In 2019, an estimated 2.2 million people were living with HIV in Western and Central Europe and North America. Annual new HIV infections peaked in 2008 at 82,000, but since 2010 new HIV infections have fallen by 12% to 2018. More than half of all new HIV infections occurred in the USA, and more than a quarter occurred in six countries: France, Germany, Italy, Spain, Turkey and the UK.

In 2019, 88% of people living with HIV in the region were aware of their status, of whom 92% were accessing antiretroviral treatment (ART). Among those on treatment, 82% were virally suppressed. However, late diagnosis remains a challenge: approximately a quarter of people diagnosed with HIV between 2014 and 2016 were diagnosed at an advanced stage of infection. As a result, in 2019, 12,000 people died of AIDS-related illnesses.

In 2014, nine out of 10 new infections were among key affected populations and their sexual partners. HIV prevalence is also considerably higher among key affected populations. However, the populations most affected by HIV differ between countries.

In the three Baltic countries (Estonia, Latvia and Lithuania), most HIV transmission occurs through injecting drug use and heterosexual sex, including sex work. In North America and Western Europe, HIV transmission mostly occurs during same-sex sexual relations between men. In the USA, gay men and other men who have sex with men accounted for 67% of new infections in 2015, despite making up less than 2% of the general population.

Although there is a general decline in new infections, among certain key affected populations new infections are rising.

Men who have sex with men (MSM)

Between 2010 and 2014, the number of HIV diagnoses among men who have sex with men (sometimes referred to as MSM) increased by 17% in Western and Central Europe and by more than 8% in North America, although declines in some countries are now being seen. Ethnic disparities were further noted when analysing new infection reports – as diagnoses among men who have sex with men who identified as white declined by 18% while among those who identified as Latino, diagnoses increased by 20.6%.

In Western and Central Europe, more than 80% of new HIV infections in 2014 in Hungary, Croatia and Slovenia were among men who have sex with men. In contrast, in Latvia, Lithuania and Estonia where people who inject drugs and their sexual partners are most affected by HIV, men who had sex with men accounted for 10% of new HIV infections in 2014.

In 2016, the UK saw a 21% reduction in new infections among men who have sex with men from 2015 levels, the first decline among this group since the epidemic began. Despite this, men who have sex with men are significantly more affected by HIV than any other group, accounting for an estimated 43% of people living with HIV, despite making up around 1% of its population.

In the USA, men who have sex with men account for 67% of all new HIV infections in the country despite representing just 4% of the population. If current diagnosis rates do not change, one in six US-based men who have sex with men will be diagnosed with HIV in their lifetime. There are significant disparities by race. African American / black men who have sex with men are more affected by HIV than any other group in the USA, with one in two likely to be diagnosed with HIV, compared to one in four Hispanic / Latino men who have sex with men and one in 11 white men who have sex with men.

In Canada, around 54% of all new infections occurring in 2014 were among men who have sex with men. It is estimated that 6.7% of men who have sex with men were living with HIV at the end of 2014. In 2015, in Western and Central Europe, prevalence among men who have sex with men was highest in France and Romania (18%), and lowest in Finland (<1%).

Transgender people

Limited regional data on transgender people suggests that prevalence among this population is high. Where it does exist, data tends to focus on transgender women, with the majority of studies conducted in Western Europe and North America.

For instance, a 2017 study estimates there are 1 million transgender adults in the USA. Around a quarter (28%) of transgender women in the country are thought to be living with HIV, and more than half (an estimated 56%) of black / African American transgender women are HIV positive.

Although acceptance of transgender people is increasing in some countries in the region, many transgender people remain socially, economically, politically and legally marginalised. These factors heighten their vulnerability to HIV in many ways. The US-based National Coalition of Anti-Violence Programs (NCAVP) reports on violence against gender and sexual minorities, utilising data from across the country and some parts of Canada. Its findings suggest that transgender women are almost twice as likely to experience sexual violence than other survivors of sexual violence and are seven times more likely to experience further physical violence when reporting IPV to the police.

