Commission staff working document - Impact Assessment - Accompanying document to the Communication from the Commission to the Council, theuropean Parliament, the European Economic and Social Committee and the Committee of the Regions - Combating HIV/AIDS in the European Unionand neighbouring countries, 2009 -2013 {COM(2009) 569 final}{SEC(2009) 1403} {SEC(2009) 1405}
Date: 2009-10-26
Institutions: European Commission
Subjects: AIDS, action programme, anti-discriminatory measure, cooperation policy, disease prevention, health policy, impact study, right to health, third country

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COMMISSION OF THE EUROPEAN COMMUNITIES 

Brussels, 26.10.2009 
SEC(2009) 1404 final 

COMMISSION STAFF WORKING DOCUMENT 

Impact Assessment 

Accompanying document to the 

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

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This report commits only the Commission's services involved in its preparation and does not 
prejudge the final form of any decision to be taken by the Commission 

Impact Assessment 

TABLE OF CONTENTS 

ABBREVIATIONS / ACRONYMS.............................................................................................. 4 

GLOSSARY................................................................................................................................. 5 

executive summary.................................................................................................................. 8 

1.  Procedural Issues and Consultation of Interested Parties......................................... 8 

1.1. 

1.2. 

Organisation and Timing .......................................................................................... 8 

Consultation and Expertise....................................................................................... 9 

2.  Background ....................................................................................................................... 9 

2.1. 

2.2. 

2.3. 

2.4. 

2.5. 

2.6. 

HIV/AIDS - characteristics of the disease and epidemiology.............................. 9 

Social and economic burden of HIV/AIDS ........................................................... 15 

The first EU action plan 2006-2009 ...................................................................... 17 

Funding resources ................................................................................................... 18 

Fundamental Rights and equal treatment in employment and occupation.... 19 

External policy dimension....................................................................................... 20 

3.  Problem Definition ......................................................................................................... 21 

3.1. 

3.2. 

3.3. 

Political commitments have not been achieved .................................................. 21 

Data gaps in the centralised EU monitoring and reporting system ................. 24 

Imperfect prevention and treatment activities 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. 

4.2. 

4.3. 

Subsidiarity ............................................................................................................... 28 

Necessity Test .......................................................................................................... 28 

Added-Value Test..................................................................................................... 29 

5.  Policy Objectives ............................................................................................................ 30 

5.1. 

5.2. 

General objective ..................................................................................................... 30 

Specific objectives.................................................................................................... 30 

6.  Policy options.................................................................................................................. 31 

6.1. 

Option 1: baseline – further implementation of current action plan, and 
evaluation.................................................................................................................. 31 

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6.2. 

6.3. 

Option 2: no EU policy and action plan addressing HIV/AIDS as a single topic
  32 

Option 3: Current plus – a new Commission 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. 

7.2. 

7.3. 

Option 1: Baseline option – further implementation of the current action plan
  36 

Option 2: no EU policy and action plan on HIV/AIDS as a single topic .......... 38 

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 

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ABBREVIATIONS / ACRONYMS 

AIDS 

ART 

ARV 

acquired immunodeficiency syndrome 

antiretroviral therapy/treatment 

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 

EU 

European neighbourhood policy 

European Union 

GFATM 

Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) 

Gilead   

Gilead Sciences, Pharmaceutical company 

HAART 

highly active antiretroviral therapy 

HIV 

IASG 

IDU 

IOM 

MDG 

MS 

MSM 

human immunodeficiency virus 

Impact Assessment Steering Group 

injecting drug user 

International Organisation for Migration 

Millennium Development Goals 

Member State of the EU  

men who have sex with men 

MTCT   

mother-to-child transmission (of HIV) 

PLWHA 

people living with HIV-AIDS 

QALY   

TESSy   

Quality Adjusted Life Years 

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 

WHO 

Voluntary Counselling and Testing for HIV 

World Health Organization 

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GLOSSARY 

AIDS  -  stands  for  'acquired  immunodeficiency  syndrome'  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  retrovirus;  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 standard 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 rates of death and suffering when use is made of a 
potent ARV regiment, ART is now considered an integral 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 also 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  Yugoslav  Republic  of  Macedonia,  Montenegro,  Poland, 
Romania, Serbia, Slovakia, Slovenia, Turkey 
Clinical research - health research relating to individual patients 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  another  infectious  agents  such  as  tuberculosis  or 
hepatitis. 
Communicable  disease  -  an  illness  caused  by  a  specific  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,  Kazakhstan,  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,  Jordan,  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  with  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.  Governments  do  not  condone  illegal  risk  behaviours 
such  as  injecting  drug  use,  but  they  acknowledge  that  these  behaviours  occur  and  that  they  have  a 

