[pic] | COMMISSION OF THE EUROPEAN COMMUNITIES |

Brussels, 26.10.2009

COM(2009)569 final

COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL COMMITTEE AND THE COMMITTEE OF THE REGIONS

Combating HIV/AIDS in the European Union and neighbouring countries, 2009 -2013

{SEC(2009) 1403}{SEC(2009) 1404}{SEC(2009) 1405}

1. HIV IN EUROPE

1.1. Introduction

EU Member States and the European neighbouring countries face a high number of new HIV and associated infections and the resulting medical, social and economic consequences. 50 000 newly diagnosed HIV cases in the EU and the neighbouring countries alone in 2007 and an estimated 2 million people living with HIV/AIDS (PLWHA) illustrate the serious dimension of the situation[1].

The Commission communication on combating HIV/AIDS of 2005[2] provided a policy instrument to address HIV/AIDS on a European level and has been the basis for EU action from 2006 to 2009. However, combating HIV/AIDS remains a public health concern and a political priority for the European Union and neighbouring countries. Effective treatments for HIV/AIDS are available but no cure. Intensifying prevention is therefore the key to combat HIV/AIDS, neglecting prevention is a waste of lives and resources . The Commission is committed to continue to combat the disease and puts forward a new Action Plan, further to the previous one, which comes to an end in December 2009.

This communication complements “A European Programme for Action to confront HIV/AIDS, Malaria and Tuberculosis through External Action (2007-2011)”, which covers external action related to developing and middle-income countries[3].

After three decades of HIV/AIDS there is still no room for complacency. The best response to the epidemic remains a combination of health specific and wider social interventions. People will continue to suffer unless prevention is accelerated and universal access to treatment, care and support is ensured for all people in need.

1.2. Epidemiological situation and future trends

Numbers of PLWHA and of new HIV diagnoses differ significantly between countries, as do the prevalence rates of HIV, in a range from 0,1% to 1,2% across Europe. Currently in Eastern Europe HIV and AIDS are increasing at an alarming rate. The principal HIV transmission routes differ depending on the geographic location. In the EU HIV is predominantly transmitted by heterosexual contacts and Men having Sex with Men (MSM), while in European neighbouring countries transmission is mostly a result of injecting drug use (57%). In EU/EFTA countries the highest proportion of new HIV cases was reported among MSM (39%). Heterosexual HIV transmissions are increasing in several European countries and around 40% of these were diagnosed in persons originating from countries with generalised epidemics. Women are often particularly vulnerable to HIV infections. Other vulnerable groups such as commercial sex workers and prisoners are also considerably affected by HIV/AIDS. Between 30% and 50% of HIV infected people in the EU, and up to 70% in European neighbouring countries, are unaware of their HIV status.

Early diagnoses of HIV accompanied by counselling and timely treatment play a crucial role in reducing transmission of HIV, as well as the morbidity and mortality related to HIV/AIDS. The high numbers of HIV co-infections such as tuberculosis, hepatitis and other sexually transmitted infections are another serious concern.

1.3. Legal and social situation – obstacles and particularities

The legislative framework and standards for social and health services for people affected by HIV/AIDS in Europe differ considerably between countries. Access to services and medical treatment, as well as to prevention or harm reduction measures, is often limited[4]. Social exclusion, discrimination due to HIV status and the non-respect of basic human rights of PLWHA still persist. In some countries sexual transmission of HIV can be considered a crime.

HIV/AIDS as an issue of concern for migrants is addressed differently across Europe. Several European countries maintain restrictions on entry, stay and residence based on HIV status. These provisions are discriminatory and do not protect public health[5].

1.4. Political situation – declarations and commitments

Political declarations on a European level and global initiatives[6] define commitments and targets in the response to HIV/AIDS. They call upon the EU, national governments, international organisations, and civil society to act and to deliver. There are commitments to ensure universal access to HIV prevention, treatment, care and support, to invest into research for the development of novel preventive and therapeutic tools, to promote support for and solidarity with PLWHA and most at risk populations, to involve civil society and PLWHA in policy making and implementation, and to create a supportive social environment.

1.5. The EU action plan on combating HIV/AIDS (2006-2009)

The action plan foresaw about 50 actions to be implemented by major stakeholders. A number of key achievements relate to a stronger involvement of civil society at European level, the operational centralisation of HIV/AIDS surveillance by the European Centre for Disease Control and Prevention (ECDC), efforts to facilitate access to affordable antiretroviral medicines, funding of prevention projects and programmes, investments in research, and a close cooperation between partners. The HIV/AIDS Impact Assessment (2009)[7] has a comprehensive summary of the achievements of the first Action Plan under point 5.3 and in its Annex 4.

