EN    EN EN 
EN    EN  COMMISSION OF THE E UROPEAN COMMUNITIES 
Brussels, 26.10.2009 
SEC(2009) 1404 final 
  
COMMISSION STAFF WORKING DOCUMENT 
Impact Assessment  
 
Accompanying document to the 
 
COMMUNICATION FROM THE COMMISSI ON TO THE COUNCIL, THE 
EUROPEAN PARLIAMENT, THE EU ROPEAN ECONOMIC AND SOCIAL 
COMMITTEE AND THE COMMI TTEE OF THE REGIONS 
 
Combating HIV/AIDS in the European Union and neighbouring countries, 2009 -2013 
  
{COM(2009) 569 final} 
{SEC(2009) 1403} {SEC(2009) 1405} 
EN 2   EN Impact Assessment  
This report commits only the Commission's servi ces involved in its pr eparation and does not 
prejudge the final form of any deci sion to be taken by the Commission  
TABLE OF CONTENTS 
ABBREVIATIONS / ACRONYMS .............................................................................................. 4  
GLOSSARY ............................................................................................................................... .. 5 
executive summary .................................................................................................................. 8  
1. Procedural Issues and Consulta tion of Interested Parties ......................................... 8  
1.1. Organisation and Timing .......................................................................................... 8 
1.2. Consultation and Expertise ....................................................................................... 9 
2. Background ....................................................................................................................... 9  
2.1. HIV/AIDS - characteristics of  the disease and epidemiology .............................. 9 
2.2. Social and economic burden of HIV/AIDS ........................................................... 15 
2.3. The first EU action plan 2006-2009 ...................................................................... 17 
2.4. Funding resources ................................................................................................... 18 
2.5. Fundamental Rights and equal trea tment in employment and occupation .... 19 
2.6. External policy dimension ....................................................................................... 20 
3. Problem Definition ......................................................................................................... 21  
3.1. Political commitments ha ve not been achieved .................................................. 21 
3.2. Data gaps in the centralised EU  monitoring and reporting system ................. 24 
3.3. Imperfect prevention and treatment ac tivities and potentially diminishing 
health budgets ......................................................................................................... 24 
3.4. Persisting knowledge gaps ..................................................................................... 26 
3.5. Worrying trends in several Eastern European countries ................................... 26 
4. The Rationale for European Action ............................................................................. 27  
4.1. Subsidiarity ............................................................................................................... 28 
4.2. Necessity Test .......................................................................................................... 28 
4.3. Added-Value Test ..................................................................................................... 29 
5. Policy Objectives ............................................................................................................ 30  
5.1. General objective ..................................................................................................... 30 
5.2. Specific objectives .................................................................................................... 30 
6. Policy options .................................................................................................................. 31  
6.1. Option 1: baseline – further implemen tation of current action plan, and 
evaluation .................................................................................................................. 31 
EN 3   EN 6.2. Option 2: no EU policy and action plan  addressing HIV/AIDS as a single topic
 32 
6.3. Option 3: Current plus – a new Co mmission policy and action plan on 
combating HIV/AIDS in Europe ............................................................................. 32 
6.4. Option 4: discarded options ................................................................................... 35 
7. Analysis of Impact ......................................................................................................... 35  
7.1. Option 1: Baseline option – further impl ementation of the current action plan
 36 
7.2. Option 2: no EU policy and action plan on HIV/AIDS as a single topic .......... 38 
7.3. Option 3: Current plus – a new EU policy and action plan on combating 
HIV/AIDS in Europe ................................................................................................. 39 
8. Comparing the options .................................................................................................. 42  
9. Monitoring and Evaluation ............................................................................................ 45  
LIST OF ANNEXES .................................................................................................................. 46  
EN 4   EN ABBREVIATIONS  / ACRONYMS 
AIDS  acquired immunodeficiency syndrome 
ART  antiretroviral therapy/treatment ARV  antiretroviral medicines 
ECDC  European Centre for Disease Prevention and Control 
EMCDDA European Monitoring Centre for Drugs and Drug Addiction EFPIA  European Federation of Pharmaceutical Industries ENP  European neighbourhood policy EU  European Union GFATM Global Fund to Fight AIDS, Tuberc ulosis and Malaria (the Global Fund) 
Gilead  Gilead Sciences, Pharmaceutical company 
HAART highly active antiretroviral therapy HIV  human immunodeficiency virus IASG  Impact Assessment Steering Group IDU  injecting drug user 
IOM  International Organisation for Migration 
MDG  Millennium Development Goals MS  Member State of the EU  MSM  men who have sex with men MTCT  mother-to-child transmission (of HIV) 
PLWHA people living with HIV-AIDS 
QALY  Quality Adjusted Life Years TESSy  The European Surveillance System UNAIDS Joint United Nations Programme on HIV/AIDS UNICEF United Nations Children's Fund UNGASS United Nations General Assembly Special Session 
UNODC United Nations Office on Drugs and Crime 
VCT  Voluntary Counselling and Testing for HIV WHO  World Health Organization 
EN 5   EN GLOSSARY 
AIDS  - stands for 'acquired immunodeficiency syndro me' and is a surveillance definition based on 
signs, symptoms, infections, and cancers associated with the deficiency of the immune system that 
stems from infection with HIV. 
Antiretroviral - an agent that is active against a retroviru s; in the context of the HIV/AIDS , any 
medication that is designed to inhibit  the process by which HIV replicates. 
ART  – stands for an antiretroviral therapy that in a st andard coverage consists of the use of at least 
three antiretroviral (ARV) drugs to maximally suppress the HIV virus and stop the progression of HIV disease. Given huge reductions have been seen in rat es of death and suffering when use is made of a 
potent ARV regiment, ART is now considered an inte gral part of the comprehensive response to HIV 
prevention, care and support. 
ARV  – stands for antiretroviral drugs that are medications for the treatment of infection by 
retroviruses, primarily HIV. 
Capacity building - an approach to working with the community that aims not only to involve the 
community in dealing with the problem at hand but al so to increase the community’s capacity to deal 
with any future problems that arise. In the context of HIV/AIDS, such an approach is used to establish 
community norms and standards that support health-enhancing behaviours.  
Central Europe (Centre)  – 25 countries: Albania, Bosnia  and Herzegovina, Bulgaria, Croatia, 
Cyprus, Czech Republic, Hungary, Former Yugosla v Republic of Macedonia, Montenegro, Poland, 
Romania, Serbia, Slovakia, Slovenia, Turkey 
Clinical research - health research relating to individual pa tients and the development and evaluation 
of treatments for diseases.  
Clinical trial - a research activity designed to test a drug or  treatment in humans and so establish its 
efficacy  and safety and to identify groups of patients who can be expected to benefit from such a drug 
or treatment.  
Co-infection - in the context of HIV/AIDS, the term used  to describe the circumstance in which a 
person is concurrently infected with HIV and anot her infectious agents such as tuberculosis or 
hepatitis.  
Communicable disease - an illness caused by a speci fic infectious agent or its toxic products that 
arises through transmission of that agent or its product from an infected person, animal or other reservoir to a susceptible host.  
Eastern Europe (East)  – constitute 15 countries of the former  Soviet Union, such as: Armenia, 
Azerbaijan, Belarus, Estonia, Georgia, Kazakhsta n, Kyrgyzstan, Latvia, Lithuania, Republic of 
Republic of Moldova, Russian Federation,  Tajikistan, Ukraine, Uzbekistan. 
ENP  - the European Neighbourhood Policy applies to the EU's immediate neighbours by land or sea –
Morocco, Algeria, Tunisia, Egypt, Jo rdan, Lebanon, Syria, Israel, Occupied Palestinian Territories, Ukraine, 
Republic of Moldova, Armenia, Georgia, Azerbaijan, as well as Belarus and Libya .. 
Epidemiology - a study of the distribution and determinants of health-related states or events (such as 
likely routes of transmission of disease and trends in epidemics) in specified populations and the 
application of knowledge to deal with health problems.  
HAART  - is defined as treatment with at least three active anti-retroviral medications (ARV’s) and is 
often called the drug “cocktail” or triple-therapy. HAART affords us a potent way of suppressing viral 
replication in the blood while attempting to prevent the virus from rapidly developing resistance to the 
individual ARV’s. Suppressing viral replication w ith HAART allows the body time to rebuild its 
immune system and replenish the destroyed CD4 or  T cells. HAART has been clearly shown to delay 
progression to AIDS and prolong life.  
Harm reduction interventions/strategies - interventions designed to reduce the impacts of drug 
related harm on individuals and communities. G overnments do not condone illegal risk behaviours 
such as injecting drug use, but they acknowledge th at these behaviours occur and that they have a 
EN 6   EN responsibility to develop and  implement population health measures designed to reduce the harm that 
such behaviours can cause.  
HIV  – stands for human immunodeficiency virus that is a lentivirus (a member of the retrovirus 
family) that causes acquired immunodeficiency syndrome  (AIDS), a condition in humans in which the 
immune system begins to fail, leading to life-thr eatening opportunistic infec tions. Infection with HIV 
occurs by the transfer of blood, semen, vaginal flui d, pre-ejaculate, or breast milk. Within these bodily 
fluids, HIV is present as both free virus particles a nd virus within infected immune cells. The four 
major routes of transmission are unsafe sex, contamin ated needles, breast milk, and transmission from 
an infected mother to her baby at birth (vertical transmission). 
HIV prevalence - is a total number of PLWHA in the population at a given time, or the total number 
of PLWHA cases in the population, divided by the number of individuals in the population.  
HIV prevalence rate  – is given as a percentage of the population, meaning the total number of all 
individuals who have an attribute or disease (PLWHA) at a particular time or period divided by the 
populations at risk of having the attribute or disease at that time or midway through the period. In most 
cases, HIV prevalence cannot be accurately determin ed from reported cases because many infections 
are undiagnosed or unreported. The best estimates ar e mainly based on the results of surveys of large 
groups of people. In case of generalized epidemic th e estimate of HIV prevalence is based on surveys 
of pregnant women attending antenatal clinics, and in  case of low-level or concentrated epidemic HIV 
prevalence is based on data collected from population most at risk.  
HIV incidence - is the number of new HIV infections in th e population during a certain time period. 
People who were infected before that time period ar e not included in the total, even if they are still 
alive. 
Human capital approach  - measures the value of a person's life by his or her potential labour 
productivity. Because of the way this method assigns value, it may not place as much value on the lost 
productivity of persons who are elderly, unemployed, or children. No explicit value is placed on 
intangible costs, such as pain and suffering associat ed with illness or deterioration of quality of life. 
Prevalence  - a measurement of all individuals affected by the disease within a particular period of 
time, whereas incidence  is a measurement of the number of ne w individuals who contract a disease 
during a particular period of time.  
Non-communicable disease (NCD)  - a disease which is not infectious. Such diseases may result from 
genetic or lifestyle factors. A non-communicable disease is an illness that is caused by something 
other than a pathogen.  
People living with HIV (PLWHIV) - the 'number of people living with HIV' represents all people 
living with HIV infection, whether or not they ha ve developed symptoms of AIDS, who are alive at 
the time given.  Estimates of the number of people living with HIV are usually based on the estimated 
HIV prevalence and total population size, but mini mum estimates may be derived from case reports.  
UNAIDS and WHO favour a terminology move away from PLWHA (p eople living with 
HIV/AIDS) to PLWHIV (people living with HIV)  as a consequence of a HIV disease change 
from a series of inevitable stages to a spectrum.  
Prevention  – it encompasses different methods and dime nsions: personal inform ation and counselling, 
targeted information for vulnerable groups, the av ailability of testing facilities, and structural 
prevention which addresses the social and political environment of vulnerable people such as poverty 
and discrimination but also factors influencing be haviours e.g. availability of information, condoms 
and sterile syringes. 
Western Europe (West)  – 23 countries: Andorra, Austria, Belgium, Denmark, Finland, Germany, 
Greece, Iceland, Ireland, Israel, Italy, Luxembour g, Malta, Monaco, Netherlands, Norway, Portugal, 
San Marino, Spain, Sweden, Switzerland, United Kingdom 
Willingness to pay (WTP) method  – also called the contingent va luation method, places a value on 
life according to how much an individual is willing to pay to reduce the probability of illness or death. 
This approach measures the value that patients place on improving their health or preventing further 
deterioration of their health. The WTP method allows a consumer to evaluate treatment benefits from 
an individual perspective. 
EN 7   EN LIST OF FIGURES, BOXES AND TABLES 
 
Figure 1  People living with HIV/AIDS (PLWHA) and adult HIV prevalence 
Figure 2  A view of HIV infection across the EU and neighbouring countries Figure 3 Rates of newly diagnosed cases of HIV per million inhabitants Figure 4 Rates of newly diagnosed cases of HIV per million inhabitants, 2006, with a 
distribution of transmission modes 
Figure 5 Poundstone's 3-level determinants of HIV model 
Box 1 Examples of HIV/AIDS interventions at national level Box 2 Dublin Declaration on Partnership to fi ght HIV/AIDS in Europe and Central Asia 
Box 3 Vilnius Declaration on Measures to Strengthen Responses to HIV/AIDS in the 
European Union and in Neighbouring Countries 
Box 4 Bremen Declaration on Responsibility and Partnership – Together Against HIV/AIDS 
Box 5 Example of Action Plan 2006-2009's unachieved action Figure 6 Estimated coverage of antiretrovira l treatment in selected MSs and neighbouring 
countries. 
Box 6 Example of HIV/AIDS problematic in one of the Eastern neighbouring countries – 
Ukraine 
Box 7 Action Plan 2006-2009 – areas with open actions 
Table 1 Comparison of priorities and objectiv es between Action Plan 2006-2009 and a new 
Action Plan (Option 3) 
Box 7 Possible actions under Option 3 Table 2 Comparison of options  
Table 3 Impacts summary  
 
EN 8   EN EXECUTIVE SUMMARY  
This impact assessment considers policy options for a possible EU initiative on HIV/AIDS as a follow up to 
a first Action Plan 2006-2009. The Commission announ ced such initiative in the 2009 work programme.  
This assessment provides information on the previous EU action plan and its key deliverables and 
completed actions and what lessons can be drawn for the design of a successor plan, in particular for 
spending priorities and priority setting. It describes th e current trends in infections and HIV prevalence 
rates for both EU and its neighbouring countries, in par ticular focused on Eastern Europe. Considering that 
HIV/AIDS as disease is more than a "medical prob lem", when compared to other chronic diseases, it 
implies significant social and economic burdens. This  report explains the change of the disease from a 
deadly to a chronic condition and its implications fo r health services provision. It outlines a rationale for 
future EU action and proposes a number of options a nd related policy actions which are then appraised. 
Option 1 consists of a prolongation of the current Ac tion Plan allowing for its comprehensive evaluation, 
option 2 assumes that EU activities would be ceased and option 3 introduces a new EU Action Plan for 
2009-2013, setting also new objectives and priorities. The report commits only the Commission's services 
involved in its preparation and does not prejudge th e final form of any decision to be taken by the 
Commission. 
Principle responsibility for action to address HIV/AIDS re mains within a control of Member States, but EU 
policies have also a role through funding under the umbrella of the Health programmes, the Research 
Framework programmes and, EU-wide harmonised data gathering and surveillance as well as exchange of 
best practice and benchmarking. Thus, EU action appraised here explores options to support and 
complement the efforts of Member States and stakehol ders and to mobilise EU policies towards HIV/AIDS 
prevention, treatment and care as well as research a nd medicines, with regard to the cross-border 
cooperation, in full respect of subsidiarity. 
The possibility of EU action is to be also considered in the context of the economic crisis the EU and its 
MSs are currently facing. Given the rising strains between resources and needs, it is particularly important to re-iterate the long-term benefits of preventiv e health action for a communicable disease with high care 
costs.  
1. PROCEDURAL ISSUES AND CONSULTATION OF INTERESTED PARTIES  
1.1. Organisation and Timing 
DG Health and Consumers (SANCO), as the service in  lead of the HIV/AIDS policy for the EU and 
neighbouring countries, invited Commission services to  contribute to an IASG, and received input 
from: ADMIN, AIDCO, DEV, EAC, ECHO, EMPL, ELARG, ENV, INFSO, SG, RELEX, RTD and TRADE. 
The first roadmap for this project was established in June 2007. The impact assessment process was 
launched on 19 January 2009, and three meetings of the impact assessment steering group, composed 
of representatives of the above mentioned DGs, were  held, on 22 January, 3 March and 6 May 2009. 
Written versions of the draft IA were circulated be tween meetings for comments. The final version of 
the IA report was agreed in a written procedure by the DGs on 26 May 2009, and then was sent to the 
IAB on 4 June 2009. 
The IAB considered the document at its meeting of  24 June and provided its initial opinion on 29 June 
2009. The IAB issued a second opinion on the revised  draft IA report on 25 September 2009. This 
version of the document incorporates the following main changes in response to the comments and 
observations of the IAB.  
(1) The section on the previous action plan has been expanded, in particular with regard to an 
assessment of the achievements and lessons to be dr awn for future EU actions for policy and funding 
priorities. It has been better explained, in Opti on 1, why and which actions and political commitments 
within the current action plan have not been implemented yet. 
EN 9   EN (2) Options have been clarified and reorganised, in or der to take into consideration the suggestion of 
the IAB to develop a new policy option – that is th e continuation of the current action plan followed 
by its evaluation. Option 3 now provides for a co mparison of priorities and objectives between Action 
Plan 2006-2009 and a new strategy (Option 3). 
(3) Operational objectives in terms of specific deliv erables, targets and deadlines have not been 
included in the report since they will be agreed along the broad lines defined  in cooperation with 
relevant stakeholders (e.g. civil society forum,  Think Tank, internationa l organisations)playing a 
significant role in implementing the action plan. This will be developed further along with a new 
Communication and Action Plan. 
(4) Finally, the assessment section has been divided,  as suggested, into 2 parts analysing separately 
economic and social impacts. 
 