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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-threatening opportunistic infections. Infection with HIV 
occurs by the transfer of blood, semen, vaginal fluid, pre-ejaculate, or breast milk. Within these bodily 
fluids,  HIV  is  present  as  both  free  virus  particles  and  virus  within  infected  immune  cells.  The  four 
major routes of transmission are unsafe sex, contaminated 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 determined from reported cases because many infections 
are undiagnosed or unreported. The best estimates are mainly based on the results of surveys of large 
groups of people. In case of generalized epidemic the 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 the population during a certain time period. 
People who were infected before that time period are 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 associated 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 new 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 have 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 minimum estimates may be derived from case reports. 
UNAIDS  and  WHO  favour  a  terminology  move  away  from  PLWHA  (people  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 dimensions: personal information and counselling, 
targeted  information  for  vulnerable  groups,  the  availability  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  behaviours  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,  Luxembourg,  Malta,  Monaco,  Netherlands,  Norway,  Portugal, 
San Marino, Spain, Sweden, Switzerland, United Kingdom 
Willingness to pay (WTP) method – also called the contingent valuation 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. 

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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 

Figure 4 

Rates of newly diagnosed cases of HIV per million inhabitants 

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 

Box 2 

Box 3 

Box 4 

Box 5 

Examples of HIV/AIDS interventions at national level 

Dublin Declaration on Partnership to fight HIV/AIDS in Europe and Central Asia 

Vilnius  Declaration  on  Measures  to  Strengthen  Responses  to  HIV/AIDS  in  the 
European Union and in Neighbouring Countries 

Bremen Declaration on Responsibility and Partnership – Together Against HIV/AIDS 

Example of Action Plan 2006-2009's unachieved action 

Figure 6 

Estimated  coverage  of  antiretroviral  treatment  in  selected  MSs  and  neighbouring 
countries. 

Box 6 

Box 7 

Table 1 

Box 7 

Table 2 

Table 3 

Example  of  HIV/AIDS  problematic  in  one  of  the  Eastern  neighbouring  countries  – 
Ukraine 

Action Plan 2006-2009 – areas with open actions 

Comparison  of  priorities  and  objectives  between  Action  Plan  2006-2009  and  a  new 
Action Plan (Option 3) 

Possible actions under Option 3 

Comparison of options  

Impacts summary  

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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 announced 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  the  current  trends  in  infections  and  HIV  prevalence 
rates for both EU and its neighbouring countries, in particular focused on Eastern Europe. Considering that 
HIV/AIDS  as  disease  is  more  than  a  "medical  problem",  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 for health services provision. It outlines a rationale for 
future  EU  action  and  proposes  a  number  of  options  and  related  policy  actions  which  are  then  appraised. 
Option 1 consists of a prolongation of the current Action 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  the  final  form  of  any  decision  to  be  taken  by  the 
Commission. 

Principle responsibility for action to address HIV/AIDS remains 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 stakeholders and to mobilise EU policies towards HIV/AIDS 
prevention,  treatment  and  care  as  well  as  research  and  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 preventive 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 between 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 drawn for future EU actions for policy and funding 
priorities. It has been better explained, in Option 1, why and which actions and political commitments 
within the current action plan have not been implemented yet. 

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(2)  Options have been clarified and reorganised, in order to take into consideration the suggestion of 
the IAB to develop a new policy option – that is the continuation of the current action plan followed 
by its evaluation. Option 3 now provides for a comparison of priorities and objectives between Action 
Plan 2006-2009 and a new strategy (Option 3). 

(3)  Operational  objectives  in  terms  of  specific  deliverables,  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,  international  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  comments  on  the  project.  The  commentaries,  received 
from  civil  society  organisations  (CSF,  Aids  Action  Europe,  European  AIDS  Treatment  Group), 
economic  operators  and  federations  (Gilead,  EFPIA),  Member  States  (SL,  PT,  DE,  ES)  and 
international  organisations  (UNAIDS,  IOM)  concerned  mainly  the  need  for  continuity  of  European 
initiatives  and  undertaking  actions  on  targeted  prevention,  priority  regions  and  most  at  risk 
populations. The responses were considered while drafting this IA as they 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 consultation with delegations in all neighbourhood countries to collect 
first hand information on the contribution, involvement, and usefulness of a Commission policy for the 
delegations' HIV/AIDS related activities in the partner 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  consultations  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. 

2.1. 

BACKGROUND 

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  epidemic,  the  surveillance  is  done  in  relation  to 
western, central and eastern parts of the WHO European Region.  The presentation of the following 
data is done within this framework 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 advisory 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 consultation forum, which brings together 
umbrella  organisations  representing  stakeholders  in  the  health  sector  to  ensure  that  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. 