Marginalisation leads many transgender people to stay away from health services. In a study in the USA, 73% of transgender women who tested HIV-positive had been unaware of their status. Another USA study found that only 59% of transgender participants, compared to 82% of those with a birth-assigned gender, were accessing antiretroviral treatment (ART).

Migrants

Around 4 out of every 10 people living with HIV in the European Economic Area (EEA), which comprises the European Union countries plus Norway and Iceland, is a migrant to the country in which they are diagnosed. ’ African women still form the largest single group of migrants diagnosed with HIV in the European Economic Area (EEA); 43% of migrants with HIV in 2012 were women compared with 16% of non-migrants. Around half (53%) of newly diagnosed people of non-native origin in the EEA were from Sub-Saharan Africa. ’

Some migrants will have acquired HIV in their home country, however there is evidence that a considerable proportion of infections are acquired post-migration. A comprehensive evidence review carried out in 2015 found estimates of post-migration HIV infection to range from as low as 2% among Sub-Saharan Africans who had migrated to Switzerland to 62% among black Caribbean men who have sex with men who had migrated to the UK. In 2016, black African men and women comprised 39% of heterosexual adults with a new HIV diagnosis in the UK, however overall the majority of infections (55%) were acquired while in the UK.

High prevalence among migrants has much to do with restrictive health policies, preventing access to treatment. Treatment has a public health benefit by reducing viral load and preventing further transmission of HIV - reducing long-term health costs. However, 16 European countries (including Spain and Sweden) do not provide antiretroviral treatment (ART) to undocumented migrants living with HIV. By contrast, Portugal and the UK currently provide treatment, regardless of a person’s immigration status.

African Americans

African Americans are one of the groups most affected by HIV in the USA. In 2016, this group accounted for 44% of the total number of people living with HIV in the USA, despite making up just 12% of the population. Moreover, in 2015 AIDS-related illnesses were the sixth leading cause of death among African American men aged 25-44 and the seventh leading cause of death for African American women aged 20-34.

African American men and women in the USA are most likely to be infected with HIV through unprotected sex with a man or by injecting drugs. Other factors, such as heightened levels of poverty, lack of access to adequate healthcare, and stigma surrounding men who have sex with men also increase this group's risk of HIV infection.

From 2005 to 2014, the number of new HIV diagnoses among African American women fell by 42%, although the new diagnosis rate is still around three times higher compared to rates among women from other racial or ethnic groups. One of the biggest risk factors for African American women is being the sexual partner of an African American bisexual man who may not know or want to reveal his HIV status.

People who inject drugs (PWID)

In 2014, people who inject drugs (sometimes referred to as PWID) accounted for 15% of all new HIV infections across the region. In the USA, heroin use increased among men and women in most age groups and across all income levels, with a total increase of 63% between 2002 and 2013. This trend coincided with an increase in hepatitis C virus (HCV) infections and new outbreaks of HIV associated with injecting drug use. Around 3.6% of people who inject drugs in North America were thought to be living with HIV as of 2016, 80% of whom also had HCV. The majority of people who are living with HIV who inject drugs are African Americans (46% in the USA).

In the USA, in 2014 an estimated 8% of new HIV infections were among people who inject drugs. Although the annual number of new HIV diagnoses among people who inject drugs in North America decreased by 56% between 2008 and 2014.

Over the last decade, new HIV diagnoses among people who inject drugs in Western and Central Europe have remained fairly stable overall, standing at 4% of all new infections in Western Europe and 9% in Central Europe in 2014. This is due to significant efforts in the region to expand harm reduction programmes. Overall, 0.8% of people who inject drugs in this part of the region are living with HIV.

While the vast majority of countries in the region have seen HIV prevalence decline or stabilise among people who inject drugs, a number of countries are facing a worsening epidemic among this group. In 2017, the countries with the highest prevalence among people who inject drugs in the region was Estonia (54%), followed by Romania (28.9%) and Latvia (26%).

