starting to fund treatment themselves and where the Global Fund still finances 97% of the work with risk groups. The affordability of drug prices is thus a critical issue; it’s unfair that Russia pays so much more than Kazakhstan, or Eastern Europe than Latin America. Jean-Elie Malkin said that the Europe we are living in is schizophrenic. In the eastern part of the European
Region, we – the UN, the countries, and civil society too – have failed. For EECA, we need to take the UNAIDS slogan – zero new infections, zero deaths and zero stigma and discrimination – and put zero stigma and discrimination at the front of the list. Brian Gazzard challenged the audience to be appalled at what they’d heard, comparing his experience to his feeling in 1983 when he realized what was going on in Africa. He called for better health-economic data, to help policymakers see the disaster they are creating for themselves, and for the HIV in Europe initiative to be more confrontational with countries – to say, You could change the face of the epidemic overnight by implementing needle exchange schemes. Ukraine could treble its ART coverage if it used generics and chose to live with some lipodystrophy. Martin Donoghoe noted that the conference had been very quiet about Russia, though it is home to some 60% of the infections in Europe and, not coincidentally, one of the few countries prohibiting the use of methadone and buprenorphine. Unfortunately, WHO works for its member states and cannot force them to do the right thing, only try to persuade them to. There’s a lot of talk about providing more data, but WHO already provides plenty of figures, strategies and documents; at the end of the day it still comes down to national political will. Andreas Berglöf (Sweden) decried the fact that many countries in the East are starting to see their funding dry up because donors now consider them middle-income. Jean-Elie Malkin said that countries in EECA – and around the world – simply have to take on more financial responsibility and find other ways to finance HIV services. Cost-effectiveness is important, but deeper political and psychological issues are involved. Only when the epidemic enters the general population will things start to change.
We can provide Russian policymakers with all the cost-effectiveness data anyone could want, but I will tell you frankly: they don’t care about drug addicts! They just don’t care! – Jean-Elie Malkin, UNAIDS Europe and Central Asia
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Part 2. Political considerations: the way forward Jürgen Rockstroh focused attention on challenges in the West, where there are still problems with late presentation, adequate funding, stigmatization and the criminalization of transmission. Brian Gazzard reminded participants that while WHO and the ECDC are critical to the achievement of the conference goals, the participants themselves have a passion that it is critical to concentrate and channel.
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As we’ve heard, it’s all political – and politicians are very simple people. Much of the literature is too complicated for policymakers to understand, and caveats just provide excuses to people who don’t want to act. HIV in Europe needs to reach consensus on a few very simple points – for instance on whether point-of-care testing is the right way forward – and then make them clearly. – Brian Gazzard, Chelsea Westminster Hospital, UK
Nikos Dedes challenged people to act, and to act together; national change is achieved by collaborating with other stakeholders. Too often we depend on civil society to do the advocacy work, but everyone needs to. He called on HIV in Europe to convene a working group in every country to translate testing guidelines to national conditions. Martine de Schutter (AIDS Action Europe) expressed concern about a shift in European Commission funding during the past year from community groups and networks to governments. Civil society programmes are already vastly underfunded at the national level. Jürgen Rockstroh found it heartening that HIV in Europe has inspired so many cost-effectiveness studies, which can support a different kind of evidence-based advocacy. The indicator disease work is also quite important, but implementing it in countries will demand a great deal of political engagement. Lali Khotenashvili (WHO Europe) responded to comments about whether to keep counselling as an integral part of testing by stating that removing it would not normalize testing. WHO does not claim that public health requires cumbersome pre-test counselling, but it does say that public health requires apprising test clients of their options and the consequences so that they can give informed consent. Martin Donoghoe closed by commending HIV in Europe for showing what can be accomplished when clinicians, activists, and policymakers meet and work together with the support of international institutions.
HIV in Europe Call to Action, 2012–2014 All of us - people living with HIV, civil society representatives, health professionals and decision-makers, policy workers, European Union and national institution representatives and researchers - need to continue to closely collaborate in order to save lives by decreasing the number of people starting HIV treatment late. The HIV in Europe Initiative is working to: 1. Monitor and share research and best practices on HIV testing standards in order to improve practice and policy; 2. Stimulate the scientific development of activities and events to inform the European agenda on optimal testing and earlier care; 3. Review data and studies on the impact of counselling and HIV/STI testing on risk behaviour and support a consensus process to agree on optimal counselling practices; 4. Facilitate the implementation and assessment of HIV indicator condition guided testing; 5. Stimulate an evidence base on and reduce barriers to testing that include human rights, stigmatisation, discrimination and criminalisation; 6. Continue supporting the implementation of novel models to estimate the number of infected but not yet diagnosed individuals; 7. Investigate linkages and collaboration between HIV testing and hepatitis testing and access to care; and 8. Support the international institutions and agencies (European Commission, European Centre for Disease Prevention and Control (ECDC), WHO Regional Office for Europe, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and UNAIDS) to increase their engagement in working for optimal testing and earlier care and reinforce collaborative links.
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