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2.1.1.  A chronic disease without a cure  

The human immunodeficiency virus (HIV) was discovered 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 people 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 when 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 prevalence11, 2007 

Estimated number of PLWHA and adult HIV prevalence, 2007

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a
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%

2

1,6

1,2

0,8

0,4

0

Finland 
Estonia 

Ireland 
France 
Hungary 
Germany 
Greece

Belgium 
Austria
Denmark
Czech Republic

Spain 
Lithuania 
Slovenia 
Luxembourg 
Sweden 
Italy
Netherlands 
Malta
Latvia
Slovakia
Russian Federation 
Poland
Portugal
Romania

UK 

Algeria
Azerbaijan
Armenia
Belarus

Egypt
Georgia

Jordan
Israel
Lebanon

Moldova
Morocco
Ukraine
Tunisia

1000

800

600

400

200

0

)
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a
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t
(

A
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Source: UNAIDS, WHO 

% HIV prevalence, adult (15-49)

Number of PLWHA

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/KnowledgeCentre/HIVData/GlobalReport/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) 

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Figure  1  and  Figure  2  show  there  are  huge  disparities  of  HIV  prevalence  rates  among  EU  MSs  and 
their  neighbouring  countries.  Estimated  HIV  prevalence  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 diagnoses 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 

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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  comparable  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 diagnoses 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 these 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 developments coming from Eastern Europe are much higher 
than  those  reported  in  the  Mediterranean  non-EU  countries.  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 increasing sexual transmission in many countries.14 

2.1.3.  Mode of transmission  

HIV can be transmitted in three main routes: (1) sexual transmission, (2) transmission through blood 
and (3) mother-to-child transmission. Wherever there 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 was 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  states  -  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/Health_topics/Tuberculosis/facts.aspx  
13 UNAIDS global AIDS epidemiology report 2008, Annex 
14 For more comprehensive data see HIV/AIDS Surveillance in Europe, ECDC/WHO, 2007. 

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young people in Eastern Europe who get infected through 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 from 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 the causes and determinants of the infectious disease 
transmission  and  progression.  Although,  the  root  causes  of  a  steady  high  number  of  new  HIV 
infections are heterogeneous and can also differ across geographical 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 

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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 population groups and subgroups. All categories may affect 
the health outcome in the direct and indirect way.  

Social networks generating the quality, density and structure 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  include  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, exposure to poor socioeconomic conditions). Cultural context can be 
defined  as  a  complex  aggregation  of  knowledge,  beliefs,  art,  law,  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,  demographic  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 empowerment to enact HIV prevention. Given that stigma 
and  discrimination  play  a  crucial  role  in  shaping  responses  to  HIV/AIDS  epidemics,  relevant 
interventions to overcome these problems shall result 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 direct 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 

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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  subpopulations  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  trends  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 emergence and control of HIV/AIDS epidemic. 

This implies that a successful HIV/AIDS policy needs to be based on health-sector interventions for 
HIV/AIDS  prevention,  treatment  and  care  including  interventions  based  in  individual  and 
communities and health facilities, delivered through outreach to most at risk populations as well as EU 
wide measures for supporting service delivery.  

All 27 EU Member States have already endorsed national 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  and  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  increasing  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  groups  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 programme 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 significant and is further compounded by the potential 
social stigmatisation and discrimination which can affect many areas of life – family, work, education, 
travel, housing, insurance, finances, etc. PLWHA and 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 HIV/AIDS infection reduces the stock of skills and 
experience of the labour force. In other words significant 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 

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Thus,  social  limitations  are  strongly  interrelated  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 effect of the epidemic on populations and support 
policy-makers  in  allocating  public  and  private  health  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-infected 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  remain  an  important  barrier  to  treatment.  As  it 
places a severe strain on health care budgets across Europe, levels of availability of treatment and care 
differs  significantly  by  country  and  the  geographical  area  (review  sentence:  strange  causal  link). 
Estimated ARV costs in the EU are on average between 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 ratio than Russia or Ukraine) 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  therefore  important,  but  it  has  to  include  sufficient 
funding for prevention measures of new HIV infections. 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 markets, represent productivity losses, measured with a 
use of two commonly known methods: human capital (basal 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 limitations 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  countries23.  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 terms of social welfare costs, given the diversity of the prevalence and 
incidence rates among countries, the highest losses would 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 already quite a high degree of HIV/AIDS infection are 
particularly  threatened  by  the  further  epidemics  expansion  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  industrial  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/AIDS in Eastern Europe: An Empirical Assessment Using the 
Economic Value-of-Life;  
http://siteresources.worldbank.org/INTUKRAINE/Resources/328335-1147812406770/ukr_aids_eng.pdf  

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much as possible into social and labour processes. Especially 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  view  of  a  process  of  reprioritisation  of  HIV/AIDS 
programmes  and  reallocation  of  funding.  Such  balanced  approach  focused  on  HIV/AIDS  program 
efficiency and effectiveness shall contribute to maintaining 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 for 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  Action Plan  have  been  realised  in  terms  of  EU  policies 
and actions, Health Programme and 7th Framework 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 progress 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 particular 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, academic organisations, international organisations like WHO Europe 
or UNAIDS and business operators contributed to the realisation 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  the  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  measured,  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  reflected  in  identifying  HIV/AIDS  as  a  priority  and 
addressing the problematic by several EU presidencies (Germany, Portugal, France), the emergence of 
new  national  HIV/AIDS  policies  and  strategies,  or  in  taking  up  HIV/AIDS  issues  in  the  bilateral 

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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  operational  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  European  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 important 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  (successful  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 development 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, prevention 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 targeted 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  regionally  expressed  at  different  levels,  present  and  future 
efforts on a European level have to concentrate on particular regions of the EU - mostly affected by 
HIV/AIDS,  i.e.  those  in  Eastern  Europe,  including  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 effective measures towards containing the epidemics. 

