Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) case reporting in the World Health Organization European Region in 2006.

This article presents information on HIV and AIDS case reporting systems as part of a survey on HIV/AIDS surveillance practices in the World Health Organization (WHO) European Region. A standardised questionnaire was sent to the 53 national correspondents of the European Centre for the Epidemiological Monitoring of AIDS(EuroHIV). The HIV and AIDS case reporting section of the questionnaire comprised four parts: data collection system, HIV/AIDS case definition for surveillance, variables collected, and evaluation of surveillance systems). Individual-based data collection systems for HIV case reports have been implemented in 43 of 44 countries in the WHO European Region and for AIDS case reports in all the countries. For HIV case reports, a coded identifier is used in 28 countries, and full names are used in 11 countries. The European AIDS case definition has been adopted in 35 countries(80%). Information on molecular epidemiology is available in 30 countries, and HIV drug resistance is monitored in 11 countries.HIV/AIDS case reporting systems have been evaluated for underreporting in 17 countries and for completeness in 11 countries.This article outlines the future needs for HIV/AIDS surveillance and presents recommendations on how to improve data comparability across European countries in the WHO region.

Diagnosed and undiagnosed HIV-infected populations in Europe.

This article aims to build a picture of HIV epidemiology in Europe by combining existing surveillance data to mathematical modelling to achieve observations closer to the dynamic reality of HIV infections across different parts of Europe. In the European Union (EU), where it is estimated that 30% of HIV-infected persons have not been diagnosed, the number of new HIV diagnoses has risen in recent years. However, trends must be interpreted with some caution around the differences and variations in surveillance systems and testing rates among affected populations and regions. By introducing mathematical models, we can build an overall picture from the pieces of information available. We present a mathematical model of the course of infection and the effect of ART which has been developed to fit as closely as possible to observed data from HIV cohorts. The preliminary estimates for the entire WHO European Region are that around 2.3 million people were living with HIV in Europe at the end of 2006, of whom around 50% have not been diagnosed. The model can also be used to assess the potential impact of earlier diagnoses. Observations show how a combination of surveillance data and modelling allows an estimation of the current state of the epidemic in Europe, though further developments in both areas are needed.

Male circumcision in Slovenia: results from a national probability sample survey.

OBJECTIVES: To estimate the prevalence of male circumcision and to explore its association with demographic characteristics and self-reported sexually transmitted infection (STI) diagnosis in Slovenia. METHODS: Data were collected over 1999-2001 from a national probability sample of the general population aged 18-49 years at respondents' homes by a combination of face-to-face interviews and anonymous self-administration of questionnaires. Statistical methods for complex survey data were used to account for stratification, clustered sampling and weighting. RESULTS: Overall, 4.5% (95% CI 3.2 to 6.5) of Slovenian male citizens reported being circumcised. Major variations in the prevalence of circumcision were observed across religious groups, with 92.4% (95% CI 59.8 to 99.0) of Muslims being circumcised, 1.7% (95% CI 0.9 to 3.1) of Roman Catholics, 0% of other religious affiliations (Evangelic, Serbian Orthodox, other), and 7.1% (95% CI 4.4 to 11.2) of those with no religious affiliation (p<0.001). The prevalence of circumcision did not vary across age groups. There were no significant differences in the proportion of circumcised and uncircumcised Slovenian men reporting ever being diagnosed with bacterial STI or viral STI. CONCLUSIONS: The prevalence of circumcision among Slovenian men is low. No evidence was found for an association between STI diagnosis and circumcision status, which may be due to the low prevalence of both STI and circumcision in this population as well as a small sample size. In Slovenia, where HIV prevalence is <1/1000 citizens and HIV infection is concentrated in men who have sex with men, promoting male circumcision in the general population may not be effective for HIV prevention purposes.

The HIV infection in Europe: large East-West disparity.