2. THE RESPONSE

Actions to respond to the challenges concentrate on prevention, priority areas, most at risk populations and an improved knowledge base through a better cooperation and knowledge transfer among stakeholders.

The overall objectives of this Communication are: (i) to reduce new HIV infections across all European countries by 2013, (ii) to improve access to prevention treatment, care and support and (iii) improving the quality of life of people living with, affected by or most vulnerable to HIV/AIDS in the European Union and neighbouring countries. All EU Member States, candidate and potential candidate countries, European Free Trade Agreement (EFTA) countries and countries in the European Neighbourhood Policy area as well as the Russian Federation are invited to contribute to the implementation of these goals. The Commission underlines the importance of mobilising all necessary efforts and resources to prevent HIV transmission effectively, to promote the human rights of PLWHA and affected communities, embedded in the Charter of Fundamental Rights of the EU[8], and to deliver high quality HIV treatment and care to all who need it. The current HIV epidemic and expected future trends are best addressed through:

(i) Scaling up the implementation of prevention strategies, which effectively target local realities and needs, while working towards ensuring universal access to prevention, treatment, care and support,

(ii) Supporting an effective response to HIV/AIDS in priority regions, such as the mostly affected EU Member States, the Russian Federation and the most affected neighbouring countries, and

(iii) Developing means to reach and support the populations most-at-risk and most vulnerable to HIV/AIDS across Europe.

2.1. Political leadership

Political leadership is an important asset the European Union can provide in the fight against HIV/AIDS.

HIV/AIDS remains a stigmatised condition which, within the European Union and its neighbouring countries, mainly affects marginalised groups. Not addressing the HIV epidemic would cause considerable harm to the individual and public health, and increasing costs to societies. An effective response to HIV requires political leadership to ensure that the health and rights of vulnerable and affected groups are promoted.

Political leadership is important to define and assure the implementation of priorities and actions. Unambiguous political advocacy is indispensable to align these priorities to needs and resources.

The Commission

- underscores the need to link the response to HIV/AIDS with the socio-economic priorities in political strategies at country level

- continues to support activities that aim at (1) to decreasing HIV-related stigma, (2) promoting respect for the human rights of all PLWHA and (3) addressing all forms of HIV-related discrimination and support the social inclusion of PLWHA

- promotes the mainstreaming of HIV/AIDS-related issues across EU policies, legislation and agreements

- supports monitoring the implementation of international commitments at country and European level, and supports international organisations such as UNAIDS in their work to mobilise political leadership in Eastern Europe

- calls upon the ECDC to continue monitoring the progress in meeting commitments of the Dublin, Vilnius and Bremen Declarations

2.2. Involvement of civil society and people living with HIV/AIDS

Civil Society is a key actor in combating HIV/AIDS at all levels and it is instrumental in keeping HIV/AIDS on the political agenda.

Civil Society organisations, including those representing PLWHA and affected communities, were instrumental in developing practical and political solutions to address HIV/AIDS. To this end, the Commission set up the HIV/AIDS Civil Society Forum (CSF) in 2005. Civil society has undergone strong internationalisation and professionalisation. The Commission wants to ensure that civil society stays involved in HIV/AIDS related policy development and implementation and remains a front line partner in a coordinated response, sharing responsibility for meeting commitments. Civil society should have the necessary freedom to act and to be involved at all levels in the response to HIV/AIDS across Europe and beyond.

The Commission

- supports the involvement of civil society organisations, including those representing PLWHA and affected communities, in planning, implementing and evaluating the response to HIV/AIDS in the European Union and neighbouring countries

- will maintain the HIV/AIDS Civil Society Forum as the principal interface to advise the Commission and the HIV/AIDS Think Tank

2.3. Wider society responsibilities

Equal treatment and solidarity are key assets of tolerant and open societies.

Any form of HIV/AIDS related discrimination and stigmatisation is unacceptable. National policies should prioritise improvements across the general population of basic knowledge on HIV/AIDS and the prevention of HIV transmission. Unprejudiced attitudes remove potential barriers to gaining HIV-related information and may support risk reducing behaviour patterns.

HIV/AIDS associated stigma and discrimination create barriers to access HIV testing, treatment and care. The Commission will further address this issue on a political level and in its equal treatment policies[9].

The Commission

- reiterates the need to ensure the respect for the human rights of all persons irrespective of their health status, sexual orientation, lifestyle, national and social origin

- will work with all relevant stakeholders and public authorities to step up awareness raising efforts and to initiate public campaigns on HIV/AIDS

- encourages wider professional training on HIV, in particular in the health and social sectors as well as in law enforcement and education

2.4. Universal access to prevention, treatment, care and support

Adequate funding and political support is necessary to achieve ´universal access´ across Europe.