More  detailed  evaluation  of  the  Action  Plan,  including  a  state  of  implementation  of  the  specific 
actions, main achievements and lessons 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  through  its  Health  Programmes  (HP)  to  support 
projects to combat HIV/AIDS in Europe. The Health Programme (HP) provided the means to realise 
projects touching on commitments specified in the current action plan and from 2003 to 2008 funded 

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28 projects focusing on prevention of new HIV infections 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 Framework 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  European  HIV/AIDS  research  field  with  a 
multifaceted approach, supporting basic as well as translational research for a broad range of vaccine 
and  drug  candidates.  In  addition,  it  has  been  financing  research  on  microbicides,  continuing  the 
support of cohort studies which provide follow-up and 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  European  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  infections  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,  microbicides,  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  collaborations  offering  more  robust  prevention  and 
treatment guidelines and a better public health impact.  

Furthermore,  in  order  to  promote  coordination  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 treatment 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 Fundamental 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  Directive  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,  age  or  sexual  orientation  as  regards  employment  and 
occupation. It is based on Article 13 of the EC Treaty, which grants the European Union powers to 
take appropriate action to combat discrimination based on those four grounds, 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 - (Directive 2000/87/EC Equal treatment in employment and occupation) 

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This Directive does not provide for a definition of disability. The ECJ held that as regards employment 
and occupation, the concept of ‘disability’ mentioned 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  professional  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  works  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 value 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  countries25  where  the  HIV/AIDS 
problematic  is  severe  (e.g.  Ukraine,  Republic  of  Moldova).  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  Solidarity  in  Hospitals  against 
AIDS' that represent innovative approaches seeking to involve a large number of research and health 
institutions and civil society organisations in Member States and partner countries in capacity building 
through twinning programmes and networking. 

The EDCTP was established in June 2003 to tackle the challenge of an increased prevalence of HIV 
and  other  poverty-related  diseases  infections  resulting  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) build 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. 

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network,  although  its  prime  focus  is  sub-Saharan  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 developing 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 activities (i.e. prevention of MTCT, paediatric care, 
equipment,  psychosocial  activities,  operational  research,  monitoring  and  evaluation,  technical 
assistance at country level, strong involvement in University 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 following issues can be identified: 

3.1. 

Political commitments have not been achieved 

While many political commitments agreed by Member 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  yet  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  involvement  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  action  to  tackle  HIV/AIDS  through  a  deepening  of 
coordination, cooperation and partnership 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.gouv.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/download_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,  and  to  ensure  rapid  action  and  results-based  management:  One 
agreed HIV/AIDS Action Framework that provides the basis for coordinating the work of all partners. One National AIDS 
Coordinating  Authority,  with  a  broad-based  multisectoral  mandate.  One  agreed  country-level  Monitoring  and  Evaluation 
System. 

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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 required 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  equitable  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 improving 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: 

(cid:131)  more  research  and  development  activities,  including  raising  funding,  investing  in  new  preventive 

technologies, promoting the participation of new MSs and neighbouring countries; 

(cid:131)  better surveillance systems, in view of behavioural and social data access; 
(cid:131)  facilitating cooperation and networking on HIV/AIDS; 
(cid:131)  supporting the development of health care infrastructures for HIV/AIDS related purposes; 
(cid:131)  establishing fora and mechanisms, including the involvement of civil society and PLWHA for assessment of 

progress. 

EU MSs commitments: 

(cid:131)  promoting the fight against the epidemic recognizing the fundamental factors of equality; 

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(cid:131)  addressing the vulnerability of particular groups of people as well as the specific needs of immigrants; 
(cid:131)  working  progressively  on  the  behavioural  and  epidemiological  data  collection  in  line  with  adequate  and 

comprehensive national surveillance, monitoring and evaluation systems; 

(cid:131)  providing  universal,  affordable,  non-judgmental  and  non-discriminating  access  to  prevention,  care  and 

treatment (i.e. voluntary and confidential counselling and testing, ART and harm reduction measures); 

(cid:131)  developing new preventive technologies and reinforcing targeted education efforts; 
(cid:131)  developing  and  implementing  relevant  regulatory  frameworks  with  regard  to  non-discrimination,  social 

inclusion, protection of human rights. 