In 2001, western Europe faces an endemic situation for AIDS (22.8 cases per million population) and for HIV infection (54.9 cases per million), the most affected groups remaining injecting drug users and the homo/bisexual men. However, numbers of new HIV diagnoses are increasing among persons infected through heterosexual contact. Central Europe have been relatively spared, with AIDS incidence under 6 cases per million per year, and new HIV diagnoses between 7 and 10 cases per million. On the other hand, eastern Europe shows an epidemic increase in the number of newly diagnosed HIV infections (233 cases in 1994, around 100,000 reported cases in 2001, ie 349 cases per million population) affecting all countries.

Europe-wide surveillance for sexually transmitted infections: a timely and appropriate intervention.

Sexually transmitted infections (STIs), including HIV, pose a significant threat to the health and wellbeing of Europeans and require concerted and sustained intervention. Over the past decade, the number of reported cases of STIs, including antimicrobial resistant Neisseria gonorrhoeae, has increased appreciably, and outbreaks of syphilis have recently been reported in many Member states of the European Union (EU). Young people, homosexual men, and those with poor access to health care (including preventive and educational services) seem to be particularly affected, with increased travel and migration, high risk sexual behaviours, and a deterioration of public health responses to STI control (for example, partner notification) being key driving factors. Many of these demographic and behavioural trends are similar across EU states, as is the desire to develop and implement effective STI prevention and control programmes.

Surveillance of HIV/AIDS in Europe: update at end 2000.

In the Western area of Europe, AIDS incidence decreased by 12% in 2000 compared to 1999 (22 cases per million population). In the Eastern area, the incidence of notified cases remained low, but newly diagnosed cases are still rising. In the Centre, the rates of AIDS cases and HIV infections remain low. EuroHIV (European Centre for the Epidemiological of AIDS) coordinates the surveillance of AIDS in the WHO European Region since 1984 and of newly diagnosed HIV infection since 1999. The main findings of the latest update at end 2000 are presented here. To take into account the diversity of the epidemiological situation in the region, countries have been grouped into three geographic areas: the West (the 15 countries of the European Union plus Norway, Switzerland, Iceland, Israel, Malta) the East (the 15 Newly Independent States of the former Soviet Union) and the Centre (the remaining countries of the region).

Back-calculation by birth cohort, incorporating age- specific disease progression, pre-AIDS mortality and change in European AIDS case definition. European Union Concerted Action on Multinational AIDS Scenarios.

OBJECTIVES: To adapt and improve methodology for back-calculation of AIDS in Europe and to examine the feasibility of estimating past HIV incidence by birth cohort. METHODS: Empirical Bayesian back-calculation (EBBC) used Markov disease progression models, modified to allow for three diseases added to the AIDS case definition in 1993 and for pre-AIDS mortality, and estimation by penalized maximum likelihood with a neighbour prior. EBBC by 5-year birth cohort assumed a minimum age at infection and age-dependent progression rates; three versions, with varying age effects, were investigated using AIDS cases diagnosed prior to the introduction of highly active antiretroviral therapies (HAART). RESULTS: Compared with the no age-effect version, EBBC by birth cohort tended to produce flattened HIV incidence curves in country-exposure groups with < 1000 AIDS cases, reflecting effects of the neighbour prior when data become sparse. Otherwise, birth cohort analysis, with moderate effects of age on progression, gave initially increasing incidence curves and consistent patterns across countries, with the 1960-1964 cohort most affected. In the European Union, incidence is estimated to have peaked in 1983 among homosexual men and in 1988 among injecting drug users; 460000 persons were estimated to be living with HIV/AIDS at the end of 1995. CONCLUSIONS: Our improved methodology deals effectively with the change in AIDS case definition and has allowed quantitative assessments of the HIV epidemic by birth cohort using all AIDS cases diagnosed before 1996, thus providing a sound basis for public health policy at a time when estimation of more recent prevalence is compromised by the effects of HAART.

Cervical squamous intraepithelial lesions in HIV-infected women: prevalence, incidence and regression. European Study Group on Natural History of HIV Infection in Women.