In the Czech Republic, where drug use is decriminalised and coverage of harm reduction services is relatively high, HIV prevalence among people who inject drugs is 0.2% in 2017. Outbreaks related to injecting drug use in areas of Greece and Romania led to an approximately 20-fold increase in HIV diagnoses among people who inject drugs in these two countries between 2010 and 2012 which still had an effect on the number of new diagnoses in 2015.

Sex workers

HIV prevalence among female sex workers in Western Europe is generally thought to be low (1% or less). However, higher prevalence rates have been recorded in some countries. For example, a 2015 study of sex workers in Portugal reported HIV prevalence of 7.4% among female sex workers.

High prevalence was found among female sex workers who also inject drugs in the Netherlands. Prevalence is also relatively high in Italy and Spain among migrant, street and transgender sex workers. HIV prevalence is low among female sex workers in Central Europe - between 1% and 2%. HIV prevalence has been recorded at under 1% in Albania, Bosnia and Herzegovina, Bulgaria, the Czech Republic, Kosovo, Romania and Serbia. A 2% prevalence was detected among sex workers in Poland and Croatia.

Studies conducted in Belgium, the Czech Republic, Germany and Spain between 2011 and 2015 suggest prevalence among male sex workers to be high. For example, the German study found male sex workers were 6.5 times more likely to test positive for a sexually transmitted infection (STI) than their female counterparts.

In comparison, the 2015 Portugal study mentioned above found HIV prevalence among male sex workers to be 5%, a lower rate than among female sex workers, but 17.6% among transgender female sex workers. Data on national HIV prevalence among sex workers in both the USA and Canada is very limited. Although a 2016 evidence review of USA studies found prevalence to be 10% or higher in the majority of studies analysed.

The number of HIV tests performed in Western and Central Europe and the USA continues to steadily increase. By 2016, two European countries—Denmark and Sweden—had already met the UNAIDS’ target of diagnosing 90% of people living with HIV, and another 10 European countries plus the USA reported that 85% or more people living with HIV were aware of their status.

In 2016, only three countries in Western and Central Europe - France, Norway and the UK - had laws and policies in place authorising self-testing. Saliva-based self-testing kits have been available in the USA since 2012.

Late diagnoses of HIV, indicated by low CD4 counts, remain a major issue. Nearly a quarter of all people in Western and Central Europe diagnosed with HIV between 2014 and 2016 recorded CD4 T-cell counts below 200 cells/mm³.

In 2016, more than half of people diagnosed with HIV were diagnosed with CD4 counts under 350 in eight countries Western and Central Europe: 66% in Lithuania, 64% in Romania (64%), 58% in Greece, 56% in Croatia, 56% in Italy, 54% in Estonia, 52% in Finland and 51% in Germany.

Despite increases in testing levels, in 2017 the European Centre for Disease Prevention and Control reported testing rates among key populations below 50% in many countries and current data on testing is limited. According to the most recent data available (2011–2015) in the USA, between 50 and 75% of both men who have sex with men and people who inject drugs have been tested for HIV. Around a third of African Americans have never been tested for HIV.

In Canada, 25% of people living with HIV are unaware of their status. Less than 50% of men who have sex with men have tested for HIV. However, testing rates among people who inject drugs is high at more than 75%.

The annual number of new infections among adults across Western and Central Europe and North America has declined by 9% over the last six years, from 79,000 in 2010 to 72,000 in 2016. Half of all new infections in the region in 2016 occurred in the USA.

While HIV infections through injecting drug use and heterosexual contact in the USA declined by 56% and 36%, respectively, new infections through male same-sex contact remained stable, but with large differences between ethnicities.

In Canada in 2016, there was an 11.6% increase in the number of HIV diagnoses compared with 2015, which represents the highest prevalence since 2011. A number of possibilities exist to explain this increase in cases including more testing due to the implementation of provincial testing initiatives.