Box 4: Bremen Declaration on Responsibility and 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: 

(cid:131)  implementing the action plan, highlighting HIV/AIDS prevention, treatment , care and support 
(cid:131)  ensuring the FP7 provides sufficient funding for HIV/AIDS projects and programmes 
(cid:131)  promoting exchange of best prevention practices by setting up a clearing house for models of good practice; 
(cid:131)  involving civil society in twinning projects 
(cid:131)  initiating the extension of the Council regulation 953/2003 to countries in need of price reduced drugs for 
PLWHA 

EU MSs commitments: 

(cid:131)  fully  implementing  the UNGASS  Declaration    of  Commitment  on  HIV/AIDS  'Global  crisis  –  global  action' 
(2001) and 'Political Declaration on HIV/AIDS (2006); 
(cid:131)  involvement  in  facilitating  inclusive  country-driven  processes  of  scaling  up  HIV  prevention,  treatment,  care 
and support (in line with UNGAR, 2005); 
(cid:131)  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; 
(cid:131)  respecting human rights, especially addressing stigma and discrimination; 
(cid:131)  promoting universal access to evidence-based prevention; 
(cid:131)  reducing  MTCT  of  HIV  and  promoting  comprehensive  sexuality  education,  counselling  and  services  on/for 
HIV/AIDS; 
(cid:131)  involving civil society and other international and national partners; 
(cid:131)  increasing research and development activities for new preventive technologies 
(cid:131)  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, there has not always been 
adequate  monitoring  of  their  implementation.  The  report  on  "Progress  on  implementing  the  Dublin 
Declaration on Partnership to Fight HIV/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 monitoring 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/show/799D79A1-F203-1EE9-B241692C98378A9F  

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Analysing  Action  21  (universal  access  to  effective,  affordable  and  equitable  prevention,  treatment  and  care, 
including ARV) it has to be admitted that not everybody has access to effective prevention 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 monitoring and reporting system  

Much  progress  has  been  made  since  the  ECDC  started  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 consistently reported data to EuroHIV/ now ECDC and will 
until  remedied  undermine,  EU  level  surveillance.  Given  the  differences  in  national  surveillance  and 
reporting  systems,  the  quality  and  coverage  of  'data  source'  are  not  always  consistent,  and  therefore 
interpretation  and  cross-country  comparisons  still  have  to  be  made  with  caution  as  the  amount  of 
under-diagnosis  and  under-reporting  differs  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  strengthened  with  respect  to  completeness,  comparability  and 
compatibility, and quality of data. The ECDC also experiences problems with data availability on the 
nature  of  the  epidemic,  migration  in  terms  of  access  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, but which is expected to raise in importance along 
with  increased  mobility  of  people.  Overcoming  these  data  gaps  would  enable  policy-makers  to 
develop a comprehensive  understanding of the drivers of the  epidemic  and therefore to develop and 
implement fully adequate policy responses. 

3.3. 

Imperfect  prevention  and  treatment  activities  and  potentially  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  status.  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 concluded 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 internationally 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  adapted  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  has  been  compulsory  in  Italy,  thus  their  national  data  are 
expected to be included in the next year's data collection. 
33  Prevention  encompasses  different  methods  and  dimensions:  personal  information  and  counselling,  targeted  information 
for vulnerable groups, the availability 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 behaviours e.g. availability 
of information, condoms and sterile syringes. 
34 Marks et al., AIDS, 2006. 

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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  annual  diagnoses  more  than  doubled  in  several  countries,  including 
Finland, Germany and Norway. 

IDUs represent the most serious risk population for HIV/AIDS in Eastern Europe with the highest rate 
of new HIV cases. In countries like EE, LV or Ukraine, 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 undocumented, also represent an increasingly important share of 
people potentially infected by heterosexual transmission, which often occurred already in their country 
of  origin.  Often  faced  with  severe  economic,  social  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 medical 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  UNAIDS36,  many  countries  in  Europe  have  already  adopted  different  policies  or 
strategies  to  promote  HIV  prevention. However,  translating  these  strategies  into  a  prioritised  set  of 
interventions  based  on  evidence  of  impact  has  proved  difficult  and  certain  difficulties  have  been 
encountered to bring to scale prevention services for 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  targeted  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 exception 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 treatment in selected MSs and neighbouring countries. 

Estimated ART coverage (% ), 2007

120
100
80
60
40
20
0

Belgium 

Bulgaria 

Estonia 

Finland 

Source: UNAIDS 

France 

Germany 

Hungary 

Ireland 

Lithuania 

Luxembourg 

Netherlands 

Romania 

Slovenia 

Spain 

Sweden 

UK 

Ukraine 

Moldova 
Russian Federation 

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 HIV cases reported among men who have sex with men in Europe, 
2000–6: implications for a European public health strategy. Sexually Transmitted Infections 84: 499-505, 2008. 
36 UNGASS Country Progress Reports, 2008 
37  Costs  for  antiretroviral  HIV  treatment  and  treatment  of  AIDS  related  symptoms  can  be  significant,  knowing  that  ARV 
costs only amount to a fraction of total treatment and follow-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,  

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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  places  a  severe  strain  on  health  care  budgets  across 
Europe,  it  will  be  indispensable  for  MSs  to  reflect  on  how  to  ensure  the  sustainability  of healthcare 
budgets as stated in the Lisbon reform agenda. The challenge is even bigger in the wake of the current 
financial and economic crisis that has hit public finances 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 resources, 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 actions, 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 already been carried out, at both national and EU 
level,  in  a  wide  range  of  fields.  However,  these  research  activities  have  so  far  not  closed  the 
knowledge gaps in certain fields, such as:  

(i)  Social  science  with  particular  regard  to  the  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 implications of the new trends,  

(iii) The development and implementation 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, continued 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  Eastern  neighbouring  countries  is  particularly  worrying. 
Today,  Eastern  Europe  (Baltic  Member  States,  Ukraine,  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 epidemic 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 mobility in Europe: a phylogeographic approach. Retrovirology, 2009. 