OBJECTIVES: To assess the impact of HIV-related immunodeficiency and antiretroviral treatment on the occurrence and evolution of abnormal Papanicolaou tests. STUDY DESIGN: Cohort of 485 HIV-infected women with a known date of infection, enrolled during May 1993-April 1998 in 23 centres (gynaecology, infectious disease or STD clinics, or drug treatment centres) in 12 European countries; in 21 centres, follow-up was performed every 6 months (median follow-up: 2 years). METHODS: Human papillomavirus (HPV) was detected at inclusion by Southern blot and PCR. The prevalence of squamous intraepithelial lesions (SIL), the incidence of SIL and regression from low-grade SIL were studied according to CD4 count after controlling for HPV detection results. RESULTS: Compared with women with CD4 cell counts > 500 x 10(6)/l, women with CD4 cell counts < 200 x 10(6)/l had a twofold increase in both prevalence and incidence of SIL and in non-regression from untreated low-grade SIL; in addition, these women had a lower response rate to treatment of high-grade cervical intraepithelial neoplasia. The increase in SIL incidence associated with a low CD4 cell count was significant in women not receiving antiretroviral treatment (relative risk, CD4 cell count 200-499 x 10(6)/l, 1.9; CD4 cell count < 200 x 10(6)/l, 2.9; CD4 cell count > 500 x 10(6)/l, reference), whereas it was less marked and not statistically significant in treated women. CONCLUSIONS: Severe HIV-related immunodeficiency strongly increases the risk of occurrence of SIL; antiretroviral treatment may reduce this risk, probably by restoring or at least preserving immune function.

HIV infection in Ukraine (1987-96).

In Ukraine, the number of reported HIV infections increased extremely rapidly during the second half of the 1990s, from less than 50 per year until 1994 to more than 12,000 in 1996. The increase was initially observed and was particularly striking in the regions along the Black Sea. The majority of reported HIV infections were diagnosed in injecting drug users. The extend of HIV spread through sexual transmission is more difficult to assess because of the strong social stigma attached to homosexuality and the lack of information on sexual behaviour in general. The reported number of syphilis cases have also dramatically increased, from 3,000 cases in 1990 to nearly 80,000 cases in 1996. In this paper, we describe the surveillance systems for, and epidemiologic data on HIV infections, AIDS, and other STD in Ukraine from 1987 to 1996. We review the contributions of different vulnerable groups and we also discuss the factors influencing the past spread and the potential for future spread of HIV infection and make recommendations for surveillance, research and prevention.

The HIV/AIDS epidemic in eastern Europe: recent patterns and trends and their implications for policy-making.

OBJECTIVE: To describe recent patterns and trends in the HIV epidemic in eastern Europe. METHODS: AIDS programme managers and epidemiologists of 23 countries were contacted and requested to provide national HIV surveillance data. Joint United Nations Programme on HIV/AIDS/World Health Organisation country fact sheets were reviewed and analysed, and this information was supplemented with published HIV prevalence and sexually transmitted disease case reporting information, unpublished travel reports and expert evaluations. RESULTS: The cumulative number of HIV cases reported in the region increased more than fivefold between 1995 and 1997, from 9111 to 46573; Ukraine, Russia and Belarus accounted for about 90% of all new cases. Dramatic increases in the number of HIV-infected injecting drug users (IDU) were reported from these countries, and a similar pattern was emerging in Moldova, the Baltic States, the Caucasus and Kazakstan. In central Europe, the increase in the number of cases was much lower, and (with the exception of Poland) homosexual transmission was most common, whereas in the Balkan countries, cases due to heterosexual transmission were reported relatively more frequently. At the end of 1997, more than 50% of all cases region-wide had been reported from IDU. HIV prevalence data were inconclusive. The number of reported syphilis cases had risen significantly in the countries of the former Soviet Union. CONCLUSION: Our data confirm that HIV must have been rapidly spreading among IDU in several countries of the former Soviet Union, whereas central and southeast Europe have so far escaped a more extensive spread of HIV. Factors that might have fuelled a massive spread among IDU include changes in drug demand and supply, migration and specific local drug production and consumption patterns. High rates of syphilis reported in the countries of the former Soviet Union highlight that subregion's increased vulnerability with regards to a further spread of the epidemic, via heterosexual intercourse, into the general population.