In Western and Central Europe, the Netherlands experienced a 55% decline in new HIV infections between 2010 and 2016. More gradual declines were achieved in France, Ireland, Italy, Latvia, Lithuania, Romania and Spain. New infections increased by nearly 80% over the same period in the Czech Republic, by more than 70% in Serbia and by more than 60% in Slovakia.

Most countries in the region adopt combination HIV prevention strategies, some of these are outlined below.

Condom availability and use

Increases in the annual number of cases of sexually transmitted infections (STIs) such as gonorrhoea, syphilis and HIV diagnoses among men who have sex with men in the European Union and the USA suggest that condom use among this population has not improved.

In 2012, the USA began a five-year HIV prevention programme with health departments across the country which included condom distribution for people living with HIV and people at highest risk of acquiring HIV. Between 2012 and 2014, more than 248 million condoms were distributed.

In the UK, condom distribution schemes are available in most parts of the country, targeted at 15-24 years olds, with 3% coverage. In Europe, coverage of condom promotion and distribution for key populations is low, meaning free, easily accessible condoms are not reaching enough people.

HIV education and approach to comprehensive sexuality education

Sex education in schools is widespread in Western Europe, with many countries in this area of the region taking a comprehensive approach by including topics such as sexuality, gender inequality and gender norms, alongside topics such as pregnancy, contraception and STIs including HIV. A similar situation exists across Canada.

In stark contrast, sexuality education in Central European countries tends to reduce it to a basic anatomical study of the human body and the promotion of abstinence, traditional family values marriage and religious morality.

In the USA, only 13 states require sexulaity education to be medically accurate, creating disparities in what children learn. Even when sexulaity education is required, state policies vary widely, and a number of states leave issues such as sexuality, gender identity and contraception unaddressed. Many link this to the fact that, in 2016, the USA had higher rates of teen pregnancy and STIs among teenagers than most other high-income countries.

Harm reduction

In 2015, 50% to 60% of reporting countries in Western and Central Europe reported high access to harm reduction services, particularly needle and syringe programmes and opioid substitution therapy. As a result, the number of people who inject drugs newly diagnosed with HIV has fallen from 2,161 in 2005 to 1,126 in 2014.

Needle and syringe programmes (NSPs)

Almost all European countries provide clean injecting equipment at specialised outlets free of charge. Most reach the recommended World Health Organization (WHO) target of 200 syringes per person who injects drugs. However, Belgium, France and Turkey distribute less than 100 syringes per person.

Across this region, NSPs are provided in a number of ways including fixed sites, outreach and mobile units as well as pharmacies (in Belgium, France, Ireland, the Netherlands, Portugal, Spain and the UK) and vending machines (in Austria, France, Germany, Luxembourg and the UK).

NSPs are available in both Canada and the USA. Although the exact number of NSPs operating in Canada is not known, it is estimated that 94.5% of people who inject drugs used sterile injecting equipment at last injection. In the USA, 244 NSPs were operating across the country by 2016, a 25% increase since 2014.

Opioid substitution therapy (OST)

In Europe in 2014, an estimated 680,000 people who inject drugs received opioid substitution treatment (OST) although numbers have fallen by around 50,000 since 2010. Methadone is the most commonly prescribed opioid substitution drug, received by 61% of people enrolled in substitution therapy. A further 37% are treated with buprenorphine-based medications.

In England and Wales, progress in the provision of OST is being threatened by a drive towards abstinence-based treatment, even though these approaches often lead people to stop their treatment. OST is available in both the USA and Canada. In the USA, 48 out of 50 states provide OST, and around 382,200 people were enrolled in programmes.

People can access OST in some parts of Canada but there have been calls to expand provision further due to the rising numbers of opioid overdoses across the country in recent years. In 2016, Canada made heroin-assisted therapy (HAT) legal. Under the new regulations, physicians can prescribe pharmaceutical-grade heroin to help individuals for whom other OST approaches, such as those involving methadone and buprenorphine, have failed.