1.2. Consultation and Expertise 
SANCO has several permanent advisory groups in place, some with a special expertise on HIV/AIDS 
such as the HIV/AIDS Think Tank1 (the Think Tank), the Civil Society Forum2 (CSF) and the EU 
Health Policy Forum3 (EUHPF). The Think Tank, the CSF and the EUHPF were consulted4 in a 
targeted way with an opportunity for written co mments on the project. The commentaries, received 
from civil society organisations (CSF, Aids Ac tion Europe, European AIDS Treatment Group), 
economic operators and federa tions (Gilead, EFPIA), Member States (SL, PT, DE, ES) and 
international organisations (UNAIDS, IOM) concerne d mainly the need for continuity of European 
initiatives and undertaking actions on targeted prev ention, priority regions and most at risk 
populations. The responses were consid ered while drafting this IA as th ey fed into the development of 
potential objectives set out in section 5 and influenced  the organisation of the actions under the three 
options, the appraisal process and the final decision on the best option. 
RELEX carried out a general consu ltation with delegations in all neighbourhood countries to collect 
first hand information on the cont ribution, involvement, and usefulness of a Commission policy for the 
delegations' HIV/AIDS related activities in the part ner countries. A number of delegations responded 
and delivered primary information, which is attached  in Annex 1. The broad lines were included in the 
reasoning on an EU added value. 
In terms of the broader policy contexts, general c onsultations organised prior to the adoption of the 
Renewed Social Agenda (2008)5 and the EU Health Strategy (2007)6 also touched upon communicable 
diseases, including HIV/AIDS. 
2. BACKGROUND  
2.1. HIV/AIDS - characteristics of the disease and epidemiology  
The WHO and ECDC jointly report on epidemiological  surveillance on HIV/AIDS in Europe.  For the 
purposes of analysis and reflecting patterns of the ep idemic, the surveillance is done in relation to 
western, central and eastern parts of the WHO Euro pean Region.  The presentation of the following 
data is done within this framewor k and has no political signification. 
                                                 
1 The HIV/AIDS Think Tank, established by a High Committee on Health in 2004, is a forum to exchange information 
between the Commission, the Member States, Candidate and EEA countries (Lichtenstein, Iceland and Norway)  
2 The HIV/AIDS Civil Society Forum (CSF) is an informal ad visory body established in 2005 by the European Commission 
to facilitate the participation of NGOs and networks.  
3 The EU Health Forum, established in 2001 is an informal communication and cons ultation forum, which brings together 
umbrella organisations representing stakehol ders in the health sector to ensure th at the EU's health strategy is open, 
transparent and responds to  the public concerns.  
4 Date of consultations: The Think Tank and the CFP on 7/11/2008 and 24-25/03/2009; the EUHOF on 
10/12/2008. 
5 Consultation ended in February 2008, Social Agenda Forum took place on 5-6 May 2008. 
6 Public consultation ended in early 2007. 
EN 10   EN  
2.1.1.  A chronic disease without a cure  
The human immunodeficiency virus (HIV) was di scovered in 1983 and, according to WHO/UNAIDS 
statistics, there have been 33M people worldwide in 2007 living with the virus. 
HIV/AIDS is a serious health problem since there is  no cure or preventive vaccine for HIV infections 
available. While effective antiretroviral therapy (ART ) has dramatically reduced the risk of illness and 
death for people living with HIV/AIDS (PLWHA) they still have an elevated mortality rate relative to 
the general population. HIV-infected pe ople under effective treatment live longer7 and are therefore at 
increased risk of progressive conditions such as a cardiovascular or liver disease, or non-AIDS-defining cancers, and may experience acute or long term side effects of the medication.  
2.1.2.  Trends and epidemiology  
Effective combination of 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 of HIV-infected  individuals. However, there is still a danger that 
this progress has contributed to complacency. Even though the number of people living with 
HIV/AIDS (PLWHA) in the EU is relatively small wh en compared with figures in Sub-Saharan Africa 
or Asia, HIV/AIDS is still perceived as a major public health issue8. 
In the EU and its neighbourhood9 according to UNAIDS10, the number of people living with 
HIV/AIDS increased in the years 2001 -2007 from around 1.5 million to 2.2 million, approximately 
730.000 of which live in the EU. In 2007, as Figure 1 shows, among the EU members, the highest number of PLWHA were reported in FR, IT and ES, accounting for nearly 60% of the total EU. 
However, Russia and Ukraine have the highest number of PLWHA in Europe, accounting for nearly 
90% of the region's total infections.  
 
Figure 1: People living with HIV/AIDS (PLWHA) and adult HIV prevalence
11, 2007 
Estimated number of PLWHA and adult HIV prevalence, 2007
00,40,81,21,62
Austria
Belgium 
Czech RepublicDenmarkEstonia 
Finland 
France 
Germany 
Greece
Hungary Ireland 
ItalyLatvia
Lithuania 
Luxembourg 
Malta
Netherlands 
Poland
Portugal
Romania
Slovakia
Slovenia 
Spain 
Sweden UK 
Russian Federation 
Algeria
Armenia
AzerbaijanBelarus
Egypt
Georgia
Israel
Jordan
Lebanon
MoldovaMorocco
Tunisia
Ukraine% HIV prevalence, adult02004006008001000
Number of PLWHA (thousands)
% HIV prevalence, adult (15-49) Number of PLWHA 
Source: UNAIDS, WHO 
                                                 
7 The Lancet, 2008, 372, p.266  
8 WHO, ECDC; www.euro.who.int , www.ecdc.europa.eu .  
9 In this document, 'neighbourhood' or 'neighbouring countries' refer to the ENP members and the Russian 
Federation. Such a coverage of the neighbourhood corresponds to the definition of 'neighbourhood' addressed in 
COM(2005) 654 and the Action Plan 2006-2009. 
10 http://www.unaids.org/en/Know ledgeCentre/HIVData/GlobalR eport/2008/2008_Global_report.asp   
11 HIV prevalence represents a relative number of PLWHIV, expressed as a percentage of a population of adult 
people (aged 15-49) 
EN 11   EN 
Figure 1 and Figure 2 show there are huge disparities of HIV prevalence rates among EU MSs and 
their neighbouring countries. Estimated HIV preval ence varies from below 0.1% in parts of Central 
Europe to above 1% in parts of Eastern Europe, with the highest rates in EE – 1.3%, Russia – 1.1% 
and Ukraine – 1.6%. Among other EU MSs, significantly high prevalence rates are observed in LV, 
IT, PT, ES and FR. In contrast, in SK, SI, MT and LT HIV prevalence remains at a relatively low level. 
 
 
 
 
 Figure 2: A view of HIV infection across the 
EU and neighbouring countries, 2007 
 
 
 
 
Adult (15-49 aged) prevalence (%)  
 
Source: UNAIDS 
A total of approximately 90.000 new HIV infections were diagnosed in 2007 in the European Union, 
Russia and Ukraine. Less than 27 000 of these diagno ses were, according to the ECDC, reported in the 
EU. The number of newly diagnosed infections in  Russia and the Ukraine reached approximately 
55.000 in 2007, according to UNAIDS.  
Figure 3: Rates of newly diagnosed cases of HIV per million inhabitants, 2006 
EN 12   EN 
 
Source: Eurohiv  
These trends and statistics indicate that Eastern Europe  is highly affected and today this region 
reports the fastest spread of HIV epidemic in the world, often coming along with a high degree of co-
infections such as (multi-drug resistant) tuberculosis or hepatitis B and C (ECDC12). Ukraine is 
suffering a steady increase in new infections compar able to high epidemic regions. The number of 
PLWHA in Ukraine doubled from 210.000 in 2001 to 440.000 in the year 200713. The HIV epidemic 
in the Russian Federation continues to grow, although apparently at a slower pace than in Ukraine. 
The annual number of newly reported HIV diagno ses is also rising in the Republic of Moldova.  
Regarding Mediterranean partners of the EU  under the umbrella of the ENP, according to UNAIDS 
and WHO statistics, the threat of an expansion of the HIV epidemic from these countries to Europe is 
much lower. The HIV prevalence of adults in all the se countries, where data are available, is below 0.2 
% in 2007. The number of PLWHA in Algeria, Egypt, Israel, Jordan, Lebanon, Morocco and Tunisia estimates to 64.000 people that accounts for one sixth of PLWHA reported in Ukraine and only one fifteenth of PLWHA diagnosed in Russia.  
Thus, the HIV epidemic and HIV/AIDS developmen ts coming from Eastern Europe are much higher 
than those reported in the Mediterranean non-EU count ries. Therefore, this IA concerns mostly the 
Eastern neighbours that HIV/AIDS developments, if not tackled, threaten to lead a generalised 
epidemic along the EU's borders. 
The HIV epidemic in candidate and potential candidate  countries to the EU remains at low and stable 
levels, although there is evidence of increasi ng sexual transmission in many countries.
14 
 
2.1.3.  Mode of transmission  
HIV can be transmitted in three main routes: (1) sexual transmission, (2) tr ansmission through blood 
and (3) mother-to-child transmission. Wherever ther e is HIV, these three modes of transmission take 
place; however the predominant transmission group varies significantly by country and geographical area. 
In EU/EFTA countries the highest proportion of new HIV cases wa s reported among MSM 
(39%). predominating in UK, DE, FR, NL, ES PT and BE.  IDUs  (injecting drug users) constitute the 
largest proportion in the Eastern part of Europe (57%), with Ukraine, Belarus and Republic of 
Moldova at the top, followed by the Baltic stat es - LV and EE. Among the EU MSs, the highest 
number of IDUs cases is reported in PT, UK, FR, DE and PL. There is a risk that the large number of 
                                                 
12 Tuberculosis facts sheet, http://ecdc.europa.eu/en/Healt h_topics/Tubercul osis/facts.aspx   
13 UNAIDS global AIDS epidemiology report 2008, Annex  
14 For more comprehensive data see HIV/AIDS Surveillance in Europe, ECDC/WHO, 2007.  
EN 13   EN young people in Eastern Europe who get infected thr ough injecting drug use spread the infections to 
their partners and hence to the general population , especially women and children. 
 
With 256 cases reported in 2007 for the EU, MTCT  (mother-to-child transmission) accounts for just 
over 1% of all new HIV diagnoses15, but most of these cases could still be avoided and need to be 
prevented to spare children fro m an unnecessary life long disease. 
Figure 4: Rates of newly diagnosed cases of HIV per million inhabitants, 2006, with a distribution of 
transmission modes 
 
Source: Eurohiv 
 
2.1.4.  Root causes driving the epidemic 
To date, there have been a number of studies on th e causes and determinants of the infectious disease 
transmission and progression. Although, the ro ot causes of a steady high number of new HIV 
infections are heterogene ous and can also differ across geographi cal location, according to Poundstone 
approach16, factors of importance to HIV epidemiology  may be conceptualised at three levels: 
individual, social, and structural (Figure 5).   
Figure 5: Poundstone's 3-level determinants of HIV model 
                                                 
15 Ibidem  
16 Poundstone, K. E. et al. The Social Epidemiology of Human Immunodeficiency Virus/Acquired 
Immunodeficiency Syndrome, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, Vol. 26, 
2004 
EN 14   EN 
 
Source : Poundstone, K. E.: The Social Epidemiology of HIV/AIDS. This model has been adapted for the purpose 
of this impact assessment.  
Individual factors  include biologic, demographic, and behavioural risk factors that may influence the 
risk of HIV acquisition and disease progression.  
Social-level factors  include four categories: social capital, cultural context, neighbourhood effects and 
social networks. These social-level factors are critical pathways by which community and network 
structures link persons to society and constitute central structures to understanding the diffusion and 
differential distribution of HIV/AIDS in populati on groups and subgroups. All categories may affect 
the health outcome in the direct and indirect way.  
Social networks  generating the quality, density and structur e of relationships between persons as well 
as communities may, among others, influence the health outcome through prevalence of infectious 
disease and network member mixing, access to medications and information or social support and 
influence. In contrast, social capital  may impact health through the presence of health-promoting 
behaviours, access to services and infrastructure and greater political participation. Neighbourhood-
level factors  shaping population HIV/AIDS patterns incl ude mechanisms that increase either the 
probability of a person to get in touch with a HIV-positive or the population vulnerability to 
HIV/AIDS (high unemployment, exposur e to poor socioeconomic conditions). Cultural context  can be 
defined as a complex aggregati on of knowledge, beliefs, art, la w, morals, customs and other 
capabilities and habits that people acquire within society. 
Structural-level factors  include four categories relevant to HIV/AIDS epidemiology: structural 
violence and discrimination, legal structures, de mographic change, the policy environment. These 
factors affect HIV transmission dynamics and the differential distribution of HIV/AIDS.  
Structural violence  is reflected in discrimination based on race and ethnicity/gender, sexual orientation 
and HIV status. The effects of stigma, discrimination and collective denial  include individual 
reluctance to seek HIV testing and a lack of empower ment to enact HIV prevention. Given that stigma 
and discrimination play a crucial role in shap ing responses to HIV/AIDS epidemics, relevant 
interventions to overcome these problems shall resu lt from the diffusion theory of actions focused on 
social networks, opinion leaders and disease virus change. Legal structures  concerning laws, 
institutions and practices may affect health in a dir ect way (i.e. legal restrictions on access to sterile 
injection) or in an indirect way (i.e. the effect of tax laws on income inequality). Law implications 
EN 15   EN highlight several major social determinants of HIV/AIDS such as poverty, racism, income inequality. 
Demographic change  may impact HIV/AIDS through population mobility and migration, urbanisation 
and the age and gender of subpopulati ons that may be perceived as modifying interactions between 
susceptible and infected persons in populations. Structural-level policies , including macroeconomic 
policy, health and social policy as well as illicit drug control policy, play a crucial role in governing 
prevention, treatment and care, having impact on tr ends in the HIV/AIDS epidemics. Furthermore, 
policies that guide decisions about the allocation of resources in public and private sectors and the 
policy environment are essential in the emer gence and control of HIV/AIDS epidemic. 
 
