2. HIV and AIDS in the WHO European Region
2.3 HIV and AIDS diagnoses in the Centre
2.3.1 HIV diagnoses in the Centre
The HIV epidemic in the Centre remains at a relatively low level compared to other parts of the Region, but the number of new diagnoses is increasing more rapidly here than elsewhere, particularly in people infected as a result of sex between men. A total of 6814 people were newly diagnosed with HIV in 2019 from the 14 countries in the Centre of the WHO European Region, giving a rate of 3.4 per 100 000 population (Table 1). The highest rates (over 3.0) were reported by Cyprus (11.4), Montenegro (4.1), Poland (3.9), Turkey (3.9), Bulgaria (3.7), Romania (3.6) and Albania (3.5), and the lowest (under 2.0) by Bosnia and Herzegovina (0.9), Slovenia (1.6) and Slovakia (1.9).
The most affected age group in 2019 was 30–39-year-olds (32% of cases), while 15% of cases were diagnosed in young people aged 15–24 years – the largest percentage of young people among the three geographical areas (Table A, Table 9). The male-to-female ratio was 5.5, higher than in both the West and the East. This reflects the higher number of young MSM among newly diagnosed cases in the central part of the Region compared with other parts of the Region. The highest male-to-female ratios (over 10.0) were observed in Croatia (19.4), Hungary (13.0), Montenegro (12.0) and Serbia (10.3) (Fig. 2.13).
All 14 countries reporting 2019 data provided information on transmission mode, and the 2019 data (Table A, Tables 4–7) indicate the following:
• 27% of those newly diagnosed and 49% of new HIV diagnoses with a known route of transmission were infected through sex between men (1863) (Table 4); in 2019, sex between men was the predominant reported mode of transmission in 10 countries (Bosnia and Herzegovina, Bulgaria, Croatia, Czechia, Hungary,
Montenegro, Serbia, Slovakia, Slovenia and Poland) (Fig. 2.14);
• 25% of those newly diagnosed and 46% of new HIV diagnoses with a known route of transmission were infected through heterosexual transmission (1730) (Table 6), which was the main reported mode of transmission in four countries (Albania, Cyprus, Romania and Turkey) (Fig. 2.14);
• 2% of those newly diagnosed and 4% of new HIV diagnoses with a known route of transmission were infected through injecting drug use (146) (Table 5);
• 1% of those with a known route of transmission were infected through mother-to-child transmission (36) (Table 7); and
• transmission mode was unknown for 44% of those newly diagnosed (3029) (Table 8), with the two countries with the highest number of new HIV diagnoses in 2019 (Turkey and Poland – together accounting for 69% of all new HIV diagnoses reported in the Centre in 2019) also having the highest percentage of new HIV diagnoses with an unknown transmission mode (Poland 72% and Turkey 58%).
Twelve of 15 countries provided information on CD4 cell count at HIV diagnosis for 2034 people aged over 14 years (covering 30% of all new diagnoses in the Centre countries and 40% in the 14 countries with CD4 cell data) (Table 13). Fifty-six per cent were late presenters, with CD4 cell counts below 350 per mm3 at HIV diagnosis, including 35% with advanced HIV infection (CD4 under 200/mm3). In all, 18% had a CD4 cell count of between 350 and 500 cells per mm3 and 27% had a CD4 cell count above 500 per mm3. The proportion diagnosed with CD4 counts of less than 350/mm3 was 50% or above in nine countries: Cyprus (91%), Albania (75%), Montenegro (64%), Romania (63%), Bulgaria (62%), Serbia (60%), Bosnia and Herzegovina (54%), Slovenia (52%) and Croatia (50%). The percentage of late presenters varied across transmission categories and was highest for Fig. 2.12. Distribution of the three most common AIDS-defining illnesses per transmission mode, East, 2019
9
Note: no data from Russian Federation, Turkmenistan and Uzbekistan.
Fig. 2.13. Male-to-female ratio in new HIV diagnoses, by country, Centre, 2019
0 5 10 15 20 25
Cyprus Albania Romania Slovenia Bulgaria Centre average Turkey Poland Czechia Bosnia and Herzegovina Slovakia Serbia Montenegro Hungary Croatia
Male-to-female ratio
Fig. 2.14. New HIV diagnoses, by country and transmission mode, Centre, 2019 (n = 6713)
0 20 40 60 80 100
Heterosexual contact Sex between men
Injecting drug use Other
Unkown
Percentage Albania
Turkey Poland Romania Centre average Cyprus Bulgaria Slovakia Montenegro Slovenia Czechia Bosnia and Herzegovina Hungary Croatia Serbia
50
SURVEILLANCE REPORT
HIV/AIDS surveillance in Europe 2020 – 2019 data
those infected as a result of injecting drug use (73%) and heterosexually (65%) and lowest for men infected through sex with men (47%) (Table 13, Fig. 2.15).