Pre-exposure prophylaxis (PrEP)

Pre-exposure prophylaxis (often referred to as ‘PrEP’), whereby someone at heightened risk of HIV takes antiretroviral drugs to greatly reduce the risk of infection, is available in Canada, France and the USA.

In Europe, only Norway and France provide PrEP for high-risk populations through public health services, mainly to men who have sex with men at higher risk of infection. In the UK, PrEP is available through the National Health Service in Scotland and Wales and is being provided to 10,000 people in England. In the rest of Europe, PrEP demonstration projects had been completed in one country, were ongoing in three and were being planned in a further 10 as of 2016.

More than three out of four people living with HIV (1.7 million) in Western and Central Europe and North America were accessing antiretroviral treatment (ART) in 2016, up from 1.2 million in 2010. As the total number of people living with HIV in the region has increased over the last six years, this scale-up has translated into an increase in treatment coverage from 63% of people living with HIV in the region in 2010 to an estimated 78% in 2016.

Treatment coverage among people living with HIV varies across countries. In 2016, it was above 81% in Denmark, Iceland, Sweden and the UK, whereas just one in four people living with HIV was accessing treatment in Bulgaria, Latvia and Lithuania. In Estonia and Poland, the rate was around one in three.

The WHO’s Regional Office for Europe released a 2016–2021 action plan on HIV/AIDS and viral hepatitis in 2016. This adopted 2015 WHO treatment guidelines that all people living with HIV should be started on treatment regardless of CD4 count.

In contrast, in the USA, an estimated 71% of people living with HIV were receiving medical care in 2014, but only 57% of people living with HIV met the national criteria for continuous HIV medical care. National data on ART enrolment and retention is limited in Canada.

Most people accessing ART in the region had access to routine viral load testing. Among people living with HIV on treatment in 2015, 84% were virally suppressed; equivalent to 64% of all people living with HIV in the region.

More than 70% of all people living with HIV were virally suppressed in Denmark, Iceland, The Netherlands, Sweden, Switzerland and the UK. In Bulgaria, Czechia, Greece, Hungary, Lithuania, Poland, Serbia and Slovenia, however, less than half of all people living with HIV had suppressed viral loads. In the USA, 55% of the total number of people who had been diagnosed with HIV by the end of 2012 and were still alive in 2013 and were virally suppressed.

Research from Europe and North America shows the impact of high levels of treatment coverage, adherence and viral suppression, as people living with HIV on successful treatment were found to have similar life expectancies to people who are HIV negative.

In Europe, a study found drug-resistant HIV prevalence to be highest among men who have sex with men, at 11.1%, followed by heterosexuals at 6.6% and people who inject drugs at 5.1%.

Civil society is well established in North America and Western Europe. In Central Europe, the influence of civil society tends to be greater in higher-income countries.

Political activism has been a key part of the region’s HIV response since the very beginning and continues to this day. In the early days of the epidemic, HIV activism was closely associated with gay communities in the USA and other industrialised Western nations.

A move towards more conservative agendas and a roll back of rights in some countries such as the USA has seen civil society groups and governments in the region clash in recent years. For instance, a number of governments have suggested that the basic freedoms of association, assembly and expression should be limited in favour of ‘national interests’. There are also reports of civil society scapegoating, which have a particularly high negative impact on more vulnerable groups such as people who are lesbian, gay, bisexual or transgender (LGBT).

For instance, in Spain and France, specific ‘state of emergency’ and security legislation is undermining the freedoms of assembly and expression, creating a worsening environment for civil society and citizens action. In Europe, overall financing for civil society activity is reducing, which is also a major concern.

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Legal, cultural and socio-economic barriers

HIV is still intrinsically linked with somehow you having done something wrong, because it’s sexually transmitted. I think that we assume that it’s our fault that we got it. That’s the self-judgement of it. If I didn’t have sex, I wouldn’t have HIV, fact.