This implies that a successful HIV/AIDS policy n eeds to be based on health-sector interventions for 
HIV/AIDS prevention, treatment and care incl uding interventions based in individual and 
communities and health facilities, delivered through out reach to most at risk populations as well as EU 
wide measures for supporting service delivery.  
All 27 EU Member States have already endorsed nati onal HIV policies, strategies, laws or guidelines 
that focus on prevention, testing and treatment, some  on laboratory and health systems, epidemiology, 
infrastructure or non-discrimination (see Annex 2). It  is, however, important that action plans are fully 
comprehensive, adequately resourced and focused and are properly implemented, ensuring delivery of 
policy interventions that are physically accessible, publicly acceptable, affordable and of satisfactory 
quality. Therefore, the EU role, especially regarding the policies within structural determinants of the 
HIV/AIDS epidemiology is essential as a guiding a nd supporting institution, with a full respect of 
subsidiarity. 
 
Box 1:  Examples of HIV/AIDS interventions at national level 
Example from the EU : the German authorities, alarmed by incr easing numbers of new infections since 
2000/2001 concluded that new prevention campaigns are essential, as well as more support to civil society to 
reinforce targeted prevention among gr oups most at risk and young people. It is not yet determined whether 
reinforced prevention is the reason for the current halt in  increase of new infection in  Germany, but the trend has 
stabilised since 2008. 
Example from a third country : Cambodia launched a 100% condom use pr ogramme in 1998, leading to a 96% 
rate of condom use among brothel-based sex-workers in 2003, from 42% in 1997. The result was a 
corresponding decline in  HIV prevalence in sex workers from 42,6% in 1998 to 28,8% in 200217. 
 
 
2.2. Social and economic burden of HIV/AIDS  
While many people living with HIV/AIDS can now  take up work and live more normal lives, the 
psycho-social burden of HIV infection remains signi ficant and is further compounded by the potential 
social stigmatisation and discrimination which can a ffect many areas of life – family, work, education, 
travel, housing, insurance, finances, etc. PLWHA an d immigrants being over proportionally affected 
by HIV/AIDS are often hardly accepted in a society,  facing a problem of social exclusion.. HIV/AIDS 
as disease is more than a "medical problem", when compared to other chronic diseases. The 
HIV/AIDS-infected individuals are also faced with the social burden that derives from the change in 
dependency caused by death or illness of working- age persons. Consequently, loss of economically 
productive individual or a breadwinner due to the HI V/AIDS infection reduces the stock of skills and 
experience of the labour force. In other words si gnificant losses in human capital constitute economic 
burden in terms of productivity loss and social exclusion. 
                                                 
17 WHO – Towards universal access by 2010: how  WHO is working with countries to scale up prevention treatment, care and 
support. 2006  
EN 16   EN Thus, social limitations are strongly interrelate d and complementary to the economic burden of 
HIV/AIDS especially when formulating evidence- based policy and for decision-making. Examining 
economic burden of HIV/AIDS helps quantify the e ffect of the epidemic on populations and support 
policy-makers in allocating public and private hea lth resources. The economic costs attributable to 
HIV/AIDS can be measured through direct and indirect costs of illness18. 
Direct costs  represent the value of resources used for treatment and care of PLWHA, of which 
majority is spent on ART and also recently HAART19 (a combination of antiretroviral drugs). 
Treatment based on provision of ART and HAART has proved to delay progression of the disease, 
increase the length and quality of life of HIV-inf ected patients, making HIV a chronic disease and not 
a death sentence, as well as to reduce the onward transmission of the virus and affect the epidemic's 
development. However, HIV/AIDS medication costs re main an important barrier to treatment. As it 
places a severe strain on health care budgets across Eur ope, levels of availability of treatment and care 
differs significantly by country and the geographi cal area (review sentence: strange causal link). 
Estimated ARV costs in the EU are on average be tween 4.000 to 15.000 euro per year per patient  
and ART represents a life-long regime20. EE, the country with the highest number of new infections 
per million inhabitants in Europe (two times higher ra tio than Russia or Ukrain e) spent ten times more 
(about 6M euro) for treatment in 2008 than in 2005 (0,64M euro),  whereas the absolute number of 
new infections stabilised around 600 per year since 200521 which shows the delayed cost implications 
of prevention. Prospective budget planning is ther efore important, but it has to include sufficient 
funding for prevention measures of new HIV infecti ons. Yet ARV costs amount only to a fraction of 
total treatment and follow-up costs for care of people with progressing diseases.  
Indirect costs , that can be significant in terms of e.g. reduced economic growth, loss of income, 
reduced incentives to invest or slower growing ma rkets, represent productivity losses, measured with a 
use of two commonly known methods: human capital (b asal health and stock of education and skills) 
and willingness to pay (WTP). The human capital method determines the production losses 
attributable to premature mortality and, because of li mitations to estimate economic value of the future 
earnings produced for each of the potential years of life lost, is rather considered a lower bound to a 
person's willingness to pay for a decreased risk of death22. WTP approach, based on the welfarist 
economics, reflects the value of life and health at the individual level.  
According to a 2006 study by the Kiel Institute for the World Economy, the aggregate individual 
welfare losses from HIV/AIDS would have a total welfare loss of around 16 % of the annual GDP in a 
region of 25 Eastern European countries over the seven years, between 1995 and 2001, hence an average of 2.2 % of GDP per year in that region of 25 countries
23. However, the most affected by 
HIV/AIDS problematic countries (EE followed by LV and LT) would suffer the highest per capita 
welfare loss in that region. In term s of social welfare costs, given the diversity of the prevalence and 
incidence rates among countries, the highest losses w ould amount to more than 150% of GDP in EE, 
app. 100% of GDP in Russia, 43% of GDP in LV and 18% of GDP in Ukraine, Russia and Republic 
of Moldova). In contrast, in remaining EU member states under the study (BU, CZ, HU, PL, SK, SI, RO) social welfare costs would range between 0.1% and 2.6 % of GDP in SK and CZ respectively. 
The study shows that countries experiencing alread y quite a high degree of HIV/AIDS infection are 
particularly threatened by the further epidemics e xpansion and hence the greater size of the welfare 
losses. 
The actual economic impact is also a matter of the respective economic strength, resources, health care 
and social budgets, level of i ndustrial development, and measures in place to integrate PLWHA as 
                                                 
18 Terry A., Gregory W. (1998): The economic burden of HIV/AIDS in Canada. CPRN Study No H[2], Ottawa 
19 HAART stands for Highly Active Antiretroviral Therapy. 
20 PT for example spends half of its budget for medications for HIV and cancer regimes.  
21 ECDC epidemiology report 2007. 
22 Terry A., Gregory W. (1998): The economic burden of HIV/AIDS in Canada. CPRN Study No H[2], Ottawa 
23 Fimpel, J., Stolpe, M. (2006). The Welfare Costs of HIV/AI DS in Eastern Europe: An Em pirical Assessment Using the 
Economic Value-of-Life;  
http://siteresources.worldbank.org/INT UKRAINE/Resources/328335-1147812406770/ukr_aids_eng.pdf   
EN 17   EN much as possible into social and labour processes. Esp ecially in the wake of the financial crisis when 
most economies in Europe are contracted facing with severe budget constraints, more attention shall be given to prevention and treatment however in vi ew of a process of repr ioritisation of HIV/AIDS 
programmes and reallocation of funding. Such bala nced approach focused on HIV/AIDS program 
efficiency and effectiveness shall contribute to main taining the economic growth in the long term and 
help reverse the size of welfare losses from HIV/AIDS epidemic that  many of the European countries 
are expected to incur. 
 
2.3. The first EU action plan 2006-2009  
The EU launched a first European HIV/AIDS action plan in December 2005, which has been 
implemented from 2006 onwards and comes to an end in 2009.  
The action plan served as the guiding document fo r funding through the Health Programmes and the 
Research Framework programmes (6th and 7th) and proposed about 50 different actions in the main 
three strands, sub-grouped in 7 chapters as follows: 
(A) POLITICS, AWARNESS, CIVIL SOCIETY 
(i) Leadership and advocacy  
(ii) Involvement of civil society (iii) Neighbourhood countries 
(B) SURVEILLANCE, RESEARCH and MEDICINE 
(iv) Surveillance  
(v) Treatment care and support  
(vi) Research  
(C) PREVENTION 
(vii) Prevention of new infections  
Key developments and achievements of the Ac tion Plan have been realised in terms of  EU policies 
and actions, Health Programme and 7th Framew ork Research Programme as well as actions at 
MS level and by stakeholders, ensuring coordination among major stakeholders over the last years. 
Commission services have regularly monitored progr ess in implementation and have reviewed actions 
taken under the Action Plan in collaboration with Member States, international organisations and 
stakeholders.  
EU Member States authorities and ministries, in part icular EU Presidencies, the European Centre for 
Disease Control and Prevention (ECDC) and the Executive Agency for Health and Consumers 
(EAHC, the Agency), European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), 
multiple NGOs and networks, academ ic organisations, international organisations like WHO Europe 
or UNAIDS and business operators contributed to the r ealisation of activities set out in the first Action 
Plan. Funding priorities for HIV/AIDS defined in the annual work programmes of the Public Health 
Programme followed Action Plan priorities. The Commission, in the framework of the European 
Heath programme (2003-2008) and second Health  Programme (2008-2013) co-funded numerous 
projects, amounted to over 30M Euros. A detailed description of projects and the EC co-funding for 
HIV/AIDS is attached to this impact assessment (Annex 3) .  
The first Action Plan was successful in increasing th e political commitment of European leaders to 
keep HIV/AIDS on their agenda and empowering civil society in the European Union 
Reaching a high level of political leadership and involvement of civil society  may be perceived the 
most prominent achievement because without the political will to address HIV/AIDS neither 
prevention nor treatment is accessible in a specific country. While the impact of activities focusing on 
surveillance, research and medicine can be m easured, since specific results are obtained that 
correspond to the expectations or not, the influence of  political leadership is more difficult to describe, 
but it may be concluded that raising awareness and keeping a particular item high on the political 
agenda has a political impact. This may be reflect ed in identifying HIV/AIDS as a priority and 
addressing the problematic by several EU presidencie s (Germany, Portugal, France), the emergence of 
new national HIV/AIDS policies and strategies, or in taking up HIV/AIDS issues in the bilateral 
EN 18   EN agreement on health with the Russian Federation. Therefore, political support for future investments 
and efforts (surveillance, prevention, services) should be continued in particular to reach the main 
drivers of epidemics. 
The empowerment of Civil Society  through partnership and operati onal grants allowed to improve 
both fields in which gaps have been identified, namely the advocacy for human rights and the training 
of the rather weak NGOs in the Eastern Eur opean neighbouring countries for example through 
twinning projects.  
Certain progress has been made in improving surveillance  due to relatively effective coordination role 
of the ECDC, which continues to realize remaining projects set in the Action Plan through its work 
programme, particularly with a focus on developing  behavioural data collection, setting up sentinel 
surveillance and improving country data reporting. 
In the Action Plan, the Commission has institutionalised a fully operational surveillance system  for 
HIV/AIDS, and expanded the knowledge base on impor tant HIV issues through programmes realised 
by ECDC. In order to enable the ECDC to deliver more comprehensive data all MSs are to be fully 
involved in reporting data to the ECDC surveillance system.  
Within the treatment, care and support  block, planned actions have been only partially 
implemented. Feasible outcomes are observed in improving access to treatment and care services through realizing projects focused on the capacity building, trainings of health professionals or 
promotion campaigns, and availability of ARV (su ccessful price reduction in Bulgaria). However, 
comprehensive addressing all needs for treatment and care was limited partly due to Member States 
responsibility for treatment and the curricula  of universities and training obligations.  
Research priorities  have been realised in terms of the establishment of networks for treatment, 
prevention and vaccine and microbicides research, however tangible outcomes outcomes with a public 
health relevance especially in the field of the de velopment of new vaccines and microbicides have not 
been achieved. Nevertheless, in the framework of research investments on HIV/AIDS, an RTD 
conference on poverty-related diseases in November  2008 was organized that  enabled to identify 
major research needs necessary for the future (i.e. discovery and development of new affordable 
medicines for HIV/AIDS, malaria and TB and effective measures to control these diseases). 
Regarding prevention activities , a number of training projects have been implemented especially 
focused on HIV transmission prevention, receiving the biggest part of financial funding of HIV/AIDS 
projects from the Health Programme. However, prev ention strategies in terms of public awareness and 
education have not been extensively tackled, as anticipated in the Action Plan. Given that new 
generation are growing and new challenges have to  be addressed, prevention has to be an essential 
activity and the priority with targ eted needs for future promotion. 
Less direct success is observed in the fields of actions on neighbourhood policies , majority of which 
have only started.  As the epidemic is regionall y expressed at different levels, present and future 
efforts on a European level have to concentrate on pa rticular regions of the EU - mostly affected by 
HIV/AIDS, i.e. those in Eastern Europe, includi ng the cross-border cooperation with the eastern 
partners that have proved to threaten the serious spread of the HIV/AIDS infections  in the EU MSs  
Regions where HIV/AIDS is still progressing shall be given greater attention, support and cooperation 
in order to enable them to implement effec tive measures towards containing the epidemics. 
More detailed evaluation of the Action Plan, incl uding a state of implementation of the specific 
actions, main achievements and less ons learned is presented in Annex 4, attached to this report. 
2.4. Funding resources 
2.4.1.  Health Programmes  
The Commission has been running programmes to  address HIV/AIDS and communicable diseases 
since the 1990s and provides budgetary support th rough its Health Programmes (HP) to support 
projects to combat HIV/AIDS in Europe. The Hea lth Programme (HP) provided the means to realise 
projects touching on commitments specified in th e current action plan and from 2003 to 2008 funded 
EN 19   EN 28 projects focusing on prevention of new HIV inf ections with 15,4 million euro. A more extensive 
description of achievements through HP funded projects , prepared by the Executive Agency for Health 
and Consumers, is attached to this report as Annex 2. 
2.4.2.  Research Framework Programmes 
The Commission's Research Framew ork Programmes also provide support for projects in the field of 
HIV/AIDS research.  
Research on HIV/AIDS was a top priority under the 5th, 6th EU Research Framework Programme (FP) 
and is continued under the 7th Research Framework Programme (2007- 2013). This priority is closely 
related to the priority for external and development policies.  
During the 6th FP the Commission has re-structured the Eu ropean HIV/AIDS research field with a 
multifaceted approach, supporting basic as well as tran slational research for a broad range of vaccine 
and drug candidates. In addition, it has been fi nancing research on microbicides, continuing the 
support of cohort studies which provide follow-up a nd guidelines for treatment to European patients 
(including MTCT and children), and creating two big Networks of Excellence (NoE) on prevention 
and on treatment involving most of the main Eur opean research centres in the field. The budget 
allocated to HIV/AIDS research in the 6th FP was about 126 million euro (of which 50% on prevention 
and 50% on treatment). 
In the 7th FP the Commission is pursuing the research priorities started earlier aiming at improving 
research concerning the prevention of future infec tions and the treatment of people currently living 
with HIV/AIDS. Until now around 75 mln euro has been invested in research projects that will address 
the development of new HIV vaccines, microbicid es, drugs and therapeutic options, as well as 
HIV/AIDS drug resistance. 
A call for a Network of Excellence (NoE) on cohort studies (seroconversion, MTCT, infected children 
and adults) has been launched in 2009. The grouping of all main European cohorts under a single NoE 
will allow construction of larger multi-cohort co llaborations offering more  robust prevention and 
treatment guidelines and a bette r public health impact.  
Furthermore, in order to promote coordinatio n of European national research programmes on 
preclinical and translational research against HIV/AIDS a call on HIV ERA-NET was launched in 2008 involving funding institutions from Member States. 
2.5. Fundamental Rights and equal trea tment in employment and occupation  
Taking action at EU level in the areas covered by the Communication would have a favourable impact 
on a number of rights recognised in the European Convention on Human Rights, the UN Convention 
on the Rights of the Child and the EU Charter of Fund amental Rights, in particular the right to health 
care (Article 35 of the Charter), rights of the child  (Article 24), the right not to be discriminated 
against (Article 21), the right to respect for private and family life (Article 7) and the right to the 
protection of personal data (Article 8). 
In 2000 the European Union adopted Directiv e 2000/78/EC establishing a general framework for 
equal treatment in employment and occupation. This  Directive aims at prohibiting discrimination on 
the grounds of religion or belief, disability, ag e or sexual orientation as regards employment and 
occupation. It is based on Article 13 of the EC Tr eaty, which grants the European Union powers to 
take appropriate action to combat discriminati on based on those four gr ounds, as well as on sex and 
racial or ethnic origin.  
In the case Chacón Navas24, the European Court of Justice (ECJ) held that "sickness cannot as such be 
regarded as a ground in addition to those in relation to which Directive 2000/78 prohibits 
discrimination."  
                                                 