HIV infections can be prevented and treated, and therefore effective health care infrastructures and information must be available. Leaders of the G8 countries and, subsequently, heads of states and governments at the 2005 UN General Assembly special session (UNGASS), endorsed a commitment to "develop and implement a package for HIV prevention, treatment and care, with the aim of coming as close as possible to universal access to treatment for all those who need it by 2010"[10].

As countries are striving to fulfil their commitment to scale up towards universal access to HIV prevention, treatment, care and support in 2010, the Commission reiterates this commitment and emphasizes the need to invest towards meeting and sustaining these targets in 2010 and beyond.

Economic operators and public authorities should cooperate to improve the provision of safe and affordable antiretroviral medicines to all people in need. Accessible medicines are essential for reaching universal access across Europe.

The Commission

- will work to support relevant authorities and stakeholders to develop effective approaches to ensure the provision of safe and affordable antiretroviral medicines to all people in need

- will work alongside international organisations, such as UNAIDS, UNICEF and WHO, in their efforts towards reaching universal access in neighbouring countries - encourages Member States' national authorities to assess the possibilities of structural and social funds and other instruments to scale up HIV/AIDS related health services

3. PRIORITIES

Prevention of HIV transmission is possible and it is the most effective way to address HIV/AIDS. Targeted and evidence-based prevention strategies addressing local realities and priority populations are key to success. Effective prevention measures are cost-effective investments with substantial long-term benefits.

Effective prevention requires a solid evidence base and robust surveillance systems, including meaningful behavioural data to ensure that the key forces behind the epidemic are adequately addressed. Positive prevention and the sexual and reproductive health and rights of PLWHA are important aspects for national policy planning and programmes. Prevention should promote safer sexual behaviour. Correct and consistent use of condoms remains the most effective means of HIV prevention through sexual transmission, and provision of sterile needles and injecting equipment and substitution treatment are the most effective means of HIV prevention through injecting drug use. Prevention should properly address the situation of children[11] and young people. There are also effective means to avoid mother-to-child-transmission, which should be widely applied. Prevention should be linked to voluntary and counselled HIV testing, universal access to treatment, care and support.

In implementing the strategy, EU intervention will primarily target priority regions and most at risks populations.

3.1. Priority regions

The prevalence rate of HIV in several Eastern European neighbouring countries is high, the numbers of new infections are still rising or have stabilised at a high rate, access to treatment is limited to as low as 10% of people needing it, co-infections such as tuberculosis and hepatitis are a serious public health threat, and most marginalised groups such as IDU, migrants and MSM are over proportionally affected.

Although HIV/AIDS concerns most parts of Europe, there is a particular need to address those regions suffering the highest burden. Factors contributing to this burden are: (i) size and distribution of most at risk populations (ii) poverty and economic development status, (iii) social, medical and economic inequalities, including discrimination.

The Commission recognises the need to step up cooperation among EU Member States, candidate, potential candidate, and other neighbouring countries, and to support countries to develop tailor-made strategies. There is a need to introduce effective prevention measures, in particular harm reduction measures. Public health and social policies should take into account the needs of ethnic minorities. Social inequalities and barriers to health care should be overcome at both political and operational levels.

This applies particularly to the eastern European Neighbourhood Policy area (ENP) countries and the Russian Federation where the HIV epidemic is concentrated in most at risk populations, with a potential to drift into the general population as heterosexual transmission is increasing. Although measures and strategies in response to HIV/AIDS are generally in place, access to HIV prevention, treatment, care and support still needs improvement. Supporting the efforts of neighbouring countries will prevent the spread of HIV and associated infections such as tuberculosis into the EU and to improve the conditions of PLWHA in the region.

Political commitments should lead to a constructive dialogue and help to overcome existing implementation barriers of existing or new strategies. Building on current cooperation, the Commission is ready to strengthen cooperation through existing mechanisms and instruments. With a view to strengthening surveillance, the Commission is ready to gradually promote the cooperation between the ECDC and neighbouring countries.