- Person living with HIV, HIV Stigma Index UK, 2015

A number of social barriers exist that prevent key affected populations from accessing HIV services. Language barriers, marginalisation and social exclusion contribute to the vulnerability of migrants. Many also belong to at-risk sub-populations such as asylum seekers, refugees, sex workers and men who have sex with men.

Female migrants also commonly report sexual harassment, abuse and rape. All these factors contribute to preventing many female migrants accessing vital HIV services.

HIV-related stigma and discrimination is prevalent in the region. For example, a 2014 survey of people living with HIV from 14 European countries found 32% had experienced HIV-related discrimination in the past three years. Almost half of these cases (46%) were linked to healthcare settings. As of 2016, Canada and the USA have formed Stigma Index survey implementation teams but are yet to report findings.

A 2015 review of the European MSM Internet Survey, which was conducted in 2010 across 38 European countries, found men who have sex with men who are living in countries with higher levels of stigma had reduced odds of diagnosed HIV and fewer partners, but higher odds of sexual risk behaviour such as having unprotected sex and unmet prevention needs.

In the USA, women who inject drugs experience stigma as well as fear of exposure to authorities because of strict child custody and welfare laws.

Both Portugal and the Czech Republic have adopted decriminalisation and de-penalisation of drugs for personal consumption. If other countries in the region followed this could encourage people who inject drugs to engage with HIV prevention and treatment services.

Similarly, decriminalisation of sex work could empower women and men engaged in commercial sex work to seek and utilise HIV prevention and treatment services.

Rights for men who have sex with men and people who are LGBT are stronger in Western and Central Europe and North America compared to any region in the world, although transgender rights are less well developed. Currently, the European Region of the International Lesbian, Gay, Bisexual, Trans and Intersex Association (ILGA Europe) ranks the top three EU countries in terms of LGBT rights as Malta, Belgium, Norway.

Structural and resource barriers

Even in countries with good levels of HIV prevention coverage, gaps exist. Some services are out of reach, particularly for those in rural areas, while other sites have inconvenient opening times. In some countries, young people under 18 cannot access harm reduction services.

Moreover, migrants living with HIV frequently go undocumented and the provision of services in rural areas is often underdeveloped.

A lack of funding is a significant barrier to the scale-up of harm reduction programmes in North America. A lack of government support in Canada means these services are largely delivered by local authorities, community organisations and NGOs.

As the legality of NSPs in the USA is determined by individual states, many have underground NSPs or none at all. Punitive laws also discourage some programmes from making their information public.

In Greece, expansion of NSP services has slowed down because of the country's financial difficulties.

Funding for HIV responses in the region is mainly domestic due to the high levels of income of most countries, and has increased significantly over the course of the epidemic as more people are living with HIV.

However, as of 2018, the threat of budget cuts to sexual and reproductive health services in countries such as the USA and the UK is looming.Foreign Policy (1 December, 2017) ‘Proposed U.S. Cuts to AIDS Funding Could Cause Millions of Deaths: Report’ and BBC (5 June 2018) ‘Cuts to sexual-health services imminent’ (Accessed 05/07/2018)

Countries in North America and Western Europe also provide funding and technical support to HIV responses in other parts of the world.

Western and Central Europe has made great strides in tackling the HIV epidemic in the region. Most countries report high proportions of people living with HIV on ART and, as a result, prevalence is generally low. However, far too many people are still being diagnosed at a late stage of infection. Early diagnosis and treatment must remain a high priority for the region.

Moreover, gaps in the provision of HIV services remain with key affected populations facing a number of barriers, particularly men who have sex with men. In Western and Central Europe, increasing rates of HIV infection among men who have sex with men suggest that programmes addressing condom use for this group need to be expanded. The widespread use of mobile dating apps among men who have sex with men offers opportunities to do just that.

It is important that countries in this region continue to provide the necessary resources to tackle the epidemic. In North America, greater HIV surveillance is required to better understand the need for HIV prevention services in order to mobilise resources where they are needed most.