24 C 13/05 Chacón Navas v. Eurest Colectividades - (Direct ive 2000/87/EC Equal treatment in  employment and occupation)  
EN 20   EN This Directive does not provide for a definition of disability. The ECJ held that as regards employment 
and occupation, the concept of ‘disability’ mentione d in the Directive must be understood as referring 
to "a limitation which results in particular from physical, mental or psychological impairments and 
which hinders the participation of  the person concerned in profe ssional life". In conclusion, HIV 
infected people are protected by Directive 2000 /78/EC insomuch as they have a disability. 
2.6. External policy dimension 
At the international level, the Commission work s with Member States in the framework of “ A 
European Programme for Action to confront HIV/AIDS, Malaria and Tuberculosis through 
External Action (2007-2011) ” and the United Nations Convention on the Rights of the Child and 
HIV/AIDS with its commitments to the right to life, survival and development and the right to non –
discrimination. The Programme for Action covers external action related to developing and middle-
income countries and hence is a complementary document to the “Communication on Combating 
HIV/AIDS in Europe and the Neighbouring Countries 2006 - 2009 ". The programme Action is focused 
on global action in areas where the EU can add va lue such as research on new tools and technologies, 
access to safe and affordable medicines and human resources for health.  
In the framework of the Programme for Action , the Commission finances HIV/AIDS responses in 
developing countries through an annual contribution to  the Global Fund to Fight AIDS, Tuberculosis 
and Malaria (GFTAM, the Global Fund) that in 2008 amounted to 137 mln US$. The EU and Members States collective contributions (half from the budget and half from the EDF) to the Global 
Fund have almost quadrupled, from a total of US $ 403 million in 2003 to US$ 1.546 million in 2008, 
representing around 55% of total contributions in the years 2004-2008. 
In the period 2007-2011, the Commission's support, covered by the Programme for Action, to 
strengthen health systems and confront communicable diseases, including HIV/AIDS, also in the context of MDGs, has been realized due to a financial instrument Official development Assistance 
(ODA)  that financing earmarked for health estimated  to total 3.043 euro. This financing includes 
support for research and technological development, where more than 200 million euro has already 
been allocated in the 7th Research Framework Programme (2007-2013) specifically for research on 
the three diseases. 
Under the umbrella of the European Neighbourhood Policy (ENP)  the Commission seeks to address 
HIV/AIDS as public health concern in agreements with third countries
25 where the HIV/AIDS 
problematic is severe (e.g. Ukraine, Republic of Mo ldova). Health dialogue with partners has been 
stepped up over the past years on the basis of the bilateral agreements with  partner countries and ENP 
Action Plans, covering a host of subjects such as health policy and communicable diseases including HIV/AIDS and tuberculosis. HIV/AIDS related actions are realised within the Communication on 
Combating HIV/AIDS in Europe and the Neighbouring Countries 2006 – 2009 . 
In the framework of development of new tools and interventions  for the three diseases the 
Commission has created the European and Developing Countries Clinical Trials Partnership 
(EDCTP)  and the Alliance of ESTHER  - ‘Network for Therapeutic So lidarity in Hospitals against 
AIDS' that represent innovative approaches seeking to involve a large number of research and health 
institutions and civil society organisations in Memb er States and partner countries in capacity building 
through twinning programmes and networking. 
The EDCTP
 was established in June 2003 to tackle the ch allenge of an increased prevalence of HIV 
and other poverty-related diseases infections resu lting from the lack of adequate preventive and 
therapeutic tool. The strategic objectives of the EU intervention were to (1) develop new interventions 
and products against poverty-related diseases; (2) bu ild sustainable public health and research capacity 
in Africa; (3) coordinate European Member States’  research policies. Since its inception, the EDCTP 
Programme has financed around 145 projects for over 100 mln euro, including 42 clinical trials. This 
                                                 
25 The ENP applies to the EU's immediate neighbours by land or sea – Morocco, Algeria, Tunisia, Egypt, Jordan, 
Lebanon, Syria, Israel, Occupied Palestinian Territories, Ukraine, Republic of Moldova , Armenia, Georgia, 
Azerbaijan, as well as Belarus and Libya . 
EN 21   EN network, although its prime focus is sub-Sahara n Africa, has major implications on European 
HIV/AIDS research. 
The Alliance of ESTHER's  objective is to implement capacity building activities developing twinnings 
between hospitals and health structures in the deve loping countries, in order to provide comprehensive 
and quality treatment (assurance of ART) and care for people living with HIV/AIDS. In years 2002-2008, more than 120 hospital twinnings have been launched from in about 40 developing countries 
allowing the implementation of a wide range of ac tivities (i.e. prevention of MTCT, paediatric care, 
equipment, psychosocial activities, operational research, monitoring and evaluation, technical 
assistance at country level, strong involvement in Un iversity diplomas, networking with civil society, 
PPPs). 
Regarding the Central Asian countries  that experience high levels of economic migration, with 
attendant vulnerability to HIV transmission and are in the early stages of drug injection-associated 
epidemics of HIV infection, set against a background  of high rates of sexually transmitted diseases and 
poor access to ARV treatment, the Commission provides financial support for different projects 
implemented by NGOs in the fight against HIV/AIDS in Central Asia countries, as well as a specific 
programme – Central Asia Drug Action Programme  (CADAP) to prevent drugs consumption and 
enhance treatment of addicted people. CADAP is financed by the EU and implemented by UNDP.  
Considering HIV/AIDS a cross cutting priority, the EU  tries to reflect the HIV/AIDS related problems 
in all areas of development cooperation, in collaboration with, among others, WHO, UNAIDS, 
UNICEF, UN or G8. 
3. PROBLEM DEFINITION  
Against the background of the epidemiological trends  of both HIV prevalence and new infections (as 
shown above), the identification of the root causes and determinants of the HIV/AIDS epidemic, the 
preliminary assessment of the Commission Action Plan 2006-2009, as well as the outcome of the stakeholders consultations, the fo llowing issues can be identified: 
3.1. Political commitments h ave not been achieved  
While many political commitments agreed by Memb er States and the Commission were expressed in 
the Dublin26, Vilnius27 (2004) and Bremen28 ministerial declarations (2007), or the Health Council 
conclusions of May 2007, not all of them are ye t fully realised, and the international community, 
including the EU is still behind agreed targets and realisable goals, such as universal access to 
prevention, treatment, care and support, or the invol vement of civil society in policy development, 
implementation and monitoring. The EU declarations  translate  internationally agreed commitments 
and principles expressed in UNGASS HIV/AIDS declaration of 200129 as well as the UNAIDS 'Three 
Ones' key principles30., endorsed in 2004, for coordination of national responses to HIV/AIDS All 
declarations stress the need for collective acti on to tackle HIV/AIDS through a deepening of 
coordination, cooperation and partne rship within and between countries, which are "encouraged (…) 
to strengthen the capacity of the European Union to fight effectively against the spread of HIV/AIDS". 
These declarations promote the active involvement of the institutions of the European Union to 
fund , improve, and harmonise surveillance systems .  
 
                                                 
26 http://www.sante.gou v.fr/htm/actu/europe_sante/sida/declaration_dublin.pdf    
27 http://ec.europa.eu/health/ph_threats/com/aids/docs/ev_20040916_rd03_en.pdf   
28 http://www.eu2007.de/en/News/downloa d_docs/Maerz/0312-BSGV/070Bremen.pdf   
29 http://data.unaids.org/publications/irc-pub03/aidsdeclaration_en.pdf   
30 These are guiding principles, agreed on 25 April 2004 , for national authorities and their partners, endorsed to 
achieve the most effective and efficient use of resources, a nd to ensure rapid action and results-based management: One 
agreed HIV/AIDS Action Framework that provides the basis fo r coordinating the work of a ll partners. One National AIDS 
Coordinating Authority, with a broad-based multisectoral ma ndate. One agreed country-level Monitoring and Evaluation 
System.  
EN 22   EN Box 2: Dublin Declaration on Partnership to fight HIV/AIDS in Europe and Central Asia  
Date of signature: 24 February 2004   
Signatories: 53 Members of the WHO European Region plus invited observers, including the European 
Commission  
It sets out 33 actions for governments  to undertake as related to leadership , prevention , living with HIV  
(including treatment and care) and partnership  in the 53 countries of the WHO European Region, among those 
several commit to meeting specific targets: 
Action 8: by 2005 at least 90% of young men and women aged 15-24 have access to the information, education 
and services necessary to develop the life skills requ ired to reduce their vulnerability to HIV infection. 
Action 9: by 2010 80% of the persons  at the highest risk of and most vulnerable to HIV/AIDS are covered by a 
wide range of prevention programmes, including intensified cross-border collaboration, sharing best practices. 
Action 12: by 2010 less than 2% of all new infections  are required by an infant from its infected mother  in 
Europe and central Asia. 
Action 14: by 2005 national and regional strategies and programmes  targeted to women and adolescent girls  
are developed. 
Action 21: by 2005 universal access  to effective, affordable and equita ble prevention, treatment and care is 
provided, including ART. 
The outcome of the 'Progress report...'  implies several present  and future imperatives for HIV efforts  in the 
European region, such as: 
• a need for greater accountability ; 
• amending legal and regulatory frameworks  as to better address HIV-related stigma, exclusion and 
discrimination ; 
• strengthening  national and regional HIV and STI surveillance ; 
• improving  and harmonizing  monitoring and evaluation efforts , including greater disaggregation of data for 
key indicators; 
• intensifying, scaling up and improv ing the targeting of HIV efforts  to reduce inequities; 
• a need for greater harmonization of prevention and treatment  programmes and policies; 
• increasing  civil society and private sector involvement 
 
 
Box 3: Vilnius Declaration on Measures to Strengthen Responses to HIV/AIDS in the European Union 
and in Neighbouring Countries  
Date of signature : 17 September 2004  
Signatories : Health ministers from the EU and neighbouring countries and international partners plus a Member 
of the European Commission  
The declaration endorsed a roadmap for tackling HIV epidemic in the EU and its neighbourhood, stating 
involvement of national governments, civil society and NGO-s, as well international partners in activities 
fighting against the HIV/AIDS epidemic, in line with the actions set out in the Dublin declaration.  
Commission commitments: 
 more research and development activities , including raising funding, investing in new preventive 
technologies, promoting the participation of new MSs and neighbouring countries; 
 better surveillance systems , in view of behavioura l and social data access; 
 facilitating cooperation and networking on HIV/AIDS; 
 supporting the development of health care infrastructures for HIV/AID S related purposes; 
 establishing fora and mechanisms , including the involvement of civil society and PLWHA for assessment of 
progress.  
EU MSs commitments: 
 promoting the fight against the epidemic recognizing the fundamental factors of equality; 
EN 23   EN  addressing the vulnerability of particular groups of people  as well as the specific needs of immigrants ; 
 working progressively on the behavioural and epidemiological data collection  in line with adequate and 
comprehensive national surveillance, monitoring and evaluation systems; 
 providing  universal, affordable, non-judg mental and non-discriminating access to prevention, care and 
treatment  (i.e. voluntary and confidential counselling and testing, ART and harm reduction measures); 
 developing new preventive technologies and reinforcing targeted education efforts; 
 developing and implementing relevant regulatory frameworks  with regard to non-discrimination, social 
inclusion, protection of human rights. 
 
Box 4:  Bremen Declaration on Responsibility an d Partnership – Together Against HIV/AIDS  
Under German Presidency  
Date of signature: 13 March 2007   
Signatories: Health  Ministers and representatives of Governments from the EU and neighbouring countries and 
international partners in the field of HIV/AIDS and the European Commission  
Commission commitments: 
 implementing the action plan, highlighting HIV/AIDS prevention, treatment , care and support 
 ensuring the FP7 provides sufficient fund ing for HIV/AIDS projects and programmes 
 promoting exchange of best prevention practices by setting up a clearing house for models of good practice ; 
 involving civil society in twinning projects  
 initiating the extension of the Council regulation 953/2003 to  countries in need of price reduced drugs for 
PLWHA  
EU MSs commitments: 
 fully implementing the UNGASS Declaration  of Commitment on HIV/AIDS 'Global crisis – global action' 
(2001) and 'Political Declar ation on HIV/AIDS (2006); 
 involvement in facilitating inclusive country-driven proc esses of scaling up HIV prevention, treatment, care 
and support (in line with UNGAR, 2005); 
 providing the political leadership at all levels to fight against the epidemic and exchange of best practices on 
the prevention of HIV/AIDS and STIs; 
 respecting human rights, especially addressing stigma and discrimination; 
 promoting universal access to evidence-based prevention ; 
 reducing MTCT of HIV and promoting comprehensive sexuality education, counselling and services on/for 
HIV/AIDS; 
 involving civil society and other international and national partners; 
 increasing research and development activities for new preventive technologies 
 cooperating with regard to affordable medication access 
 
Most MSs fulfil the declarations commitments when  implementing the relevant strategies, framework 
legislation or policies regarding HIV/AIDS related issues; however a degree and extent of compliance 
differ from country to country. 
While there are many commitments solemnly adopted  by Member States, ther e has not always been 
adequate monitoring of their implementation. The report on "Progress on implementing the Dublin 
Declaration on Partnership to Fight HI V/AIDS in Europe and Central Asia31", published in 2008 by 
UNAIDS and WHO/Europe has provided a descriptive view of the implementation of the Dublin Declaration. However, no comprehensive monitori ng framework based on indicators against which the 
implementation of Dublin commitments as the most comprehensive document could be monitored, has 
yet been developed. 
 
Box 5:  Example of Action Plan 2006-2009's unachieved action 
                                                 
31 http://europeandcis.undp.org/hivaids/sh ow/799D79A1-F203-1EE9-B241692C98378A9F   
EN 24   EN Analysing Action 21 (universal access to effective, affo rdable and equitable preven tion, treatment and care, 
including ARV) it has to be admitted that not everybody has access to effective preven tion even in the EU where 
social systems are strong and well developed. Many people  - present late for testing and hence receive treatment 
only late.. One measure to improve the access to prevention, testing, treatment, care and support would be to 
improve that the information is  available for everybody including immigrants. 
 
