6.3.3. HIV infection, sexually transmitted infections (STI) and
blood-borne viral infections
HIV, other STI and blood-borne viral infections remain a
priority in Europe. Even though available surveillance data have to be
interpreted with caution, it is apparent that there have to be targeted
approaches since each of the diseases has a different pattern in different
There is a need to improve data collection for STI, e.g.
through screening programmes where cost-effective, in order to determine the
full picture of these diseases. Best practices for preventive campaigns and screening
programmes could be exchanged between Member States.
papilloma virus infection
Infection with human papilloma virus (HPV) has received
renewed interest through the introduction in 2006 of a vaccine, but is not a reportable
disease in most Member States. Moreover, tere is a general lack of figures for
prevalence or incidence. Properly designed epidemiological studies would help
to define the profile of HPV strains most prevalent in the EU and its
association with cancer of the uterine cervix, assisting with the design of
adequate vaccination strategies.
HIV remains one of the most important communicable
diseases in Europe. In western and central Europe, it is estimated that 720 000
people were living with HIV/AIDS at the end of 2005 and
that about 15 000 individuals are becoming infected each year.
Effective antiretroviral combination therapies introduced
in the mid-1990s and widely used in industrialised countries, have had a
profound effect on the course of HIV infection, improving the quality of life
and delaying the onset of AIDS and death in HIV-infected individuals, although
intolerance to side effects and emergence of resistant strains remain cause for
concern. AIDS surveillance is therefore no longer relevant to assess the spread
and burden of HIV but is solely of historical interest. HIV reporting has
become the key instrument for monitoring this epidemic in Europe.
Surveillance data on HIV/AIDS are
collected by the EuroHIV surveillance network in the 53 countries of the WHO
European Region, including the data from the EU and EEA/EFTA countries (Figure
6.2). The epidemic exhibits very different patterns in the different EU Member
States in terms of magnitude, trends, and affected populations. In the EU15
countries, the epidemic is older and mature, with the highest rates found in
Portugal. Among the other most affected countries, HIV data are not available
in Italy and Spain, and have only become recently available in France. Where
data are available, the number of new HIV diagnoses has been observed to have
increased again in recent years in a number of countries, with a particularly
marked increase seen in the UK and in the Netherlands.
6.2. HIV cases per million.
The epidemic in the new Member States is again diverse. In
the Baltic States, the number of HIV diagnoses, which had been extremely low
until then started to rise abruptly in the late 1990s, peaked in 2001 or 2002,
and then declined. Estonia has, by far, the highest rate. In the other new
Member States, although the number of new HIV diagnoses is increasing, the rise
is slow and the epidemic remains at a low-level.
Much of the overall rise in the number
of new HIV diagnoses in the EU is due to a steady increase in HIV infections
diagnosed in people believed to have been infected through heterosexual
contact: from 2 314 cases in 1996 to 6 386 in 2004. This increase is largely due to the rising number of diagnoses in people
originating from high-prevalence countries outside Europe. The HIV diagnoses in
men who have sex with men declined until around the year 2000 and since then
has risen from 2 615 cases in 2001 to 4 151 in 2004. The number of newly diagnosed cases of HIV among injecting drug users (IDU)
accounts for a low proportion of total cases, and has declined since 2001 (from
1 491 to 860 cases in 2004), although data are unavailable for Estonia,
Italy, Spain and Portugal, where severe epidemics among IDU have been reported
in the past.
In contrast to HIV diagnoses, AIDS incidence has been declining since
1995, when the AIDS incidence reached its peak in Europe. Similar trends have
been observed in most EU countries. Exceptions are the Baltic States, where the
HIV epidemic is much more recent and access to antiretroviral treatment likely
to be less than in other countries.
