HIV Epidemics in the European Region: Vulnerability and Response

by World Bank, Emma Jolley, Vivian Hope, Alisher Latypov, Peter Vickerman

Overview

HIV Epidemics in the European Region: Vulnerability and Response provides a systematic review of the evidence on HIV vulnerability and response in all 53 countries of the World Health Organization’s (WHO’s) European Region, stretching from Iceland to the borders of China. The report focuses on key populations most at risk of HIV infection: people who inject drugs, sex workers, and men who have sex with men. It confirms that these populations are disproportionately affected by the growing HIV epidemic in Europe. Twenty-five percent of HIV diagnoses in Europe are associated with injecting drug use, with much higher proportions in Eastern Europe (33 percent) than in Western Europe (5 percent) and Central Europe (7 percent). Sex between men accounted for 10 percent of all HIV diagnoses, with higher rates reported in Western Europe (36 percent), followed by Central Europe (22 percent) and Eastern Europe (0.5 percent). HIV remains relatively low among female sex workers who do not inject drugs (less than 1 percent), but higher among those who inject drugs (more than 10 percent) and among male and transgender sex workers. The analysis highlights the pivotal role of social and structural factors in shaping HIV epidemics and HIV prevention responses. Poverty, marginalization, and stigma contribute to the HIV epidemic in Europe and Central Asia. Economic volatility and recession risks are increasing vulnerability to HIV and infections. Barriers to successful HIV responses include the criminalization of sex work, of sex between men, and of drug use combined with social stigmatization, violence, and rights violations. HIV prevention requires social and environmental change. The report calls for policy makers and HIV program implementers to target the right policies and programs to maximize the health and social impacts of Europe’s HIV responses and get higher returns on HIV-related investments. HIV Epidemics in the European Region: Vulnerability and Response is a product of a collaboration between the World Bank, the London School of Hygiene and Tropical Medicine, the WHO Regional Office for Europe, and UNAIDS.

Product Details

ISBN-13:	9781464803888
Publisher:	World Bank Publications
Publication date:	01/27/2015
Series:	Directions in Development
Pages:	366
Product dimensions:	7.01(w) x 10.00(h) x 0.76(d)

Table of Contents

Acknowledgments xiii

Executive Summary xv

Abbreviations xxxvii

Chapter 1 Introduction 1

Background 1

Methods 3

Notes 15

References 15

Chapter 2 HIV Surveillance 19

HIV Diagnoses and AIDS Case Reporting 19

Assessing HIV Prevalence and Risk Behavior 38

Note 51

References 51

Chapter 3 Epidemiology of HIV in Key Populations at High Risk 61

People Who Inject Drugs 61

Sex Workers 77

Men Who Have Sex with Men 97

Note 116

References 116

Chapter 4 Responses to HIV in Key Populations 143

HIV Surveillance Responses 143

HIV-Prevention Responses among People Who Inject Drugs 152

HIV Prevention Responses among SWs 171

HIV Prevention Responses among Men Who Have Sex with Men 183

Note 194

References 194

Chapter 5 Conclusion 213

The HIV Epidemics of Europe in Key Populations at High Risk 213

Intersecting Epidemics 215

Environmental Factors Shaping HIV Risk 217

Toward a Social Epidemiology of HIV Vulnerability 219

Strengthening HIV Surveillance 220

Strengthening HIV Prevention 221

A Shirt toward Social-Structural Intervention Approaches 227

References 228

Appendix A Systematic Review at Detailed Search Strategy 239

Appendix B Data Tables and Statistics 253

Appendix C Systematic Review and Summary Tables 277

Boxes

1.1 Definitions of HIV Epidemic 2

4.1 Four Core HIV-Prevention Interventions 152

4.2 Models of Regulation 176

A.1 Key Indicators of an Enabling Environment for PWID 248

Case Studies

2.1 Estimating HIV Prevalence among PWID in St. Petersburg, the Russian Federation 41

2.2 Estimating HIV Prevalence among PWID in Riga, Latvia 42

2.3 Two Decades of Scrobehavioral Monitoring of Infections among PWID in the United Kingdom 44

2.4 Serobehavioral Monitoring of Infections among FSWs in Kazakhstan 45

2.5 Estimating HIV Prevalence in the Kyrgyz Republic and Tajikistan 48

2.6 Using Biobehavioral Surveys to Measure HIV Incidence among PWID in Estonia 49

3.1 Stimulant Injection and HIV Risk in Europe 66

3.2 Sex Work and Drug Use 79

3.3 Central Asian Republics 85

4.1 Use of HPV Case Reports to Detect Outbreaks 146

4.2 The HIV-Prevention Impact of Introducing OST in the Russian Federation 153

4.3 Evidence of Commitment to HIV Prevention 166

4.4 Contact with Criminal Justice Systems in Central Asia 168

4.5 Trends Toward an Enabling Environment: Portugal 169

4.6 Sex Worker Services in Eastern Europe 172

4.7 The Importance of Location and Orgjnization of Sex Work in Facilitating Safer Sex Work: Examples from Tallinn and Moscow 175

4.8 Intervention to Reduce Violence 182

4.9 Measuring Coverage of Interventions for MSM 189

4.10 The Impact of Homophobic Polices in the Russian Federation 193

Figures

1.1 Comparison of HIV Prevalence and Incidence Projections in Three Sites in Eastern Europe (1996-2020) 12

2.1 Cumulative Total of Major Exposure Categories among All HIV Cases in Europe by Subregion since the Early 1980s 24

2.2 HIV Case Reports in Europe and Proportions by Subregion (2006-10) 25

2.3 Proportion of HIV Case Reports among Women, by Age and by European Subregion (2006-10) 26

2.4 HIV Case Reports and Proportion Associated with Injecting Drug Use (2006-10) 27

2.5 Cumulative HIV Case Reports in Europe Attributed to Injecting Drug Use, by Age and Subregion (2006-10) 28

2.6 HIV Case Reports and Proportion Attributed to Heterosexual Exposure (2006-10) 29

2.7 HIV Case Reports in Europe Attributed to Heterosexual Sex among Women and by Age (2006-10) 30

2.8 HIV Case Reports in Europe and Proportion Attributed to MSM (2006-10) 31

2.9 Proportion of HIV Diagnoses in Europe Attributed to MSM 30 Years Old or Less (2006-10) 33

2.10 Major Exposure Category among Cumulative HIV Case Reports in Europe (2006-10) 34

2.11 Exposure Categories among HIV Case Reports in the United Kingdom 35

2.12 Exposure Categories among HIV Case Reports in Ukraine (1995-2010) 36

2.13 HIV Case Reports and Heterosexual Exposure among Females: United Kingdom and Ukraine (2006-13) 36

2.14 Exposure Categories among HIV Case Reports in Tajikistan (2000-10) 37

2.15 Exposure Categories among HIV Case Reports in Estonia (1995-2010) 38

3.1 Best Estimates of HIV Prevalence among PWID in Eastern Europe 70