3.2. Data gaps in the centralised EU mo nitoring and reporting system  
Much progress has been made since the ECDC st arted its surveillance work on HIV/AIDS, which 
became fully operational only in 2008 though.  However, still not all MSs (missing: IT32, ES) and 
Eastern countries (Russia, Ukraine) have consisten tly reported data to EuroHIV/ now ECDC and will 
until remedied undermine, EU level surveillance. Gi ven the differences in national surveillance and 
reporting systems, the quality and coverage of 'dat a source' are not always consistent, and therefore 
interpretation and cross-country comparisons still ha ve to be made with caution as the amount of 
under-diagnosis and under-reporting di ffers across countries. Thus, in order to obtain a complete 
picture of HIV/AIDS epidemic in Europe, the HIV/AIDS surveillance in  the European region, 
particularly in EU/EFTA, needs to be strengthene d with respect to completeness, comparability and 
compatibility, and quality of data. The ECDC also e xperiences problems with data availability on the 
nature of the epidemic, migration in terms of acces s to testing, treatment and care, or infection and 
resistance patterns (and genotypes) across Europe.  
A future focus for EU level surveillance could be  the cross-border dimension of HIV infections on 
which currently only piecemeal data is available, bu t which is expected to raise in importance along 
with increased mobility of people. Overcoming th ese data gaps would enable policy-makers to 
develop a comprehensive understanding of the driver s of the epidemic and therefore to develop and 
implement fully adequate policy responses. 
 
3.3. Imperfect prevention and treatment ac tivities and potent ially diminishing 
health budgets  
A large number of PLWHA have not been diagnosed yet in Europe. It is estimated that between 15% 
in Sweden to 32% in the UK and 60% in Poland of people, infected with HIV, have not yet been 
diagnosed and hence are not aware of their stat us. There is therefore a need to improve the 
effectiveness of prevention  strategies33. The provision of counselling and voluntary testing  is, more 
specifically, an important instrument of HIV prevention as it is beneficial, both for the person 
concerned, and for society. Recent literature conc luded that "new sexual HIV transmission could be 
reduced by 30% if all persons already infected learn about their HIV status …" and "estimated 
transmission is 3,5 times higher among persons who are unaware of their infection than among 
persons who are aware of their infection"34. But it requires functional infrastructures and access to 
counselling and testing, implemented according to inte rnationally agreed principles, which is not yet 
the case in all settings across Europe. 
In addition to this, HIV/AIDS is a disease, which mostly affects specific groups  of the populations, 
e.g. injecting drug users, MSM, and immigrants,  in particular those from high prevalence regions. In 
order to effectively reach these populations most at  risk, HIV/AIDS policies have to be targeted 
towards these specific groups and ad apted to the specific problems they are confronted with (e.g. 
discrimination and stigmatisation, the social situation).  
                                                 
32 Since 2009 the notification of new cases of HIV infections ha s been compulsory in Italy, thus their national data are 
expected to be included in th e next year's data collection.  
33 Prevention encompasses different methods  and dimensions: personal information and counselling, targ eted information 
for vulnerable groups, the availability of testing facilities, a nd structural prevention which addresses the social and politic al 
environment of vulnerable people such as poverty and discrimination but also factors influencing behaviour s e.g. availability 
of information, condoms and sterile syringes.  
34 Marks et al., AIDS, 2006.  
EN 25   EN Between the year 2000 and 2006 the number of new HIV infections among MSM  nearly doubled 
based on an analysis of figures from 23 countries in Europe35. For instance, in the UK, cases increased 
by 91%, and the number of annu al diagnoses more than doubled in several countries, including 
Finland, Germany and Norway. 
IDUs  represent the most serious risk population for HI V/AIDS in Eastern Europe with the highest rate 
of new HIV cases. In countries like EE, LV or Ukra ine, the group of IDU has a HIV prevalence of 
60% or more, that significantly increases the risk of infecting their sexual partners.  
Immigrants , both documented and undocumente d, also represent an increasingly important share of 
people potentially infected by heterosexual transmi ssion, which often occurred already in their country 
of origin. Often faced with severe economic, soci al and cultural problems and difficulties to access 
health services, they hardly reach prevention and treatment and at the same time are particularly vulnerable to HIV/AIDS.  
NGOs can be helpful in bringing them closer to me dical services but in certain MSs, the involvement 
of civil society in the design and implementation of HIV/AIDS policies has not always been secured 
due to low political support for NGOs. 
According to UNAIDS
36, many countries in Europe have al ready adopted different policies or 
strategies to promote HIV prevention . However, translating these strate gies into a prioritised set of 
interventions based on evidence of impact has pr oved difficult and certain difficulties have been 
encountered to bring to scale prevention services fo r populations at higher risk of HIV exposure. 
Commitments have been undertaken  towards universal access to testing and treatment coverage across 
Europe and the neighbourhood, initially target ed for 2010 (MDG 6, UNGASS 2001, Dublin 2004 
commitments). However, access to treatment , in particular antiretroviral treatment still varies across 
Europe37. As shown, among reporting selected MSs38 in 2007 from 8% to 100% people with HIV 
infections received ARV treatment, with an exceptio n of BU where the percentage of ART coverage 
accounted for 33%39. The lowest coverage of ARV treatment, however, is observed in the 
neighbouring countries, with Ukraine accounting only for 8%. 
Figure 6: Estimated coverage of antiretroviral trea tment in selected MSs and neighbouring countries. 
Estimated ART coverage (%), 2007
020406080100120
Belgium 
Bulgaria Estonia 
Finland 
France 
Germany 
Hungary Ireland 
Lithuania 
Luxembourg 
Netherlands 
Romania 
Slovenia 
Spain 
Sweden 
UK 
Ukraine Moldova 
Russian Federation 
 
Source: UNAIDS 
Note: Data not available for: AT, CY, CZ, DK, EL, It, LV, MT, PL, PT 
EE - the costs cover those receiving therapy; FI – number shown relates to coverage for adults and children, as 
for pregnant women it is 95%; RO – according to  UNGASS estimation coverage accounts for 100%. 
                                                 
35 Likatavicius G et al. An increase in newly diagnosed HI V cases reported among men who have sex with men in Europe, 
2000–6: implications for a European pub lic health strategy. Sexually Tran smitted Infections 84: 499-505, 2008.  
36 UNGASS Country Progress Reports, 2008 
37 Costs for antiretroviral HIV treatment and treatment of AI DS related symptoms can be significant, knowing that ARV 
costs only amount to a fraction of total treatment and foll ow-up costs for care of people with progressing disease.  
38 BE, BU, EE, FI, FR, DE, HU, IE, LT, LU, NL, RO, SI, ES, SE, UK  
39 Source: UNAIDS,  
EN 26   EN The changing character of the disease from a deadly threat to a chronic condition implies a need to 
review policies and strategies. As HIV/AIDS plac es a severe strain on health care budgets across 
Europe, it will be indispensable for MSs to reflect on how to ensure the sust ainability of healthcare 
budgets as stated in the Lisbon reform agenda. The cha llenge is even bigger in the wake of the current 
financial and economic crisis that has hit public fina nces of most EU MSs, with a budget deficit set to 
more than double in 200940. In response to the fiscal and budget threats, governments are more 
inclined to compress public r esources, especially through cuts within health care allocations41, risking 
an insufficient delivery of critical health services,  including HIV/AIDS related treatment and care and 
programmes. This is also worrying concerning prevention programmes, which are particularly 
exposed to cuts in the health budget. Thus, a role of the EU would be to make national governments 
aware of the importance of communicable diseases ac tions, and encourage them for prioritisation of 
the public health spending with a special focus on the vulnerable groups and preventive health 
services.  
 
3.4. Persisting knowledge gaps  
As explained above, many research activities have al ready been carried out, at both national and EU 
level, in a wide range of fields. However, thes e research activities have so far not closed the 
knowledge gaps in certain  fields, such as:   
(i) Social science with particular regard to th e behavioural aspects of the transmission of HIV. 
Research in this field appears necessary to better map and to understand the drivers of the epidemics, 
and the ways to address these drivers in a targeted  manner. This research would also feed into ECDC 
activities.  
(ii) Socio-economic analysis, to improve understanding  of the cost effectiveness of prevention and the 
economic and social implica tions of the new trends,  
(iii) The development and implementati on of novel prevention technologies, 
(iv) The cross-border dimension of the disease in EU and neighbouring countries (infections of non-
residents, immigrants from third countries etc.)  
(v) More intensified biomedical research on the HIV virus remains necessary to develop biomedical 
solutions, as until now it has developed neither a cure  nor a vaccine. . Despite relevant investments 
into the research of vaccines and microbicides, conti nued cost intensive efforts are required to develop 
safe and efficient preventive vaccines and microbicides.  
3.5. Worrying trends in several Eastern European countries  
As already shown, the situation in several Easter n neighbouring countries is particularly worrying. 
Today, Eastern Europe (Baltic Member States, Ukra ine, Republic of Moldova, Belarus, the Russian 
Federation) is one of the regions in  the world with the fastest spread of HIV that calls for a prompt 
action in order to avoid a more generalised epid emic along the EU's borders . Cross-border movements 
are to a certain extent relevant to the spread of HIV (e.g. including42, labour movement, sex tourism). 
Also, in this region, HIV often comes along with a high degree of co-infections such as (multi-drug 
resistant) tuberculosis or hepatitis B and C, diseases which are communicable. 
 
Box 6:  Example of HIV/AIDS problematic in one of the Eastern neighbouring countries - Ukraine   
                                                 
40 10133/1/09 
41 According to OECD report 'Health and the economic crisis' (July 2009), the greater proportion of public 
expenditure goes to health services, public health allocations are more likely to decrease. This is the case for majority of MSs that government health expenditure as a %of total public spending accounts to between 10% 
and 23%, and as a percent to GDP to between 21% and 57%. 
42Paraskevis, D. et al. Tracing the HIV-1 subtype B mobilit y in Europe: a phylogeographic approach. Retrovirology, 2009.  
EN 27   EN Ukraine is suffering a steady increase in new infections, in particular among IDU. With a total population of 46 
million, about 0,44 (0,34-0,54) mln people already live with HIV/AIDS. More than 13000 people become 
infected every year, and the antiretroviral treatment covera ge reaches only about 8 (7-11) % of people in need.  
Despite a new governmental AIDS Concept and Programme for the period 2009-2013, based on the results and 
recommendations of the external evaluation of the recent National AIDS Programme, which was conducted in 
2007, UNAIDS still sees larg e challenges in the response to HIV/AI DS in Ukraine, that are, among others: 
- a scale-up substitution maintenance therapy for IDU to prevent the transmission of HIV and to promote 
compliance with antiretroviral therapy among opiod addicted patients with advanced HIV infection. 
- a lack of adequate funding to scale-up and sustain HIV/AIDS programmes and activities. While there has been 
- a significant increase in funding fo r HIV/AIDS in recent years, the ove rall needs to scale-up prevention, 
treatment, care and support programmes still exceeds available resources.  
In 2007, of about 520 0 pregnant women living with HIV, only an estimated 58% received antiretroviral 
treatment to prevent mother to child transmission (UNAIDS). 
At the Think Tank meeting in March 2009, UNICEF strongly expressed its concerns about a large number of 
street kids in Ukraine, many of whom use drugs and risk HIV infections, or are already infected. 
 
First actions have been undertaken as foreseen in the action plan from 2006-2009. As the main course 
of infection in the ENP is drug in jection HIV /AIDS affects people who are not a priority group for the 
government. Some Member States, UNAIDS, WHO and the GFATM have worked since the beginning of the epidemics to convince the governme nts of the need to tackle the disease. However, 
this requires a change of attitudes which is a long term process. It is not facilitated by the present 
crisis. Health systems are not well equipped, th e government changed frequently, prevention through 
information is a completely new concept as compared  to the prevailing repressive epidemic control 
approach and NGOs did not have  a voice neither in the development of policy nor in the 
implementation. The latter has changed especially th rough the GFATM, that entrusted the distribution 
of ARV to NGOs after the government had failed to deliver. 
In this situation the few projects funded by the EU were a beginning. The inclusion of government 
representatives in the Think Tank and of civil society organisation into the civil society forum was an 
important step. These are fora where open discussions  take place and prevailing perceptions can be 
challenged. While the Ukrainian NGOs took part in  both Think Tank and civil society meetings the 
Ukrainian government that was invited to present did not attend the meeting. Integrating NGOs and 
the governments of the ENP into EU's mechanisms  to exchange good practices is paramount to 
support the design and implementation of national HIV/AIDS policies.  
It would furthermore be important to involve this region more in th e surveillance work  carried out by 
ECDC, and to harmonise systems of monitoring and reporting. 
In summary, many reports from various organisations  on countries in the East underline that political 
will has improved over the years, but much needs to  be done. And therefore, cooperation at European 
level, using all existing approaches, including external relations instruments, is needed to contribute to 
an improvement of the situation. 
The situation in the Southern neighbouring countries is different. Here, human rights issues are more a 
matter of concern, and are therefore vigorously obs erved by the Think Tank and particularly by the 
Civil Society Forum. One organisation from Morocco is currently a member of this group and actively 
providing first hand information as the EC delegations  in these countries do. It should be noted that 
Commission addresses its HIV/AIDS policy to all ENP countries but data suggest that a focus on 
Eastern countries is most needed in view of the development of the epidemic. 
4. THE RATIONALE FOR EUROPEAN ACTION  
Addressing the HIV/AIDS challenge at EU level woul d take place in the context of the overall health 
and social policy orientation. Embedded in the EU health strategy (2008), a second HIV/AIDS 
initiative would respond to political commitments take n by the European Union and its Member States 
EN 28   EN and specifically by the Commission, as e.g. expr essed in the Dublin, Vilnius (2004) and Bremen 
ministerial declarations (2007). The Health Counc il conclusions of May 2007, and the European 
Parliament's reports on HIV/AIDS of April 2007 and of November 2008 underline the broad political 
support and commitment to EU action in this fiel d. Tackling HIV/AIDS is fully in line with the 
renewed EU Sustainable Development Strategy43. The EU Health Programme44 continues to provide 
financial support for EU action in Member States and additional eligible countries.  
HIV/AIDS has changed its character from an imme diate threat of death to a chronic disease. When 
diagnosed and treated early, PLWHA in Europe have a longer life expectancy and a higher quality of life compared to when treatment did not exist. While condoms remain the best way of preventing HIV, 
new modes of prevention are discussed and availabl e. They raise new questions and require new 
answers. While there is on the one hand, a need for the continuity of promoting prevention there is a 
need on the other hand for new strategies on how to best approach PLWHA and people at risk with prevention messages and treatment options. Fears in society of working together and living together 
with PLWHA have to be addressed. 
4.1. Subsidiarity  
The EU Member States and the neighbouring countr ies have the prime responsibility for protecting 
and improving the health of their citizens. As part of  that responsibility, it is for the countries to decide 
on the organisation and delivery of health services to  patients, or on the delivery of prevention means 
to protect their citizens from avoidable health challenges.  
However, Article 152 of the Treaty explicitly acknowle dges that the EU has a role in addressing health 
issues in support of Member States: "Community action, which shall complement national policies, 
shall be directed towards preventing human illn ess and diseases, and obviating sources of danger to 
human health". This is in particular relevant for communicable diseases, which do not halt at national borders. Article 152 EC also calls for ensuring a high  level of human protection in the definition and 
implementation of all Community policy and activiti es. In this respect, Community activities in other 
fields like research, education and youth, external re lations, social and labour  policy, migration of 
third country nationals are relevant to  HIV/AIDS related aspects and actions. 
4.2. Necessity Test  
HIV/AIDS is a communicable disease and can on ly be addressed when national governments 
coordinate their efforts. This is obvious when considering population flows. Free movement of 
persons is one of the key political pillars of the European Union. People cross borders for various 
reasons such as work, travels, etc. There is also a constant flow of people to and from third countries. 
Cross-border movements are to a certain extent re levant for the spread of HIV (e.g. including sex 
tourism of sex workers and their clients45). We do not yet have a total overview of the cross-border 
dimension of HIV/AIDS for all EU MSs, but can refer to various studies. The 2006 study of the Kiel Institute for the World Economy indicated cross bor der infections at least for a few countries and 
found out that e.g. in Cyprus most HIV infections  occurred in non-permanent residents and that in 
Croatia 90% of men were infected outside the country.  
An estimated total of 64 million migrants from thir d countries currently live in the EU. Although there 
is an enormous diversity in the proportion of migr ants with HIV infection in the different countries, 
immigrants in the EU have a relevant share ( up to 50%) of new heterosexually transmitted HIV 
infections. As this group is also at risk of so cial exclusion, they often experience difficulties in 
accessing diagnosis, prevention, treatment and care.  
The European Union needs a harmonised surveillance system in order to follow the infection trends 
and assist Member States in taking adequate public  health measures, arising e.g. from mobility and 
                                                 