In 2005, 28 044 HIV diagnoses were reported by 26
countries. Previous trends have generally continued throughout 2005, i.e. a
rise in diagnoses in men who have sex with men and people infected through
heterosexual contact. Heterosexual contact accounts for the largest proportion
of HIV infections diagnosed overall and in most countries, but reflecting the
diversity of the epidemic across Europe, men who have sex with men is the
largest transmission group in several countries (Czech
Republic, Denmark, Germany, Greece, Hungary, the Netherlands,
Slovenia), and IDU the largest group in Latvia, Lithuania and Poland (no data
by transmission available from Estonia). With 171 cases reported in 2005,
mother-to-child transmission accounts for less than 1% of all new HIV
EuroHIV collects information on the country of origin of
the case, rather than on the possible location of infection. Overall, nearly
half (47%) of the newly diagnosed cases of HIV infection believed to have been
acquired by heterosexual contact were among people originating from countries
with more generalised epidemics, ranging from 17% in Portugal to 80% in
Iceland. Data from several countries suggest that the majority of these people
were infected in their country of origin, although transmission within the host
EU country does occur.
Control tools and policies
It is estimated that 30% of the people living with HIV
(PLHIV) in the EU are unaware of their infection. There is evidence to suggest
that this group may be contributing disproportionately to the spread of the
disease. Strong efforts must be made to increase testing uptake; thus, ECDC has
started work to provide guidance on this issue for Member States. As for
prevention, action should continue to target the populations at a higher risk.
These are the high-incidence countries, where an integrated national effort is
needed; men who have sex with men, where new methods are needed to implement
the prevention messages; and migrants from high-risk countries, where research
is needed on how to successfully approach these groups in society.
Immediately following diagnosis, PLHIV will need to
receive life-long treatment, care and support. Currently 90% of infected people
in the EU receive highly active anti-retroviral therapy (HAART). More work is
needed to improve accessibility of this therapy to PLHIV. Counselling and
support is of paramount importance to PLHIV and vulnerable populations at
higher risk of infection and therefore best practices will have to be reviewed
on how to improve these services in the EU.
sexually transmitted infections (STI)
This section addresses Chlamydia infections gonorrhoea
Chlamydia infection, caused by the bacterium Chlamydia trachomatis, is often asymptomatic,
but can lead to severe long-term complications such as ectopic (outside the
uterus) pregnancy and infertility. In many European countries, Chlamydia
infection is the most commonly reported STI, but in several countries the
infection is not notifiable. Comparisons between reporting countries are also
inhibited by differences in data collection. Screening studies in Europe have
shown that between 1.7% and 17% of women with no symptoms are infected.
Fourteen countries reported data for the full period (a further four reported
for part of the period), and of those, quite dramatically increasing trends
over the period 1995–2004 were observed in the Nordic countries, Belgium, the
United Kingdom and Ireland, while the opposite was seen in Estonia, Latvia and
Slovakia (Lithuania shows a stable trend). In 2005, 203 691 cases of Chlamydia infection were reported
by 17 countries, with almost 96% of cases from (in descending order) UK,
Sweden, Denmark and Norway. The highest incidence rate was reported by Iceland
with 552.45 per 100 000, followed by Denmark with 441.29 per 100 000.
Available data show that the disease is most common in the 15–24 age group and
that infection is reported more often in women than in men (female to male
A specific variant of the bacteria, lymphogranuloma
venereum (LGV), gives a more severe systemic disease. LGV considered eradicated
from Europe has again, since 2004, been noted in several large
European cities among men who have sex with men.
Gonorrhoea is caused by the bacterium Neisseria gonorrhoea. The extent of the infection
can range from genital infection to a variety of systemic symptoms. In the last
10 years, the Baltic States (Estonia, Latvia and Lithuania) saw a steady
decrease from levels of up to 200 cases per 100 000 per year in 1995, to
below 40 per 100 000 per year in 2004. In the low-incidence countries in central Europe (Slovakia, Poland and Hungary) gonorrhoea incidences declined
steadily to very low levels in 2001–03. In the Southern European countries,
gonorrhoea has been decreasing since 1995, while in the UK, Belgium and Sweden
the incidence appeared to decline during 1996–97 (and Norway in 1998), but has
risen steadily since then (figure 6.3). In 2005, a total of 27 537 cases were reported by 22 countries. The highest incidence rate was
observed in the UK (33.98 per 100 000), followed by Latvia (30.09 per
100 000) and the lowest in Luxembourg (0.22 per 100 000), followed by
Spain and Portugal (both with 0.42 per 100 000). However, different
surveillance systems operate in these countries making direct comparisons
inappropriate. The highest incidence rates were observed in the 15–24 age group
, while the incidence was 4.5 times higher in men than in women.