3.2. Priority groups - most at risk populations

Although the highest absolute number of new HIV cases in the EU occur through heterosexual transmission, most at risk groups are over proportionally affected. Full integration of minorities, marginalised or socially disadvantaged groups is a key factor in successful HIV/AIDS policies. Universal access to prevention, treatment, care and support as well as to health and social services and a non-discriminatory legal environment should be available to all most at risk groups. Targeted prevention programmes and effective solutions should include adapted communication, access to confidential, anonymous and, ideally, free testing and timely high-quality treatment. Targeted prevention should in particular reach young people within most at risk populations. A large proportion of young people have not experienced the AIDS realities of the past making them more negligent towards the risk of HIV infection. Future actions to combat HIV/AIDS should concentrate on most at risk populations to have the biggest impact on the epidemic:

(i) Men having Sex with Men is the main at risk population in the EU. The real dimension of the MSM HIV epidemic in European neighbouring countries is unknown. Stigma, discrimination and homophobia are often associated with homosexuality and may lead to biased surveillance data and subsequent underestimation of this group in the HIV/AIDS epidemic.

Targeted prevention programmes should be reinforced to reach MSM, and voluntary and counselled HIV testing (along with effective screening and treatment for sexually transmitted infections) needs to be intensified for MSM and risk populations. Accessible, non-discriminatory and confidential HIV treatment, care and support services for MSM are paramount.

(ii) Injecting drug use (IDU) is the main driver of HIV transmission in Eastern Europe, where it accounts for 2/3 of all new infections. Drug addiction calls for an integrated medical and social response. Access to sterile needles, evidence-based addiction treatment, including substitution and other harm reduction measures, have proven to be very effective, including in high prevalence areas and in particular settings such as prisons. Investment in comprehensive IDU health care should help to decrease the number of new HIV infections among drug users, and to alleviate the burden associated with drug use.

(iii) Migrants from countries with a high HIV prevalence and mobile populations are particularly affected by HIV/AIDS, although more data on the relationship between migrants´ legal, socio-economic status and access to health services and their vulnerability to HIV/AIDS would be needed. Heterosexual HIV transmission among migrants accounts for about 40% of all new sexual HIV diagnoses in the EU. Access to comprehensive prevention measures and to voluntary and confidential HIV testing and counselling and to health and social services needs to be promoted. The development of public health and social services for migrants would constitute an effective measure against the transmission of HIV.

The Commission

- promotes efforts to respect human rights, increase tolerance and solidarity to better include marginalised and most at risk populations in society

- supports effective, adapted and ethical means of HIV prevention including improved access to voluntary and counselled HIV testing to most at risk populations and in areas with high prevalence of HIV infection

- will include HIV/AIDS and sexual health related issues in its broader work on youth health, in particular towards promoting a better knowledge on HIV/AIDS

- asks the ECDC to provide data for a more accurate understanding of the HIV epidemic, including HIV incidence and prevalence, behavioural data, and undiagnosed HIV infections

- will provide resources through existing programmes (notably in public health and research,) and EU instruments to improve prevention and to address co-infections such as tuberculosis and hepatitis

- supports HIV/AIDS related work realised in the framework of the "Northern Dimension Partnership on Public Health and Social Well-Being"(NDPHS)

- will address HIV/AIDS in future negotiations on bi- and multilateral agreements with third countries where necessary

- will work with the ECDC to gradually develop by 2013 the cooperation between the ECDC and neighbouring countries to combat HIV/AIDS and associated infections

- encourages Member States to further develop and implement horizontal technical cooperation and exchange programmes to strengthen the capacity of governmental institutions and civil society organisations to develop, implement and evaluate effective national HIV/AIDS programmes

4. IMPROVING THE KNOWLEDGE

4.1. Surveillance, monitoring and evaluation

All stakeholders should contribute to a solid surveillance system.

HIV/AIDS surveillance[12] for Europe is carried out by the ECDC in cooperation with the WHO Regional Office for Europe, and by UNAIDS. National surveillance systems should become fully compatible with international requirements and all countries should report regularly on their HIV/AIDS epidemics. Second generation and behavioural surveillance must be intensified to better understand the dynamics of the epidemic in Europe. Policy development and implementation need solid and quality data, hence more behavioural studies would be needed. Policy makers need better evidence on what drives the epidemic. The contribution of sexually transmitted infections (STIs) to the transmission of HIV should be assessed to inform policies and result in improved prevention, diagnosis, treatment and monitoring.

The Commission

- urges all Member States, building on the surveillance carried out under Decision 2119/98 EC, to gather even more robust and comprehensive data on HIV/AIDS and STIs, including on co-infections

- asks the ECDC to strengthen the cooperation with neighbouring countries and other partners such as UNAIDS

4.2. Research and medicine

More biological, medical and social science is needed to reach solutions.

The Commission further encourages long-term public and private investment into research for the development of new and improved prevention technologies and treatments for HIV and associated infections. The high incidence of tuberculosis and multidrug resistant tuberculosis is especially worrying and must be closely monitored and effectively addressed. Broad access to integrated medical services and investment in effective health care infrastructures are critical to control of the spread of these infections. Understanding and responding effectively to the spread of HIV and co-infections requires more social, behavioural and economic research, as well as knowledge translation into effective evidence-informed policy and programming.