An age-period-cohort analysis of 50,875 AIDS cases among injecting drug users in Europe.

BACKGROUND: The long average incubation time from HIV infection to AIDS makes it difficult to estimate recent HIV transmission from AIDS incidence data. Age-period-cohort (APC) analysis can separate out the effects of age, calendar time and birth cohort to provide a clearer picture of transmission trends. METHODS: AIDS incidence data from 1981 to 1994 among intravenous drug users (IDU) for 12 Western European countries were used. Yearly incidences per 100,000 population or 100,000 person-years were calculated by age at diagnosis and 5-year birth cohort (1950-1954, 1955-1959, 1960-1964, 1965-1969 and 1970-1974), and corrected for reporting delay. Incidence patterns were compared between birth cohorts and countries. RESULTS: For most countries the impact was greatest on the cohort born 1960-1964. Comparing incidence patterns in the 1965-1969 to 1960-1964 cohorts suggest the epidemic has plateaued at low to intermediate levels in Austria, Greece and the North-Western European countries, and at high levels in France, Italy and Switzerland. For most countries transmission amongst the 1970-1974 as compared to the 1965-1969 cohorts could not be assessed due to small numbers and short follow-up time. In Spain the epidemic was uncontrolled with a high incidence among recent birth cohorts. In Portugal the epidemic was still at an early and expanding phase. CONCLUSIONS: The APC analysis revealed large country differences in the dynamics of the HIV/AIDS epidemic among IDU. Full interpretation of these differences is dependent on information from other sources about the local public health response and trends in drug injecting behaviours. Earlier introduction of the virus and higher prevalence of injecting drug use may explain some of the generally higher incidence in Southern European countries, but the larger part of it is most likely explained by local characteristics of drug users, such as younger age and more frequent sharing of needles and syringes, and a less effective public health response.

HIV prevalence in pregnant women in Europe: differences in assessment methods and prevalence levels across countries.

OBJECTIVE: To describe methods used to assess HIV prevalence and to assess prevalence levels and time trends among pregnant women in various European countries. METHODS: We used the European HIV Prevalence Database to examine annual HIV prevalence data in pregnant women for the years 1990 to 1996 (20 countries). RESULTS: In Western Europe, prevalences were generally obtained through unlinked anonymous surveys, whereas in most Central, and Eastern European countries, they were based on testing programs (voluntary or mandatory). Prevalences (per 10,000) were highest (i.e., 10-30/10,000) in large western urban areas including Amsterdam, Barcelona, London, Milan, Paris, and Rome; between 1 and 2 in Scandinavian countries; and down to 0.5/10,000 in Central and Eastern European countries (except Ukraine, 1996: 5/10,000). Prevalences decreased in Rome, whereas they increased in London, the Czech Republic, and since 1995 in Russia and Ukraine; elsewhere, no time trends were detected. CONCLUSIONS: Methodologic differences and potential biases should be considered when comparing these data. HIV prevalence in pregnant women is useful for monitoring the AIDS epidemic and for assessing and improving prevention. Efforts should be made to offer voluntary counseling and testing to women at risk for HIV and provide treatment to those who are infected.

A birth cohort analysis of AIDS in Europe: high incidence among young persons at risk.