Figure 6.3. Trends of Gonorrhoea within the EU, 1995 - 2004
Syphilis significantly declined after World War II thanks
to the widespread use of penicillin. However, a considerable resurgence of
syphilis occurred in the late 1980s in the industrialised countries.
In the last 10 years, the incidence decreased steadily
after 1996 from just under 3.5 to 2.2 per 100 000 per year in 2000, but
has been rising steadily since then reaching 3.1 per 100 000 per year in
2004, mainly due to outbreaks in large cities involving men who have sex with
men. In the Baltic States (Estonia, Latvia and Lithuania) where syphilis
incidence was very high in the early 1990s (over 60 cases per 100 000 per
year in 1995), a sharp decrease in incidence was observed from 1996 to 2004. In some central European countries (Slovakia, Slovenia and Poland) syphilis incidence remained
below 10 cases per 100 000 per year, with an overall decreasing trend. In
2005, 12 945 syphilis cases were reported by 24 countries. The highest
incidence rates were still recorded in Latvia (19.21 per 100 000), Lithuania
(8.61 per 100 000) and Estonia (8.24 per 100 000), with the 25–44 age
group as the most affected. Incidence was higher in men than in women (male to
female ratio, 4.4:1).
Neonatal syphilis is still unacceptably common in the
EU. It is a potentially eradicable form of syphilis within the next decade,
this depending essentially on the adequate performance of and coverage with
antenatal care services and supervised labour care of pregnant women.
Blood-borne viral infections
This section addresses hepatitis B and C.
Hepatitis B is an infection of the liver caused by
hepatitis B virus (HBV). HBV can result in either asymptomatic or symptomatic
infection. As for other types of acute viral hepatitis, acute infection may
vary from mild to severe symptoms, and HBV infection in children usually goes
with few or no symptoms. Conversely, the fatality rate can reach 2% in the
elderly. A significant proportion of those chronically infected can develop
liver cirrhosis (25%) or cancer (5%), and patients with chronic infection serve
as a reservoir for continuing HBV transmission. Hepatitis B has to be
considered increasingly as an STI, although there is evidence that common
practices (tattooing, beauty treatments, etc.) are still important in spreading
HBV infection. The infection remains concentrated in migrants from
high-prevalence countries and in people whose activities place them at high
risk of becoming infected, such as IDU and people with multiple sex partners.
Almost 180 000 cases of Hepatitis B were reported in
Europe during the last 10 years, with an overall decreasing trend from 6.6 to
2.6 cases per 100 000 per year over the period. However, this pattern is
not consistent across Europe and some countries have reported an increasing
incidence since the late 1990s. Of the 6 977 cases reported in 2005 by 26
countries, the highest incidence rates were reported by Iceland (11.24 per
100 000), followed by Latvia (7.37 per 100 000). Incidence was higher
in men than women (male to female ratio, 2.3:1).
HBV vaccination is currently the most effective way to
prevent HBV infection. Most of the EU Member States have included hepatitis B
vaccine in their national vaccination programmes. Even before this could have
had any noticeable effect, incidence of acute hepatitis B infection had been
declining slowly in most countries.
Hepatitis C is the most common type of viral hepatitis in
Hepatitis C is caused by the hepatitis C virus (HCV), for
which no vaccine is available. Up to 90% of HCV infections are asymptomatic. A
high proportion of those infected develops a chronic infection and many of
those go on to develop liver cirrhosis or cancer. Injecting drug use is the
dominant mode of transmission and studies show that IDU are generally infected
within one year of their first injection. Sexual transmission seems to be
infrequent. After 1994 transmission via blood transfusion and use of
plasma-derived products became rare, as routine HCV tests became more available.
After a relatively stable period during 1995–2000, the
incidence in Europe has increased steadily from 7.0 per 100 000 per year
in 2001, to 7.9 per 100 000 per year in 2004, but this increase may
possibly be a surveillance artefact. In 2005, more than 29 000 hepatitis C
cases were reported by 24 countries. The highest incidence rates per
100 000 per year were reported by Ireland (34.99), Sweden (28.96), and the
UK (17.54). However, due to the nature of the disease (mainly chronic,
asymptomatic infections) and the relatively recent introduction of HCV
infection into the list of diseases under surveillance at national level, the
currently available data do not permit a clear picture of the HCV trend in