The Commission

- will further provide resources to improve research focusing on HIV and associated opportunistic infections through the research framework and health programmes

- reiterates the need to amplify efforts in vaccine, including new technologies for vaccines, microbicides and in new therapeutics, research and development

- will further support investments towards the development and implementation of innovative preventive and therapeutic interventions

- will work with all stakeholders to concentrate more efforts on HIV/AIDS related social science research

5. EXPECTED OUTCOMES

The Commission expects that actions realised in cooperation with Member States, neighbouring countries and all stakeholders across Europe in line with the above mentioned priorities will lead to:

- A decreased number of in HIV infections , access to HIV testing for anyone at risk, and universal access to treatment, care and support through improved cross-border cooperation, targeted prevention measures, harm reduction measures, information on risk reduction, universal access to safe and affordable medicines and integrated medical and social services. Individual risk behaviour shall be minimised in order to avoid HIV transmission.

- A real improvement of the quality of life of people living with HIV and most at risk populations. PLWHA and most at risk populations should have general access to testing, prevention, treatment and care services, to harm reduction measures, to secondary prevention and to social and psychological services. The European Union supports a broad integration of PLWHA into labour and social processes and in HIV/AIDS policy development, implementation and assessment.

- Strengthened solidarity towards an unambiguous response to HIV/AIDS. Discrimination and stigmatisation associated with HIV/AIDS must be tackled across Europe and across all layers of society. This should result in more evidence based interventions against HIV/AIDS, in better infrastructures and improved access to information, testing, treatment, care and support.

- Improved education, knowledge and awareness on HIV/AIDS. The inclusion of sexual and reproductive health education in school curricula would be beneficial for HIV and STI prevention and should receive broad political support. Young people should also be empowered and involved in the shaping of information that concerns them, and tailored information should be developed, particularly for youth at risk of social exclusion. Restricted knowledge and unawareness of facts around HIV/AIDS and STIs lead to increased transmission rates. The knowledge base shall be assessed on a regular basis in order to prioritise distinct issues and to keep educational efforts close to the needs of target groups.

6. ACTION PLAN, MONITORING AND EVALUATION

This Commission communication is complemented by an operational action plan to be further developed in cooperation with the HIV/AIDS Think Tank, the Civil Society Forum and external stakeholders along the lines of the political actions presented here.

EU actions will be funded through the 2008-13 Health Programme and eligible countries should make use of structural funds. Funding may also be available through the 7th Research Framework Programme.

An independent evaluation of the overall EU intervention to combat HIV/AIDS in Europe will be carried out by 2012 to assess the impact and relevance of the actions. With the support of the ECDC, the HIV/AIDS Think Tank, the CSF and selected international organisations, the Commission will identify suitable indicators to monitor and assess the implementation of this Communication and the action plan. The Commission and its stakeholders will identify organisations responsible for the implementation of attributed actions during the implementation process.

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[1] ECDC/WHO. HIV/AIDS Surveillance in Europe, 2007. Stockholm, 2008; and UNAIDS report 2008.

[2] COM(2005) 654.

[3] COM(2005) 179.

[4] Progress on implementing the Dublin declaration on partnership to fight HIV/AIDS in Europe and Central Asia. WHO/UNAIDS report. 2008.

[5] Statement on behalf of the European Union at the 63rd session of the General Assembly on the Implementation of the Declaration of Commitment on HIV/AIDS and the Political Declaration on HIV/AIDS, New York, 16 June 2009.

[6] Dublin 2004, Vilnius 2004, Bremen 2007, Council conclusions 2005 and 2007, European Parliament report 2007 and 2008, UNGASS 2001/2006/2008, Millenium Development Goals 2000, Gleneagles 2005, Heiligendamm 2007.

[7] SEC(2009) 1404.

[8] OJ C 364, 18.12.2000, p. 1.

[9] Directives in the area of anti-discrimination are: the Racial Equality Directive, 2000/43/EC, and the Employment Equality Directive, 2000/78/EC. Council Directive 2000/43/EC implements the principle of equal treatment between persons irrespective of racial or ethnic origin, and Council Directive 2000/78/EC establishes a general framework for equal treatment in employment and occupation.

[10] WHO report 2008: Towards universal access by 2010.

[11] Cf. the provisions of the UN Convention on the Rights of the Child, that has been ratified by all EU Member States.

[12] Cf. Decision No 2119/98/EC.