2.3.2 Trends in HIV diagnoses in the Centre
The rate of new HIV diagnoses increased by 113%
between 2010 and 2019 in the 14 reporting countries of the Centre, from 1.6 per 100 000 population (2945 cases) to 3.4 (6814 cases) (Fig. 2.2). Rates increased in all countries except Slovenia. The largest increases were in Bosnia and Herzegovina, Slovakia and Turkey.
Information on trends by reported mode of HIV transmission for the period 2010–2019 in the 12
countries with consistent data25 (Fig. 2.16) indicates the following.
• The number of new diagnoses in those infected as a result of sex between men nearly doubled, from 593 to 1025. The percentage of new HIV diagnoses attributed to sex between men also increased, from 40% in 2010 to 48% in 2019.
• The number of new diagnoses in those infected through heterosexual transmission increased by 48%, from 568 to 841. The percentage of new HIV diagnoses attributed to heterosexual transmission decreased slightly from 40% in 2010 to 38% in 2019.
• The number of new diagnoses in those infected as a result of injecting drug use increased from 96 to 117.
25 Data from North Macedonia, Poland and Turkey were excluded due to incomplete reporting on transmission mode during the period.
Fig. 2.16. New HIV diagnoses, by transmission mode and year of diagnosis, Centre, 2010–2019
0 200 400 600 800 1000
New AIDS diagnoses
Year of diagnosis
Sex between men Heterosexual transmission Injecting drug use Mother-to-child transmission Other/undetermined
2019 2018 2017 2016 2015 2014 2013 2012 2011 2010
Note: data from North Macedonia, Poland and Turkey excluded due to incomplete reporting on transmission mode during the period.
Fig. 2.15. New HIV diagnoses, by CD4 cell count per mm3 at diagnosis and transmission mode, Centre, 2019 (n = 1847)
0 20 40 60 80 100
Injecting drug use Heterosexual transmission Sex between men
< 200 cells/mm3 200 to < 350 cells/mm3 350 to < 500 cells/mm3
≥ 500 cells/mm3 n = 824
n = 873
n = 102
Percentage
Transmission mode
Note: no data from Hungary, North Macedonia or Poland.
The 2011–2013 outbreak in Romania that caused higher numbers of cases during this period has levelled off, as evidenced by the decrease in new diagnoses since 2013. The percentage of new diagnoses attributed to injecting drug use was 6% in both 2010 and 2019.
• The number of new diagnoses as a result of mother-to-child transmission decreased from 31 cases in 2010 to 16 cases in 2019.
• The number of new diagnoses reported with unknown transmission mode in 2019, although still high at 44%
for the 15 countries, decreased by 47%, from 211 to 112 in the 12 countries with consistent data on transmission mode. The percentage of new diagnoses with missing information about transmission mode decreased from 14% in 2010 to 5% in 2019 in the 12 countries included in the trend assessment.
2.3.3 AIDS cases, morbidity and mortality in the Centre
In 2019, 802 people were diagnosed with AIDS in the 14 reporting countries in the Centre, corresponding to a rate of 0.4 per 100 000 population (Table 14). The highest rates (1.0 or above) were reported by Montenegro (1.6), Romania (1.5), Albania (1.4) and Bulgaria (1.0).
AIDS rates remained below 0.8 per 100 000 population in other countries in the Centre. In contrast to the distribution of transmission modes for new HIV diagnoses in the Centre (where sex between men is the predominant mode), more AIDS diagnoses are reported in people infected through heterosexual contact (52% of new diagnoses) than with sex between men (32% of new diagnoses).
The rate of new AIDS diagnoses remained stable at 0.4 per 100 000 between 2010 and 2019, with almost no change during the period (Fig. 2.4). Trends were more heterogeneous at country level. Of the nine countries reporting more than 10 AIDS cases in 2019, the rate increased by more than 50% in four (Albania, Bulgaria,
Croatia and Hungary) (Table 14). In terms of the mode of transmission, new AIDS diagnoses increased most among men infected as a result of sex between men (by 93% for the decade) but have been relatively stable or declining since 2014 in those infected heterosexually or through injecting drug use (Fig. 2.17).
The most common AIDS-indicative diseases diagnosed in 2019 were wasting syndrome due to HIV (21% of all recorded disease events), Pneumocystis pneumonia (13%) and pulmonary TB (12%) (Table 22).
Mortality also remained stable in the Centre, with 282 deaths reported by the 14 countries in 2010 and 260 in 2019 and little variation being seen during the decade (though the numbers were slightly higher during 2011–2015) (Table 23). These numbers do not represent the true burden of AIDS-related mortality due to underreporting of deaths in countries that do not match their HIV/AIDS registries with the national mortality registry.