43 10917/06  
44According to the EU Health Strategy  (COM(2007)630) , the general objective stipulated in article 152 of the EC 
treaty was extended, including problems and solutions across borders, through the coordinated approach to combat HIV/AIDS in the EU and neighbourhood countries. 
45 Sex work, HIV/AIDS and human rights in Central and Eastern Europe and central Asia, CEEHRN, 2005.  
EN 29   EN migration. Given the frequent cross-border movements within the EU, it is necessary that all MSs 
contribute to the reporting of HIV infections, should the surveillance system be reliable. 
The EU needs to continue to pursue a common re search agenda and to exploit economies of scale 
from joint efforts at EU level and between public  and private research. As has already been 
demonstrated, the latter is today already centralised by a few private players at EU level and has thus long transcended national boundaries. 
It is finally in the interest of the European Uni on to include the neighbouring countries in the response 
to HIV because there are frequent movements of pe rsons across the borders. An  effective response to 
HIV/AIDS cannot be limited to the national territory as the virus spreads from one country to the other 
in an area of open borders, mobility of workers a nd a great deal of tourism including sex tourism
46 as a 
recent study on the phylogeny of different HIV s ubtypes suggests. Cooperation at European level 
could contribute to supplement multilateral and b ilateral cooperation, which could suffer from the 
current economic crisis and potential reduction of the resources available to address HIV/AIDS. 
The promotion of effective prevention policies can have an important positive impact on the incidence 
rate in the EU and the neighbourhood. A common understanding and an exchange of approaches to 
tackle HIV/AIDS across borders is of particul ar importance for more effective cooperation and 
measures between EU MSs and neighbouring countries. 
4.3. Added-Value Test  
As highlighted in contributions from Member States and the Civil Society during the consultation, 
there is a clear expectation that  the Commission should continue to play an important role in 
facilitating and coordinating efforts across Europe on multiple levels, public health, research, external 
and development policies. The politi cal support delivered so far has been widely recognised. This is 
especially relevant for those regions where the HIV/AIDS burden is highest. HIV infections are 
preventable. Consequently, the need to share experiences and best practices becomes obvious as a 
cost-effective undertaking. The Commission provides a firm data base, a forum for discussion and 
targeted exchange of practices between Member States to promote the transfer of ideas and 
approaches. Single Member States can hardly maintain this kind of cross-border cooperation. 
The EU could mainstream HIV as public health challenge  across relevant EU policies, in particular in 
those related to the free movement of people, the protection of human rights, research and discrimination and gender equality. Co untries may benefit if they adopt elements of their own policies 
on the basis of better knowledge of European good practice. 
With regard to HIV, there is a strong difference in experience between old and new Member States 
and neighbouring countries. HIV has been a rela tively new phenomenon in the new States and has hit 
some of them like Estonia quite strongly. An ex change of best practice can accelerate effective 
measures in response to the epidemic. 
In the past, work under the current action plan h as led to a better cooperation among civil society 
organisation, between authorities and civil society, and international organisations such as UNAIDS or 
WHO. As a practical example, Commission services have supported the ARV pricing initiative of the 
German - Portugal - Slovenia Trio Presidency, which resulted in reduced prices for ARVs in Bulgaria 
in the range of about 30%, as compared to the level before price negotiations. 
Moreover, among business operators, HIV medicati on remains an economically and socially 
challenging business despite the strong position of generic drug producers. A recent merger of the 
HIV/AIDS businesses of two important pharmaceuti cal companies shows this. It also underlines the 
need of EU level involvement a nd cooperation of research activities to avoid redundancy and to spend 
funding in the right direction. 
                                                 
46 Paraskevis, D. et al. Tracing the HIV-1 subtype B mobilit y in Europe: a phylogeographic approach. Retrovirology, 2009.  
EN 30   EN The EU can finally also complement action at the global level, with the WHO developing technical 
standards and clinical guidance and the EU focussi ng more on political advocacy and areas with clear 
EU added-value (such as research and pricing issues).  
A major benefit resulting from the current action plan was that all stakeholders, including WHO, 
UNAIDS, ILO, IOM, other international organisati ons, or civil society organisations, engaged in 
fighting HIV/AIDS, had been assigned to tasks and deliv erables. In this particular field of public 
health, the EC is in the unique position to be able to define an action plan based on a policy framework 
for such a large range of stakeholders. This resu lts in a strong commitment to address relevant aspects 
in combating HIV/AIDS as defined in a European  consensus. Consequently, a translation of 
appropriate actions into trans-na tional, national or regional settings helps to lower the impact of 
HIV/AIDS in a particular setting. 
Through bringing together Member States and nei ghbouring states, with different knowledge of all 
factors necessary for the fight against HIV e.g. in  the Think Tank or in high level conferences, the 
Commission can raise awareness and underline im portant aspects such as the human rights of 
vulnerable groups and PLWHA. 
The EU advocates its common principles such as non- discrimination in global policy to the Member 
States. This policy is not forced upon Member States or neighbouring countries, they remain actors on their own in most fields of public health, incl uding measures against HIV/AIDS. The exchange of 
practices and making declarations at European level will, however, facilitate the possibility of taking 
action for vulnerable groups. Concre te polices and related health measures remain a matter of national 
competence. 
5. POLICY OBJECTIVES  
5.1. General objective 
The general objective is to contribute to the pr evention and reduction of human illness and diseases 
stemming from HIV infections, to obviate sources of danger to human health, as laid down in Article 
152 of the Treaty as well as to improve the quality of life of PLWH and most at risk of infection. As mentioned above, this general objectiv e was stipulated already in the EU Health Strategy as well as in 
the EU Sustainable Development Strategy (SDS).  
 
5.2. 
Specific objectives  
(a) To maintain  political leadership and all stakeholders' commitment and involvement and 
ensure regular monitoring of implementation of targets on HIV/AIDS, as agreed on the political and stakeholders' agenda and sti pulated in international agreements  
(b) To complete HIV/AIDS epidemiological data including monitoring, primary and secondary 
surveillance and reporting in order to improve  the basis for HIV/AIDS policy development 
and implementation. 
(c) To encourage and support EU Member States and neighbourhood countries, also in the 
framework of cross-border cooperation, in designing and implementing effective public 
health interventions aiming to: 
– reinforce a focus of national HIV/AIDS strategies and activities on populations most 
at risk (i.e. MSM, IDU, immigrants), with focus on prevention and testing 
– improve the quality of life and living conditions  of the vulnerable people, at high risk 
of HIV infection and ensure universal access to high-quality care and treatment services 
EN 31   EN – adapt national HIV/AIDS strategies and ac tivities to non-resolved and/or newly 
emerging challenges (under-diagnosis, ne w prevention methods, new treatment 
options, economic and social burden, etc) 
– with regard to the current economic crisis , ensure that sufficient public and private 
funding is allocated to HIV/AIDS actions,  
(d) To address research and knowledge gaps in  treatment development, vaccine and 
microbicide research and development, public health research, behavioural science, socio-economic analysis.  
 
6. POLICY OPTIONS  
In order to realise the objectives proposed in the pr evious section, three different options have been 
envisaged. Option 1 calls for a continuation of im plementation of the current action plan, thus 
maintaining 'status quo' policy. It is considered to be the baseline option in order to facilitate a 
comparison between option 2 – discontinuing exis ting EU policy - and option 3 – enhancing and 
setting another focus on activities to be implemented along agreed actions, in response to current and 
future challenges. Thus, effects and impacts of op tions 2 and 3 can be assessed against the level of 
remaining actions of option 1 and identified in a more discernible and comprehensive way. 
 
6.1. Option 1: baseline – further implemen tation of current action plan, and 
evaluation 
The initial "baseline option" would consist of exte nding the lifespan of the current action plan and 
continuing the implementation of open actions. An extension of the current strategy would still 
provide a political chapeau and demonstrate that HIV/AIDS remains in po litical agendas at an 
European level, along the lines alread y defined in the current action plan47. This option would allow 
the Commission and stakeholders to continue the implemention of those activities which have not 
been completed yet as well as to continue ac tivities which have proven to be successful. 
While this option would consist in rolling over th e current action plan, as it currently is, one new 
element would be to include a set of indicators, in order to more concisely monitor its implementation 
and the resulting effects of progress. This would allow for a more comprehensive evaluation of the 
current action plan. 
Actions around surveillance and research would be continuously implemented, based on the existing 
set of priorities. 
Box 7:  Action Plan 2006-2009 – areas with open actions  
Prevention: Actions in the area of education and information campaigns have not been implemented everywhere 
in Europe. The process of exchange of experience started but it needs time to generate first of all confidence 
among partners and secondly concrete results.  
Actions concerning laboratory networking and univers ity and medical education (e.g. integration of HIV 
                                                 
47 The current Communication covering 2006-2009 states the following: "The Commission (will) focus on 
prevention, which remains the cornerstone for all other activities within the comprehensive approach to tackle 
HIV/AIDS. The other areas of action which need strengthen ing are human rights issues, surveillance, and actions 
targeted at specific vulnera ble groups. Providing political leadership and advocacy is th e main value added of the 
EU activities on HIV/AIDS. The Commission will continue to keep HIV/AIDS and related issues on the wide 
political agenda and provide leadership to combat stigma and discrimination, and promote the provision of 
universal access to prevention services, ARV treatment and harm reduction services for injecting drug users. 
Coordination, facilitating the development of a comm on knowledge base, provision of common tools for 
decision-making and additional funds to support national activities and research and development programmes in 
this field are other areas where joint action at EU/Eur opean level can add value to the work done elsewhere." 
EN 32   EN prevention into the curricula) could still be wider addressed. But this needs an active role of competent entities, 
e.g. international organisations, medical associations an d MS authorities responsible for university and education 
curricula.  
Health infrastructure is a MS jurisd iction with very different financing systems - therefore difficult to reach 
equal levels of implementation. The same applies to sex education, access to treatment and treatment 
preparedness.  Here, the Commission remains in a coordinative role.  
More progress has to be made in access to affordable  of ARV drugs, even in the European Union, but 
particularly in neighbouring countries.  
The promotion and development of training modules for of medical staff, in particular regarding diagnoses, 
awareness, co-infections, sexually tran smitted infection etc. should become one focus in the future action plan. 
Due to the  many actions suggested SANCO had to choose priorities that could be achieved at European level  
The cooperation with media could be strengthened in a new strategy as actions in this area could not yet be 
realised, probably due to conceptual and financial shortcomings. . 
Surveillance at European level has improved but still ECDC does not receive data from all MS yet.  
No activities have been carried out with regard to data protection 
The report on Mother to Child transmission (MTCT) has not yet been commissioned, but ECDC issues every 
year numbers on the level of MTCT across Europe.  
 
 
6.2. Option 2: no EU policy and action plan addressing HIV/AIDS as a single topic 
The Commission will not opt for a new HIV/AIDS-s pecific policy initiative (action plan plus 
communication). 
This option would not exclude a further cooperation and intervention of the EU in the field through 
financial and technical support. The Commission would focus on existing funding activities/programmes, such as the Research Framework Programme, the Public Health Programme, 
European Social Fund, European Neighbourhood Policy Instruments (ENPI), external HIV policies, 
and would also continue to provide technical s upport through specialised agencies such as ECDC, or 
EMCDDA.  
However, without an updated EU guidance doc ument for activities on HIV/AIDS, HIV-related 
spending could be re-attributed to other policy ar eas. Indeed, in the case of the Health Programme 
2008-2013, priorities are defined on an annual basis a nd the budget is allocated on a competitive basis 
(i.e. no budget has been earmark ed for HIV/AIDS specifically). Similarly, spending within the 
framework of the 7
th Research programme would continue as currently planned, but research priorities 
defined in annual work programmes would risk to be assigned to other research activities.  
Surveillance by ECDC would continue independe ntly, without taking into account the new policy 
needs though. Any improvement of the surveillance would stem from ECDC, without the guidance of 
an action plan on specific data needs.  
 
6.3. Option 3: Current plus – a new Commission policy and action plan on 
combating HIV/AIDS in Europe 
The Commission would provide a political chapeau to  ensure that HIV/AIDS remains a priority in 
political agendas and would depict the main priorities for policies in the fight against HIV/AIDS in the 
form of a second action plan covering the years 2009-2013.  
As for the current action plan, the new action plan would denominate the lead parties for 
implementation. A new Commission policy could pr ovide the broad action lines and the Commission 
services and their principal stakeholders, assembled in the Think Tank and in the Civil Society Forum, will decide on a specific action plan. In addition to l ead parties, this plan would identify particular 
indicators to measure and describe the degree and the quality of realisation. These indicators would 
EN 33   EN ideally be selected among the set of 33 indicators or currently applied by the ECDC in the framework 
of the monitoring of the Dublin declaration implementation48. If this set of indicators would not be 
specific enough, new indicators would be established, in order to monitor the implementation of the 
new action plan and the resulting pr ogress. This would allow for a mo re comprehensive evaluation of 
the new action plan.  
More importantly, items of the new action plan w ill correspond to the upcoming priorities for the next 
years, including for research and EU Health Pr ogramme spending. This option would take into 
consideration the new trends and challenges deriving from HIV/AIDS at EU and neighbouring 
countries level, already identified in the problem definition. 
As presented in the illustration below, any future EU action should draw lessons from the experience 
of the first EU action plan 2006-2009 and shift th e attributed weights towards more action under 
pillars: prevention, treatment and care as well as  research, with slightly  reduced action under 
awareness/stakeholders and maintained efforts fo r monitoring. Research could become a separate 
strand. More specifically, actions under these pillars should focus on the topical priorities: prevention, 
Eastern Europe and most at risk populations. A ne w action will therefore be more focused, outcome 
oriented and less generic than the first action plan. A stronger focus will help to achieve greater effects 
along the above mentioned lines. 
                                                 
48 ECDC project 2009/2010: monitoring of the Dublin declaration on partnership to fight HIV/AIDS in Europe 
and Central Asia.  
EN 34   EN Table 1: Comparison of priorities and objectives between Action Plan 2006-2009 and a new Action Plan 
(Option 3) 
Action Plan 2006-
2009  A new EU policy and action plan (Option 3) 
(A) 
Politics/Awareness 
      /Civil Society  (A) 
Politics/Awareness 
      /Civil Society  ↑ Cross-border cooperation 
(Western-Eastern Europe) 
↓ Political leadership and 
stakeholders involvement 
 
↓ Overall budget reduction  More focus on: 
- EU – Eastern Europe 
cooperation and partnership 
projects  
-address stigma and 
discrimination more as 
principal barriers to effective 
prevention  
- mainstreaming of HIV in 
EU policies and bi-/ multi-
lateral agreements  
  