OBJECTIVES: To study trends in AIDS incidence in Europe by age and year of birth. DESIGN: Age-period-cohort analyses were adopted to distinguish the different time factors of calendar year, age and year of birth. METHODS: Non-aggregate AIDS incidence data from 12 European countries (1978-1994) were adjusted for reporting delay and expressed per unit of population (per 100000 persons or 100000 person-years). Age-specific incidence patterns (absolute level and rate of increase) were compared between 5-year birth cohorts for homo-/bisexual men, injecting drug users (IDU) and heterosexual contact cases. RESULTS: Mean age at diagnosis increased strongly amongst IDU, but less so among homo-/bisexual men and heterosexual contact cases. Of a total 110646 reported cases (116311 after adjustment for reporting delay), 87167 (78.8%) were among people born in 1950-1974 [91951 (79.1%) after adjustment for reporting delay]. The relative impact on specific birth cohorts differed strongly by exposure group. Incidences at age ranges of 20-24 and 25-29 years among cohorts born in 1965 and after were about the same level (homo-/bisexual men, IDU) or higher (heterosexual contact cases) than older birth cohorts when these were in the same age range; rates of increase were less among homo-/bisexual men and IDU, but higher among heterosexuals. There were large differences between counties. CONCLUSIONS: Overall, AIDS incidence among cohorts born in 1965 and after is about the same level (homo-/bisexual men, IDU) or higher (heterosexual contact cases) than older cohorts when these were in the same age range. Rates of increase of AIDS incidence curves suggest reduced HIV transmission amongst the most recent cohorts of homo-/bisexual men and IDU, but among young heterosexuals the epidemic is still expanding.

Living with HIV. Experiences and perspectives of HIV-infected sexually transmitted disease clinic patients after posttest counseling.

OBJECTIVES: To determine whether human immunodeficiency virus (HIV)-infected STD clinic patients receive needed services and to determine the social consequences of testing HIV-positive. STUDY DESIGN: Sexually transmitted disease clinic patients in Baltimore, Miami, and Newark who had first been told about a positive HIV test 6 to 24 months previously were recontacted and interviewed. RESULTS: Out of 416 persons we attempted to contact, we interviewed 142 who had first learned that they were HIV-infected 6 to 24 months previously. Most interviewees were male (57%), black (82%), and heterosexual and had a low socioeconomic status. Twenty-five percent said they had never received medical care for their HIV infection. Most of those not in care said they were never referred, were "in denial," or did not want medical care. Interviewees had disclosed their status selectively; but "because of HIV," 4% had lost a job, 1% had been asked to move by a landlord, and 1% had been assaulted. Seventy-six percent would recommend that others take an HIV test; 11% would not recommend it. CONCLUSIONS: Most patients interviewed were getting medical care and, despite some negative consequences, most would recommend HIV testing to others. To identify and address local barriers to needed services, we suggest that clinic staff routinely recontact consenting HIV-infected patients after posttest counseling.

[European surveillance of infectious diseases: the case of AIDS and tuberculosis]. / Surveillance européenne des maladies infectieuses: les cas du SIDA et de la tuberculose.

In 1992, the Maastricht treaty gave specific responsibilities to the European Community in the field of research, information and health education. Several European surveillance systems for infectious diseases have been organised. The surveillance of AIDS was set up in 1984 after the emergence of this new disease. Seven western European countries participated initially. The system currently covers 48 of the 51 countries of the WHO European region. Based on a common case definition, it enables analysis of trends and comparisons which considerably facilitate the understanding of the epidemic and its determinants, and the evaluation of preventive actions. European countries have now decided to set up a reporting system for HIV infection. The surveillance of tuberculosis started in 1996 in response to the reversal of trends in reported cases observed in western Europe and to the threat of multi-drug resistant tuberculosis epidemics. Common recommendations on definitions and data collection procedures facilitated its establishment. Most countries of the WHO European region participated in the first year, revealing a very heterogeneous epidemiological situation. The next objective is to set up a surveillance system for antituberculosis drug resistance. The European surveillance of AIDS and tuberculosis are examples of systems adapted to the specific characteristics of Europe: similarities in diagnostic procedures, similarities in access to treatments, and common requirements regarding both the exchange of information and the coordinated response to public health threats. They are not simply looking for a common denominator. They are creating a real momentum among participating countries towards a better quality and a higher level of pertinence of the information.