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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 coverage 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 large challenges in the response to HIV/AIDS 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  for  HIV/AIDS  in  recent  years,  the  overall  needs  to  scale-up  prevention, 
treatment, care and support programmes still exceeds available resources.  

In  2007,  of  about  5200  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 injection 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 governments 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, the 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 through 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 the 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 observed  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 would 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 taken by the European Union and its Member States 

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and  specifically  by  the  Commission,  as  e.g.  expressed  in  the  Dublin,  Vilnius  (2004)  and  Bremen 
ministerial  declarations  (2007).  The  Health  Council  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  field.  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  immediate  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  available.  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  countries  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 acknowledges 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  illness  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 activities. In this respect, Community activities in other 
fields  like  research,  education  and  youth,  external  relations,  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  only  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  relevant  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  border  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 third countries currently live in the EU. Although there 
is an enormous diversity in the proportion of migrants 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  social  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. 

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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  research  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 Union to include the neighbouring countries in the response 
to HIV because there are frequent movements of persons 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 and a great deal of tourism including sex tourism46 as a 
recent  study  on  the  phylogeny  of  different  HIV  subtypes  suggests.  Cooperation  at  European  level 
could  contribute  to  supplement  multilateral  and  bilateral  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  particular  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 political 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. Countries 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 relatively new phenomenon in the new States and has hit 
some  of  them  like  Estonia  quite  strongly.  An  exchange  of  best  practice  can  accelerate  effective 
measures in response to the epidemic. 

In  the  past,  work  under  the  current  action  plan  has  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  medication  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 pharmaceutical companies shows this. It also underlines the 
need of EU level involvement and 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 mobility in Europe: a phylogeographic approach. Retrovirology, 2009. 

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The EU  can  finally also complement  action at the global level,  with the WHO developing technical 
standards and clinical guidance and the EU focussing 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  organisations,  or  civil  society  organisations,  engaged  in 
fighting  HIV/AIDS,  had  been  assigned  to  tasks  and  deliverables.  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 results 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-national,  national  or  regional  settings  helps  to  lower  the  impact  of 
HIV/AIDS in a particular setting. 

Through  bringing  together  Member  States  and  neighbouring  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  important  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,  including  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. Concrete polices and related health measures remain a matter of national 
competence. 

5. 

5.1. 

POLICY OBJECTIVES 

General objective 

The general  objective is to contribute to the prevention 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 objective 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 stipulated 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 

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–  adapt  national  HIV/AIDS  strategies  and  activities  to  non-resolved  and/or  newly 
emerging  challenges  (under-diagnosis,  new  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 previous section, three different options have been 
envisaged.  Option  1  calls  for  a  continuation  of  implementation  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  existing  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  options  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  implementation  of  current  action  plan,  and 
evaluation 

The  initial  "baseline  option"  would  consist  of  extending  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  political  agendas  at  an 
European level, along the lines already 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 activities which have proven to be successful. 

While  this  option  would  consist  in  rolling  over  the  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  university  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 strengthening are human rights issues, surveillance, and actions 
targeted at specific vulnerable groups. Providing political leadership and advocacy is the 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  common  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/European level can add value to the work done elsewhere." 

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prevention into the curricula) could still be wider addressed. But this needs an active role of competent entities, 
e.g. international organisations, medical associations and MS authorities responsible for university and education 
curricula.  

Health  infrastructure  is  a  MS  jurisdiction  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 transmitted 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-specific  policy  initiative  (action  plan  plus 
communication). 

technical 

This option would not exclude a further cooperation and intervention of the EU in the field through 
financial  and 
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 support through specialised agencies such as ECDC, or 
EMCDDA.  

support.  The  Commission  would 

focus  on  existing 

However,  without  an  updated  EU  guidance  document  for  activities  on  HIV/AIDS,  HIV-related 
spending  could  be  re-attributed  to  other  policy  areas.  Indeed,  in  the  case  of  the  Health  Programme 
2008-2013, priorities are defined on an annual basis and the budget is allocated on a competitive basis 
(i.e.  no  budget  has  been  earmarked  for  HIV/AIDS  specifically).  Similarly,  spending  within  the 
framework of the 7th 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  independently,  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 provide 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  lead  parties,  this  plan  would  identify  particular 
indicators  to  measure  and  describe  the  degree  and  the  quality  of  realisation.  These  indicators  would 

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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 progress. This would allow for a more comprehensive evaluation of 
the new action plan.  