(B) Surveillance, 
research and 
medicine  
 (B) Surveillance  
 ↑ Data collection and 
reporting 
↑Cross-border cooperation 
J Overall budget kept on 
same level as in previous 
action plan  More focus on: 
- close outstanding data gaps 
in the EU and in cross-border 
dimension  
- behavioural surveillance 
- timely translation of data 
into effective policy 
responses 
(C) Prevention  (C) Prevention, 
treatment, care and 
support  ↑ New preventive methods 
↑ Prevention, treatment and 
care targeted at most at risk 
groups  
↑Promotion of VCT in 
vulnerable groups 
↑ Overall increased action 
and budget  strengthen the focus on: 
- reiterated comprehensive 
prevention as the approach 
towards controlling the 
spread of HIV 
- improving quality of life of 
all people affected by 
HIV/AIDS and in particular 
vulnerable groups 
- UNIVERSAL access to 
prevention, treatment, care 
and support 
- refocus of activities to reach 
priority groups including 
undiagnosed (MSM, IDU, 
immigrants from high 
prevalence countries) as well 
as priority regions 
  
 
  
 
  
=> 
(D) Research and 
medicine (to become 
a separate strand in 
any future EU 
action)  ↑ Funding for research and 
knowledge 
↑Overall budget increase More focus on: 
- more investments and 
strength to overcome research 
and knowledge gaps 
(behavioural science, new 
prevention methods, drug 
resistance, co-infections) 
EN 35   EN - more Public-Private 
Partnerships for innovations 
on medicines and vaccines 
development 
Weight given as compared to the previous action plan  (↑ more; ↓ less; J same) 
 
Box 8:  Possible actions under Option 3 
Possible actions under such an option could include :  
(A) Political leadership/ stakeholders  (including neighbouring countries cooperation) 
- Establish political agreements between the EU and neighbouring countries addressing i.a. HIV/AIDS. 
- Cooperation with private sector (business, media, public  personalities etc.), e.g.on social marketing of condoms 
- do more to achieve an efficient exchange of informa tion and good practices to strengthen effective multilateral/ 
cross-border cooperation, in particular regarding promotion of human rights of vulnerable people and evidence 
based prevention and treatment. 
 (B) EU surveillance   
- Encourage all Member States and neighbouring countries to consistently report to ECDC their relevant data at 
national level (as opposed to regional level) and on certain crucial issues where data gaps remain at European 
level (e.g. drug users or other vulnerable groups). 
- Assess the implications of cross-border movements and migration 
(C) Prevention, treatment, care and support - Encourage and support training of medical staff (diagnosis, 
testing, treatment) and social workers 
- Encourage ENP countries and other d ecision-makers to improve infrastructu res to provide state-of-the-art HIV 
services and the social and legal environment to encourag e populations at risk to present for testing, treatment 
and care through exchange of experience and exploring the potential of existing EU funding. HP, ENP budget 
- Encourage  and empower civil society in Eastern Europe  and promote effective peer  education and exchange  
(D) Research and medicine  
- Encourage public-private partnerships against HIV/AIDS, and in particular in cost-intensive research fields 
such as vaccines and microbicides development 
- intensify social science research, in  particular on behavioural aspects  
 
6.4. Option 4: discarded options 
Legislation:  HIV/AIDS is a health and often a social pr oblem with a considerable political dimension, 
but the Treaty does not give room for a legislative in tervention in form of a HIV-specific directive or a 
regulation. Member States and neighbouring count ries design their national plans and programmes, 
but comprehensive national approaches benefit gr eatly by access and exchange of good practices, 
experiences and evidence based solutions. 
Campaign:  A European campaign on HIV could not be ta rgeted enough to respond to all particular 
situations and cultural sensitivities in  different regions of Europe. It would not be possible to reach in 
an effective, targeted way all populations at risk, and would hence neither be cost-effective nor leading 
to the desired results. 
7. ANALYSIS OF IMPACT  
Considering that the EU only comes as one of ma ny actors in HIV/AIDS policy interventions (e.g. 
WHO, UNAIDS, MSs, NGOs, private sectors, etc.) and given that EU level spending represents just part of the overall public and private spending to combat HIV/AIDS in Europe, it is difficult to 
EN 36   EN quantify the potential social and economic impacts of the options outlined above. Their non-binding 
nature hinders even more the ability to put a fi gure on these impacts. However, a generic assessment 
describing qualitative impacts has been performed . Whenever possible, estimates are provided, 
notably regarding the economic and social burden of HIV/AIDS, partial costs of action plans and 
research funding devoted to HIV/AIDS, present and fu ture HIV/AIDS trends and finally anecdotal 
evidence from policy interventions at national leve l. All budgetary costs are estimates based on the 
expenditures under the action plan 2006-2009.  
This IA assumes that any reprioritisation of actions w ill have an impact, to a larger or lesser extent, on 
financial resources re-allocation. At the EU level, the Health Programme, for example, is implemented 
by means of annual work plans which set out priority areas and the funding criteria, taking into 
account existing multi-annual framework policy documents (e.g. action plan). Projects are then selected on a competitive basis
49. HIV/AIDS-related actions can be funded under the following three 
objectives: to improve citizens’ health security; to promote health, including the reduction of health 
inequalities; to generate and disseminate health  information and knowledge . However, no specific 
budget is automatically earmarked for HIV/AIDS in the Health Programme. This annual system also 
applies to FP7.  
Environmental impact is negligible a nd will not be considered further.  
 
7.1. Option 1: Baseline option –  further implementation of the current action plan  
Economic impact 
In this option, the different tasks to implement the action plan would continue to be distributed among 
all stakeholders involved in its realisation. Alr eady, the first action plan was mainly implemented 
through financial means of the Health Programme , research framework programme, other EU funding 
instruments, through national co-financing or comp lete financing of national authorities or of NGOs 
and the commitment of industry.  
The direct costs for the EU , although this all depends on the annual priorities set out in these 
programmes, and on the quality of proposals receive d, would most probably amount for similar levels 
of spending as over the previous period (2006-2 009) which is, as far as the Health Programme is 
concerned, in the range of about 5 million euro pe r year of spending, and on average 25 million euro 
per year allocated through the Research Framework Programme. Through the evaluation  of the 
activities implementing the action plan, this option would be instrumental in assessing how far EU and 
national investments, both financial and politi cal, have had an impact on the epidemic. 
This option, by maintaining the emphasis on HIV/AI DS as a priority at the EU level, would send a 
message of continuity and would constitute an incentive to maintain high level of investment for 
multiple stakeholders  engaged in research, service provision, training and support activities, public 
health aspects and more. 
Under this option, it is expected that  spending for activities financed through national budgets 
would remain stable, as compared to 2006-2009 period.  None of the activities in the action plan would 
present an obligation for any involved party. This acti on plan offers an array of reasonable and useful 
measures to be considered in orde r to improve national or  regional policies and measures to respond to 
HIV/AIDS in a particular setting. It fosters c ooperation and efficiency. Many examples demonstrate 
that, investments in effective measures against HIV/AI DS and for the benefit of people affected by the 
disease and its associated problems pay back in the fu ture - ethically, socially and financially.  
                                                 
49 All projects must cover one or more of the specific objectives set out in the annual work plan. They will be 
assessed on the basis of: policy and contextual relevance – projects should provide added value at European level 
and support developments at European level in the field of health; technical quality – projects should be 
innovative, with a clear evaluation and dissemination strategy, and management quality and budget. 
EN 37   EN Germany, e.g., estimates that its prevention  means and campaigns (average investments at federal 
level between 11 and 13 million euro in the last y ears) resulted in annual savings of 450 million euro 
for therapy costs through 30.000 avoided HIV in fections. Costs may increase for national health 
systems in the short term when more people are t ested and given access to treatment and prevention. 
But it results in cost reduction on multiple medical and social levels in the long term, since prevention, 
earlier diagnosis and treatment prevent or respectiv ely delay the progression of the disease, and keep 
infected people in the labour market. This exam ple underlines the win-win situation that effective 
prevention and treatment reduces human suffering in the short, medium and long term as well as the 
costs for national health systems in the long-term. 
Treatment costs  rise massively through an accumulation of more patients over time even if the 
number of new infections decreases or stagnates over the same period (as the case of Estonia, explained above, illustrates). Increasing the acces s to ART would have an economic impact on 
national health-care systems and budgets. Prospec tive budget planning is therefore important. An 
agreed action plan backed up by a strong political  commitment, an effective exchange of good 
practices, and a solid data base, reduces inefficien cies and duplication of efforts for the development 
and implementation of policies and could support appropriate planning on national levels. 
However, in time of economic downturn , as demonstrated in OECD report
50, health national 
spending is expected to be increasingly affected by  budget cuts or budgetary measures, especially in 
the short and medium term. There is a risk that  HIV/AIDS-related expenditures could follow this 
trend. 
No additional costs on MSs for reporting and  surveillance  are to be expected. The ECDC 
surveillance work is financed th rough EU budget and would remain unc hanged – the ECDC has a total 
annual budget of about 50 million euro, of whic h 1.1 million euro are earmarked for HIV/AIDS, 
Hepatitis and Sexually transmitted diseases. 
Social impact  
This option would not result in specific changes but will maintain the political focus, for the 
continuation of projects, in areas such as efforts to improve the access to prevention, treatment and 
care, or modified and improved general policies on national or regional level, as well as projects 
focusing on training programmes for NGOs, education or other issues of the current action plan not 
yet fully implemented. 
This option is expected to improve access to preven tion, treatment and care and in turn, bear positive 
social impacts. Indeed, effective prevention programmes contribute to a reduction of further 
transmission of HIV . Prevention, earlier diagnosis and treatment prevent or respectively delay the 
progression of the disease , keep infected people in the labour market , which eventually positively 
influence the quality of life of PLWHA . 
However, if international and EU political commitments  would be maintained  and could continue 
to be supported by the existence of an EU acti on plan (e.g. The WHO 'Three Ones' requirement, 
focused on actions, coordination and monitoring, as a key in the response to HIV/AIDS would be to a certain degree satisfied), without the developmen t of a specific monitoring framework of these 
political agreements, progress could be hindered towards the achievement s of these targets. 
ECDC surveillance  would not take into consideration new challenges and related data needs. The 
existing data gaps (nature of the epidemic, migration in terms of access to testing, treatment and care, 
or infection and resistance patterns (and genotyp es) across Europe, cross –border dimension of HIV 
infections) would not be bridged. Therefore, polic y-makers would encounter difficulties in developing 
a comprehensive understanding of the drivers of the epidemic and, in turn, proposing and 
implementing fully adequate policy responses. 
                                                 
50 OECD: Health and the economic crisis. DELSA/HEA (2009)1, June 2009. 
EN 38   EN 7.2. Option 2: no EU policy and action plan on HIV/AIDS as a single topic 
Economic impact 
The direct costs  for the EU – mostly through  the Health Programme and the Research Framework 
Programme – would probably decrease as compared to the current situation, however not to a large 
extent. Indeed, the effectiveness of  the political and financial support might be diminished, due to a 
lack of political guidance in setting priorities. Furt hermore, the lack in political motivation for EU 
cooperation in the field of HIV/AIDS could impact  the choice of these programmes' annual priorities, 
and given the competitive basis for projects' se lection, favour other non-HIV/AIDS priorities, 
supported by an EU policy. Any attempt to receive  funding for HIV/AIDS activities at EU level could 
be counteracted by the reference to the discontinua tion of the strategy. This may in the medium-term 
have an impact on EU research funding and action on HIV/AIDS. In the face of 2.7 million new 
infections annually worldwide and the need for a va ccination or a definitive cure for HIV/AIDS, this 
appears difficult to justify. 
A discontinuation or putting less emphasis on HIV/AIDS as priority would also have serious 
repercussions on multiple stakeholders  engaged in research, service provision, training and support 
activities, public health aspects and more.  This could e.g. lead the pharmaceutical sector  to decrease 
research in AIDS vaccines research. As any potential vaccine will have to be paid for by international 
donors, the pharmaceutical sector will carefully take decisions of a donor like the Commission into account when planning its research agenda. In additi on, in time of the economic crisis and potential 
reduction of the resources available for addressing HI V/AIDS, the lack of political commitment at EU 
level would not necessarily be compensated  by bilateral or multilate ral cooperation without EU 
funding.  
The key drawback of such an option is the politi cal message that this would send to EU MSs and 
neighbouring countries. Governments within the EU, and particularly in the neighbouring countries, 
could follow the EU example of complacency and reduce national spending  (varies considerably 
across Europe, depending on number of patients, inv estments in prevention, testing, treatment, care, 
depending on social systems). As previously mentioned,  this risk exists all the more so in time of the 
economic crisis . According to a recent UNAIDS/WB report on "The Global Economic Crisis and HIV 
Prevention and Treatment Programmes: Vulnerabilities and Impacts"
51, the negative implications of 
the economic crisis (e.g. exchange rate devaluation, budget cuts) ar e expected to have an adverse 
impact on ART , in the medium and long term, through eith er increasing the cost of ARV drugs or 
decreasing the sufficient public ART co st coverage. In addition, HIV/AIDS prevention  programmes 
are particularly vulnerable to the effects of poten tial health budgets cuts. Given that prevention has an 
influence on transmission rates of infectious diseases, public health costs  could be higher through the 
increased number of infections and higher treatme nt costs as well as social, economic and labour 
market effects in the medium and long term.  
No additional costs on MSs for reporting and  surveillance  are to be expected. The ECDC 
surveillance work is financed th rough EU budget and would remain unc hanged – the ECDC has a total 
annual budget of about 50 million euro, of whic h 1.1 million euro are earmarked for HIV/AIDS, 
Hepatitis and Sexually transmitted diseases. 
Social impact  
This option could result in changes in areas such  as efforts to improve the access to prevention, 
treatment and care, or modified and improved genera l policies on national or regional level. However, 
this option bears the risk that without a str ong political support from the Commission, HIV/AIDS 
might disappear from the radar screens of certain funding mechanisms. 
Without an EU political guidance, it is difficult to anticipate which specific actions will be undertaken 
and implemented by MSs and stakeholders. However, it may be assumed that internationally agreed 
targets  in the fight against HIV/AIDS, such as unive rsal access to prevention, treatment and care, 
                                                 
51 http://data.unaids.org/pub/Report/2009/jc1734_econ_crisis_hiv_response_en.pdf   
EN 39   EN would not be reached in all European countries (e.g. the WHO 'Three Ones ' requirement, focused on 
actions, coordination and monitoring, as a key in the response to HIV/AIDS would only be satisfied in 
countries more pro-active in combating HIV/AIDS ), solely through multinational not funded 
cooperation on a technical and operati onal level. That, in turn, could lead, in the medium and long 
term, to adverse social impacts, reflected in an increase of HIV/AIDS incidence, influencing 
negatively the quality of life of PLWHA .  
The potential of empowering NGOs  in the neighbouring countries – which are instrumental in 
advocating human rights for vulnerable group – thr ough regular and funded participation in civil 
society meetings would risk being lost.  
This option may not be effective enough to sustai n and further develop a broad scale of cooperation 
across Europe and among interested stakeholders  - specifically to steer actions towards the new issues 
and challenges  identified earlier in this report. In partic ular, this option woul d probably not enhance 
efforts to address the social issues  around HIV/AIDS, related to fear , stigma, discrimination, non 
respect of human rights, deprivation of harm reducti on measures, tolerance towards effective, targeted 
evidence based prevention, the social situation of people living with or affected by HIV/AIDS, and 
more to the necessary extent. 
As in the case of Option 1, ECDC surveillance  would not take into consideration new challenges and 
related data needs. The existing data gaps (natur e of the epidemic, migration in terms of access to 
testing, treatment and care, or infection and resi stance patterns (and genotypes) across Europe, cross –
border dimension of HIV infections) would not be br idged. Therefore, policy-makers would encounter 
difficulties in developing a comprehensive understandi ng of the drivers of the epidemic and, in turn, 
proposing and implementing full y adequate policy responses. 
 