More importantly, items of the new action plan will correspond to the upcoming priorities for the next 
years,  including  for  research  and  EU  Health  Programme  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  the  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  for  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 new 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.  

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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 

(A) 
Politics/Awareness 

↑ Cross-border cooperation 
(Western-Eastern Europe) 

      /Civil Society 

      /Civil Society 

↓ Political leadership and 
stakeholders involvement 

=> 

(B) Surveillance, 
research and 
medicine 

(B) Surveillance 

(C) Prevention 

Prevention, 
(C) 
treatment,  care  and 
support 

↓ Overall budget reduction  

↑ Data collection and 
reporting 

↑Cross-border cooperation 

(cid:74) Overall budget kept on 
same level as in previous 
action plan  

↑ Prevention, treatment and 
care targeted at most at risk 
groups  

↑Promotion of VCT in 
vulnerable groups 

↑ Overall increased action 
and budget  

↑ New preventive methods 

strengthen the focus on: 

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  

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 

- 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 

More focus on: 

- more investments and 
strength to overcome research 
and knowledge gaps 
(behavioural science, new 
prevention methods, drug 
resistance, co-infections) 

(D)  Research  and 
medicine  (to  become 
a  separate  strand  in 
any 
EU 
future 
action)  

↑ Funding for research and 
knowledge 

↑Overall budget increase 

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- more Public-Private 
Partnerships for innovations 
on medicines and vaccines 
development 

Weight given as compared to the previous action plan (↑ more; ↓ less; (cid:74) 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 information 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 decision-makers to improve infrastructures to provide state-of-the-art HIV 
services and the social and legal environment to encourage 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 problem with a considerable political dimension, 
but the Treaty does not give room for a legislative intervention in form of a HIV-specific directive or a 
regulation.  Member  States  and  neighbouring  countries  design  their  national  plans  and  programmes, 
but  comprehensive  national  approaches  benefit  greatly  by  access  and  exchange  of  good  practices, 
experiences and evidence based solutions. 

Campaign: A European campaign on HIV could not be targeted 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  many  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 

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quantify the potential social and economic impacts of the options outlined above. Their non-binding 
nature hinders even more the ability to put a figure 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  future  HIV/AIDS  trends  and  finally  anecdotal 
evidence  from  policy  interventions  at  national  level.  All  budgetary  costs  are  estimates  based  on  the 
expenditures under the action plan 2006-2009.  

This IA assumes that any reprioritisation of actions will 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 basis49. 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 and 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.  Already,  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 complete 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 received, would most probably amount for similar levels 
of  spending  as  over  the  previous  period  (2006-2009)  which  is,  as  far  as  the  Health  Programme  is 
concerned, in the range of about 5 million euro per 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 political, have had an impact on the epidemic. 

This  option, by  maintaining  the  emphasis  on  HIV/AIDS  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 action plan offers an array of reasonable and useful 
measures to be considered in order to improve national or regional policies and measures to respond to 
HIV/AIDS in a particular  setting. It fosters cooperation and efficiency. Many examples demonstrate 
that, investments in effective measures against HIV/AIDS and for the benefit of people affected by the 
disease and its associated problems pay back in the future - 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. 

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Germany,  e.g.,  estimates  that  its  prevention  means  and  campaigns  (average  investments  at  federal 
level between 11 and 13 million euro in the last years) resulted in annual savings of 450 million euro 
for  therapy  costs  through  30.000  avoided  HIV  infections.  Costs  may  increase  for  national  health 
systems in the short term when more people are tested 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 respectively delay the progression of the disease, and keep 
infected  people  in  the  labour  market.  This  example  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  access  to  ART  would  have  an  economic  impact  on 
national  health-care  systems  and  budgets.  Prospective  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 inefficiencies 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  report50,  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 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 

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 prevention, 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  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 to a 
certain  degree  satisfied),  without  the  development  of  a  specific  monitoring  framework  of  these 
political agreements, progress could be hindered towards the achievements 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 genotypes) across Europe, cross –border dimension of HIV 
infections) would not be bridged. Therefore, policy-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. 

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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.  Furthermore,  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'  selection,  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 discontinuation 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 vaccination 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 addition, in time of the economic crisis and potential 
reduction of the resources available for addressing HIV/AIDS, the lack of political commitment at EU 
level  would  not  necessarily  be  compensated  by  bilateral  or  multilateral  cooperation  without  EU 
funding.  

The  key  drawback  of  such  an  option  is  the  political  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,  investments  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)  are  expected  to  have  an  adverse 
impact  on  ART,  in  the  medium  and  long  term,  through  either  increasing  the  cost  of  ARV  drugs  or 
decreasing the sufficient public ART cost coverage. In addition, HIV/AIDS prevention programmes 
are particularly vulnerable to the effects of potential 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  treatment  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 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 

This  option  could  result  in  changes  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. However, 
this  option  bears  the  risk  that  without  a  strong  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  universal  access  to  prevention,  treatment  and  care, 

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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  operational  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  –  through  regular  and  funded  participation  in  civil 
society meetings would risk being lost.  