7.3. Option 3: Current plus – a new EU po licy and action plan on combating 
HIV/AIDS in Europe  
Economic impact 
In this option, the different tasks to implement the new action plan would be distributed among all 
stakeholders involved in its realisation. Already, the first action plan was mainly implemented through 
financial means of the Health Programme, rese arch framework programme, other EU funding 
instruments, through national co-financing or comp lete financing of national authorities or of NGOs 
and the commitment of industry.  
The direct costs for the EU , although this all depends on the annual priorities set out in these 
programmes, and on the quality of proposals receive d, would most probably amount for similar levels 
of spending as over the previous pe riod (2006-2009). It is expected that political support but also the 
increased focus on new challenges and trends – namely  on actions targeted at most-at-risk groups and 
enhanced cooperation with eastern neighbouring countries – could increase the efficiency of 
implementation, trough resources' reallocation to wards more efficient interventions. Through the 
evaluation  of the activities implementing the new action pl an, this option would be instrumental in 
assessing how far EU and national investments, both fi nancial and political, have had an impact on the 
epidemic.  
This option, by maintaining the emphasis on HIV/AI DS as a priority at the EU level, would send a 
message of continuity and would constitute an incentive to maintain high level of investment for 
multiple stakeholders  engaged in research, service provision, training and support activities, public 
health aspects and more. In particular, a new empha sis would be given to research activities, with a 
stronger focus on overcoming resear ch and knowledge gaps (behavi oural science, new prevention 
methods drug resistance, co-infections), encouraging public-private partnerships to be more involved 
in research on medicines and vaccines. This could e.g. lead the pharmaceutical sector  to increase 
research in AIDS vaccines research.   
Under this option, it is expected that  spending for activities financed through national budgets 
would remain stable, as compared to 2006-2009 period.  None of the activities in the action plan would 
EN 40   EN present an obligation for any involv ed party. However, this is expected that emphasis put on new 
priorities could lead to reallocation of national resources  towards, in particular, new preventive 
methods, prevention, treatment and care interventions  more targeted at most-at-risk groups (MSM, 
IDUs, immigrants from high prevalence countries) and stronger eastern cross-border cooperation, 
resulting in more cost-effective interventions. 
As previously mentioned, in time of the economic downturn , HIV/AIDS-related interventions could 
be adversely impacted on by the negative implicat ions of the economic crisis (e.g. budget cuts or 
budgetary measures, exchange rate devaluati on), having potentially ne gative repercussions on ART , in 
the medium and long term. In addition, prevention  programmes could be threatened with potential 
health budgets cuts, and, according to a survey  of UNAIDS, WHO, and WB staff in 71 countries 
carried out in March 2009 and whose results are pr esented in a recent report on "The Global Economic 
Crisis and HIV Prevention and Treatment  Programmes: Vulnerabilities and Impacts"52, this concern 
referred to vulnerable target groups (MSM, IDUs , immigrants) and was most pronounced in the 
Eastern European countries. In this highly uncerta in context, this option would represent an incentive 
for EU MSs and neighbouring countries, to maintain a certain level of public spending into prevention 
programmes and services, in particular targeted at most-at-risk populations, while encouraging a 
reallocation of resources towards the most  cost-effective health interventions.  
Improved reporting and surveillance  may impose additional costs on the very few countries, which 
do not report as complete data as required to ECDC . All other countries will not have any additional 
burden, and will benefit from a bett er planning based on better data – th is is usually cost-effective. The 
ECDC surveillance work is financed through EU  budget and would remain unchanged – the ECDC 
has a total annual budget of about 50 million euro , of which 1.1 million euro are earmarked for 
HIV/AIDS, Hepatitis and Sexually transmitted diseases.  
Social impact  
From a European perspective, a Commission communication would underline continuity  and political 
will towards the realisation of existing international commitments , as defined in the diverse political 
UNGASS, Dublin, Vilnius declarations that could con tinue to be supported by the existence of an EU 
action plan (e.g. the WHO 'Three Ones' requirement , focused on actions, coordination and monitoring, 
as a key in the response to HIV/AIDS would be satisfied). This new action plan would lay down precise targets to be met through intensive coope ration among stakeholders and could result in better 
and targeted resource allocation and more effective infrastructures  on a national level. 
This option would have an important positive impact especially on civil society  and their work, 
people affected by HIV/AIDS  and industry  contributing - through stronger political leadership and 
civil society involvement - to improving the livi ng conditions for all people affected by the disease. 
The Commission's example could serve as a reason or justification for EU Member States or neighbouring countries, as well as international or ganisations and resources.  The development of a 
specific monitoring framework of these political agreements , would lead to a better achievement of 
these targets.  
Technically, it would provide a framewor k for action for the identification of projects  to be funded by 
the Health Programme and Framework Research Pr ogramme. This option would maintain the political 
focus, for the continuation of projects, in areas su ch as efforts to improve the access to prevention, 
treatment and care, or modified and improved genera l policies on national or regional level, as well as 
projects focusing on training programmes for NGOs, education or other issues of the current action plan not yet fully implemented. 
In addition, this option should be effective not only in  sustaining but also in further developing a broad 
scale of cooperation across Europe and among interested  stakeholders - specifically to steer actions 
towards the new issues and challenges  identified earlier in this report. By shifting the focus on certain 
priorities, the efficiency of the interventions cont ributing to the implementation of the action plan is 
expected to increase. As explained above, this will be all the more im portant to target interventions as 
                                                 
52 http://data.unaids.org/pub/Report/2009/jc1734_econ_crisis_hiv_response_en.pdf   
EN 41   EN the economic context could lead to budget constraint s. This should particularly be the case regarding 
the new emphasis given to new preventive methods, pr evention, treatment and care interventions more 
targeted at most-at-risk groups (MSM, IDU, immi grants from high prevalence countries) and stronger 
cooperation with Eastern European countries. Mo re effective prevention, earlier diagnosis and 
treatment prevent or respectively delay the progression of the disease , keep infected people in the 
labour market , which eventually positively influence the quality of life of PLWHA .  
In particular, through increased targeting of interv entions towards more-at-risk groups, which are also 
often most-at-risk socially, this option would support efforts to address the social issues  around 
HIV/AIDS, related to fear, stigma, discrimination, non respect of human rights, deprivation of harm 
reduction measures, tolerance towards effective, targeted evidence based prevention, the social 
situation of people living with or affected by HIV/AIDS, and more to the necessary extent. Specifically, NGOs in the European neighbourhood c ountries (and in particular in Eastern European 
countries) could be actively supported and thus the response in these countries would be strengthened. 
This option would lead to more influential civil so ciety, which is indispensable for service provision, 
advocacy against discrimination and stigmatisation of marginalised groups, policy development as 
well as implementation and monitoring of policies. 
This option would help to monitor the dimension of  the HIV/AIDS epidemic and co-infections, such 
as tuberculosis, hepatitis and sexuall y transmitted infections, – at national and cross border level, in 
Europe, and help to map and disseminate best pr actices towards planning of efficient prevention, 
treatment, health and social care options. It would ser ve to bring together experts to draw up responses 
to future challenges. Improved and complete surveillance and monitoring at European level, 
mostly by ECDC , would be the basis of effective and sustainable public health measures in all 
affected countries 
 
 
 
EN 42   EN 8. COMPARING THE OPTIONS  
Table 2: Comparison of options  
 OPTION 1 OPTION 2 OPTION 3 
 
ADVANTAGES - An action plan would offer a wide range of tools 
to strategically translate political Commission goals into action. 
- It provides guidance for EU level action 
(including research spending and HP activities)  
-It provides a political back-up for a partnership 
among all relevant stakeholders and facilitates the 
exchange of good practices 
-Transparency and specificity of the EU goals and 
targets leading to implementation of set actions for 
HIV/AIDS related problems. 
- The evaluation of the activities implementing the 
current action plan would allow for assessing how 
far EU and national investments, both financial and political, have had an impact on the epidemic. 
-EU surveillance and monitoring system would be 
enhanced and improved however to a limited 
extent. 
- Research and knowledge gaps could be partially 
overcome 
 - No additional continuous funding required - HP 
would continue to support measures to address HIV/AIDS, thus occasional funding would be 
possible. There may be a risk of money transfer to 
other health policies. 
-Research framework programme (FP7) would 
probably continue to s upport HIV/AIDS research. 
There may be a risk of money transfer to other research priorities. 
- No potential administrative costs caused in MSs. 
- A certain degree of continuity could be provided– 
but only at technical level. 
 - An action plan would offer a wide range of tools to 
strategically translate political Commission goals into action. 
- It provides guidance for EU level action (including 
research spending and HP activities)  
- The Commission could facilitate a focus on 
activities around the specific objectives identified 
above.-It provides a political back-up for a strong partnership among all relevant stakeholders and 
facilitates the exchange of good practices 
-Transparency and specificity of the EU goals and 
targets leading to implementation of set actions for 
HIV/AIDS related problems, including new trends 
and challenges. 
- The evaluation of the activities implementing the 
new action plan would allow for assessing how far 
EU and national investments, both financial and 
political, have had an impact on the epidemic. 
- EU surveillance and monitoring system would be 
enhanced and improved 
- Research and knowledge gaps would be overcome.  
DISADVANTAGES - No new incentive  
- Loss of political momentum to present a future-
oriented action plan based on current evidence, - The EU sends a negative political sign of 
complacency, lost political  opportunity to recall 
importance of prevention policies for HIV in times - Potential budgetary implications for MSs (e.g. 
increased access to ARV would increase costs for national health budgets) 
 
EN 43   EN data and needs, lost politi cal opportunity to recall 
importance of prevention policies for HIV in times 
of budgetary constraints. 
- Potential budgetary implications for MSs (e.g. 
increased access to ARV would increase costs for 
national health budgets) 
- EU surveillance and monitoring system would 
continue in its present shape, and would remain 
incomplete. 
 of budgetary constraints  
- Long term costs related to reduced push for 
prevention. Potential budgetary implications for MSs (e.g. increased access to ARV would increase costs 
for national health budgets) 
- No framework for action/guidance would be 
provided to correlate thematic priorities to available 
budget. 
- No guidance for EU level action (including 
research spending and HP activities) 
- Expectations as expressed by MSs or the civil 
society would not be met, commitments would not 
be realised. 
- The EU would no longer contribute to a political 
coordination of activities in the field of HIV/AIDS, 
and could not defend the rights of PLWHA in a 
particular manner. 
- Civil society would lo se much support across 
Europe, in particular in countries where civil society 
is traditionally not very strong. 
- EU surveillance and monitoring system would 
continue in its present shape, and would remain 
incomplete. - Potential additional reporting duties of MSs for 
surveillance and monitoring (e.g. cross-border 
movement and migration) resulting in additional administrative burden  
 
 
 
 
EN 44   EN The following table summarises the impact of the three options on the specific objectives as defined in 
section 5.2. 
Table 3: Impacts summary  
Contribution towards specific objectives Option 1 Option 2 Option 3 
Political leadership and guida nce towards reaching agree d
targets + - ++ 
Strengthened surveillance and epidemiology to support polic y
development and implementation and monitoring  + + ++ 
Encourage MSs and neighbouring countries to reinforce the
focus of their activities and policies on most at risk populations+ - ++ 
Encourage MSs and neighbourin g countries to improve th e
quality of life and living conditions of the vulnerable people, a t
high risk of HIV infection and ensure universal access to high-
quality care and treatment services + - ++ 
Encourage MSs and neighbouring countries to adapt nationa l
HIV/AIDS strategies and activities to non-resolved and/o r
newly emerging challenges (under-diagnosis, new preventio n
methods, new treatment options, economic and social burden,
etc.) + - ++ 
Encourage MSs and neighbouring countries to, with regard to
the current economic crisis, ensure that sufficient public an d
private funding is allocated to HIV/AIDS actions, + - ++ 
Address research gaps by integration of resources and activities + + ++ 
Costs of achieving the specific objectives estimation estimation estimation 
Budgetary impacts for the EU: 
Health Programme 
   
approx. 20M 
euros  
approx. 20M 
euros or less, 
reallocation of 
HIV funding to 
other policies 
covered by the 
HP    
approx. 20M euros
reallocation to 
priorities defined 
in new action plan
Research Framework Programme approx. 100M 
euros approx. 100M 
euros or less 
reallocation of 
HIV funding to 
other policies 
covered by the 
HP   approx. 100M 
euros 
reallocation to 
priorities defined 
in new action plan
ECDC (surveillance and monitoring) approx. 4.4M
euros 
 approx. 4.4M 
euros 
 approx. 4.4M euros
reallocation to 
priorities defined 
in new action plan
Budgetary impacts for MSs:     
 
EN 45   EN Costs for health budgets (prevention, treatment…) an d
research 
  
Costs of reporting (surveillance) n/a 
stable 
 
 
 
no additional 
administrative
burden for 
EU MSs  n/a 
risk of budget 
cuts, due to 
economic crisis 
 
no additional 
administrative 
burden for EU 
MSs n/a 
stable 
reallocation to 
priorities defined 
in new action plan
administrative 
costs stemming 
from new data 
reporting 
requirements  
 
9. MONITORING AND EVALUATION  
This impact assessment has identified a number of open topics for future acti on to combat HIV/AIDS 
in Europe. The HIV/AIDS Think Tank and the Civ il Society Forum are impartial and objective bodies, 
thus in a good position to monitor on a regular basis,  in cooperation with ECDC, the progress made on 
specific objectives. Broader key elements could focus on an assessment of the impact on: national policy-making and spending, EU policy and policy outcomes. 
All specific objectives addressed in the impact assessm ent would be translated into actions and linked 
to lead organisations, indicators and target dead lines (as presented above). Achievements will be 
traced regularly and a monitoring report, based on da ta compiled by ECDC, could be published by the 
Commission in 2012 and 2014, respectively. 
A regular monitoring contributes to a timely di ssemination of results and achievements among all 
stakeholders engaged in combating HIV/AIDS  in Europe. Good practices, opportunities for 
coordination and cooperati on would become more transparent and accessible to and among all major 
stakeholders. 
More specific indicators for the monitoring could focus on: 
- the progress made in most at risk populati ons in form of highly disaggregated data 
- the progress made in particularly affected countries - mid-term planning established on countries most affected - the progress made on a political level, degree of  the political influence on the implementation of 
measures against HIV/AIDS: indicators selected 
- degree of involvement of civil so ciety on a national and regional level 
- the progress made towards a harmonised and meani ngful epidemiology and surveillance, in support 
of policy and decision making. - the progress made towards research in iden tified fields where knowledge gaps persist. 
- national spending allocated to HIV/AIDS interventi ons (in particular with regard to the negative 
implications of the economic crisis). 
Suitable indicators will be selected by the Thin k Tank with the technical support of ECDC and 
UNAIDS and could derive from the current work carried  out in the frame of the regular monitoring of 
the implementation of the Dublin declaration. 
 
EN 46   EN LIST  OF ANNEXES 
1. Assessment of responses on RELEX questionnaire re ceived from EU delegations in ENP countries. 
2. Compilation of EU Member States that have a specific HIV/AIDS action plan and or national 
strategy in place or under preparation. 
3. Report on contribution of projects funded by European Health Programme 2006 – 2008 to the 
implementation of the HIV/AIDS Action Plan 2006-2009. 
4. Action Plan 2006-2009 – a preliminary internal European Commission evaluation.