This option may not be effective enough to sustain 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 particular, this option would 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 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. 

As in the case of Option 1, 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 genotypes) across Europe, cross –
border dimension of HIV infections) would not be bridged. Therefore, policy-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. 

7.3. 

Option  3:  Current  plus  –  a  new  EU  policy  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,  research  framework  programme,  other  EU  funding 
instruments, through national co-financing or complete 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 received, would most probably amount for similar levels 
of spending as over the previous period (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  towards  more  efficient  interventions.  Through  the 
evaluation  of  the  activities  implementing  the  new  action  plan,  this  option  would  be  instrumental  in 
assessing how far EU and national investments, both financial and political, have had an impact on the 
epidemic.  

This  option, by  maintaining  the  emphasis  on  HIV/AIDS  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 emphasis would be given to research activities, with a 
stronger  focus  on  overcoming  research  and  knowledge  gaps  (behavioural  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 

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present  an  obligation  for  any  involved  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  implications  of  the  economic  crisis  (e.g.  budget  cuts  or 
budgetary measures, exchange rate devaluation), having potentially negative 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 presented 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 uncertain 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 better planning based on better data – this 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 continue 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 cooperation 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 living 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  organisations  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 framework for action for the identification of projects to be funded by 
the Health Programme and Framework Research Programme. This option would 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. 

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 contributing to the implementation of the action plan is 
expected to increase. As explained above, this will be all the more important to target interventions as 

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the economic context could lead to budget constraints. This should particularly be the case regarding 
the new emphasis given to new preventive methods, prevention, treatment and care interventions more 
targeted at most-at-risk groups (MSM, IDU, immigrants from high prevalence countries) and stronger 
cooperation  with  Eastern  European  countries.  More  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 interventions 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 countries (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 society, 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  sexually transmitted  infections,  –  at  national  and  cross  border  level,  in 
Europe,  and  help  to  map  and  disseminate  best  practices  towards  planning  of  efficient  prevention, 
treatment, health and social care options. It would serve 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 

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8. 

COMPARING THE OPTIONS  

Table 2: Comparison of options  

OPTION 1 

OPTION 2 

OPTION 3 

-  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  support  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. 

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 

- 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) 

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-  Potential  additional  reporting  duties  of  MSs  for 
(e.g.  cross-border 
surveillance  and  monitoring 
movement  and  migration)  resulting  in  additional 
administrative burden  

data  and needs,  lost  political  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  lose  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. 

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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  guidance  towards  reaching  agreed
targets 

Strengthened  surveillance  and  epidemiology  to  support  policy
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  neighbouring  countries  to  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 

Encourage  MSs  and  neighbouring  countries  to  adapt  national
HIV/AIDS  strategies  and  activities  to  non-resolved  and/or
newly  emerging  challenges  (under-diagnosis,  new  prevention
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  and
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 

Research Framework Programme 

approx. 100M 
euros 

approx. 20M 
euros or less, 
reallocation of 
HIV funding to 
other policies 
covered by the 
HP   

approx. 100M 
euros or less 
reallocation of 
HIV funding to 
other policies 
covered by the 
HP   

ECDC (surveillance and monitoring) 

approx. 4.4M
euros 

approx. 4.4M 
euros 

Budgetary impacts for MSs:  

approx. 20M euros
reallocation to 
priorities defined 
in new action plan

approx. 100M 
euros 
reallocation to 
priorities defined 
in new action plan

approx. 4.4M euros
reallocation to 
priorities defined 
in new action plan

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Costs  for  health  budgets  (prevention,  treatment…) and
research 

n/a 
stable 

n/a 
risk of budget 
cuts, due to 
economic crisis 

Costs of reporting (surveillance) 

no additional 
administrative
burden for 
EU MSs  

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 action to combat HIV/AIDS 
in Europe. The HIV/AIDS Think Tank and the Civil 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 assessment would be translated into actions and linked 
to  lead  organisations,  indicators  and  target  deadlines  (as  presented  above).  Achievements  will  be 
traced regularly and a monitoring report, based on data compiled by ECDC, could be published by the 
Commission in 2012 and 2014, respectively. 

A  regular  monitoring  contributes  to  a  timely  dissemination  of  results  and  achievements  among  all 
stakeholders  engaged  in  combating  HIV/AIDS  in  Europe.  Good  practices,  opportunities  for 
coordination and cooperation 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 populations 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 society on a national and regional level 
- the progress made towards a harmonised and meaningful epidemiology and surveillance, in support 
of policy and decision making. 
- the progress made towards research in identified fields where knowledge gaps persist. 
-  national  spending  allocated  to  HIV/AIDS  interventions  (in  particular  with  regard  to  the  negative 
implications of the economic crisis). 

Suitable  indicators  will  be  selected  by  the  Think  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. 

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LIST OF ANNEXES 

1. Assessment of responses on RELEX questionnaire received 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. 

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