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OBJECTIVES: to determine limitations and strengths of three methodologies developed to estimate HIV prevalence and the number of people living with HIV/AIDS (PLWHA). METHODS: the UNAIDS/WHO Workbook method; the Multiparameter Evidence Synthesis (MPES) adopted by the Health Protection Agency; and the UNAIDS/WHO Estimation and Projection Package (EPP) and Spectrum method were used and their applicability and feasibility were assessed. All methods estimate the number infected in mutually exclusive risk groups among 15-70-year-olds. RESULTS: using data from the Netherlands, the Workbook method estimated 23 969 PLWHA as of January 2008. MPES estimated 21 444 PLWHA, with a 95% credible interval (CrI) of 17 204-28 694. Adult HIV prevalence was estimated at 0.2% (95% CrI 0.15-0.24%) and 40% (95% CrI 25-55%) were undiagnosed. Spectrum applied gender-specific mortality, resulting in a projected estimate of 19 115 PLWHA. CONCLUSION: although outcomes differed between the methods, they broadly concurred. An advantage of MPES is that the proportion diagnosed can be estimated by risk group, which is important for policy guidance. However, before MPES can be used on a larger scale, it should be made more easily applicable. If the aim is not only to obtain annual estimates, but also short-term projections, then EPP and Spectrum are more suitable. Research into developing and refining analytical tools, which make use of all available information, is recommended, especially HIV diagnosed cases, as this information is becoming routinely collected in most countries with concentrated HIV epidemics.

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Objective. To assess the level of access to highly active antiretroviral therapy (HAART) for women and children in the WHO European Region. Methods. Analysis of data from three national surveys of 53 WHO European Member States. The comparative level of access to HAART for women and children was assessed by comparing the percentage of reported HIV cases with the percentage of HAART recipients in women at the end of 2002 and 2006 and in children at the end of 2004 and 2006. Findings. Overall, the data suggest that there is equivalence of access to antiretroviral therapy by gender and age in Europe. However, in central and eastern Europe women were disproportionately more likely to receive HAART when compared with men in 2006, representing 29% of HIV cases when compared with 39% of HAART recipients in central Europe, and 34% of HIV cases when compared with 42% of HAART recipients in eastern Europe. In comparison with adults, children (<15 years of age) were over-represented among HAART recipients when compared with HIV cases in eastern Europe, accounting for 1% of HIV cases and 9% of people on HAART in 2004 and 1% of HIV cases and 8% HAART recipients in 2006. Conclusion. Access to HAART remains inequitable in terms of gender in central and eastern Europe, favouring women over men, and in terms of age in eastern Europe, favouring children over adults. Despite high and increasing coverage with HAART in many European countries, countries must address how to further increase the number of people on treatment while ensuring equitable access for all population groups in need.

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AIMS: To assess changes in access to highly active antiretroviral therapy (HAART) between the end of 2002 and the end of 2005, and to review the capacity for further HAART scale-up in the then 52 Member States of the WHO European Region. METHODS: Analysis of data from four surveys evaluating access to HAART, supplemented by regional estimates of the number of people receiving HAART. Changes in access to HAART are evaluated in terms of changes in the number of people receiving HAART over time and changes in country-level HAART coverage. RESULTS: During 2003-2005, the total number of individuals receiving HAART increased by an estimated 101,000, from 242,000 to 343,000 (a 42% increase); 85,000 were in the west region (a 36% increase) and 16,000 in the centre and east regions (a 229% increase). The number of countries providing "high'' coverage with HAART (>75% of those in need receiving it) increased from 29 to 38, and the number of countries providing no HAART declined from eight to four. CONCLUSIONS: Despite high and increasing coverage in many European countries, access to HAART remained inequitable in terms of geographical location. By the end of 2005, all countries in the west provided "high'' HAART coverage as compared with half of countries in the centre and east. Six east countries still provided poor or no HAART coverage. Countries must address how to further equitably increase the number of people receiving HAART.

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Scaling-up access to HIV/AIDS prevention, treatment and care for injecting drug users (IDUs) has been frustrated by the lack of a framework, indicators and agreed targets for interventions specifically targeting IDUs. Major progress in this regard has been achieved with the recent development of a joint Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users and related technical consultations. This guide provides technical guidance to countries on setting ambitious, but achievable national targets for scaling-up towards universal access (UA). The guide has been developed as a collaboration between the Joint United Nations Programme on HIV/AIDS (UNAIDS), the United Nations Office on Drugs and Drugs (UNODC), the World Health Organization (WHO) and with national and international expertise and builds on previous UNAIDS guidelines. The guide serves to provide more consistent methods of measuring and comparing countries' progress towards universal access and offers consensus as to which interventions should be included in a comprehensive package. It provides guidance on defining and estimating denominator populations and proposes a set of indicators to measure coverage, as well as indicative targets or benchmarks against which to measure progress towards UA. The guide moves on from a narrow focus on coverage that neglects other important aspects of access, namely availability and quality of interventions. Finally, the guide encourages country involvement in, and ownership of, what are sometimes perceived as politically motivated coverage targets. Technical consultations, with country experts using the guide to set national targets, suggested a tendency for targets to be proposed that are achievable but fall short of what is required to achieve universal access and have a real impact on HIV/AIDS epidemics. Consensus and improved guidance on achieving universal access needs to be supported by political will, good leadership and, in some countries, remedies to inadequacies in health systems.

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Providing equitable access to highly active antiretroviral treatment (HAART) to injecting drug users (IDUs) is both feasible and desirable. Given the evidence that IDUs can adhere to HAART as well as non-IDUs and the imperative to provide universal and equitable access to HIV/AIDS treatment for all who need it, here we examine whether IDUs in the 52 countries in the WHO European Region have equitable access to HAART and whether that access has changed over time between 2002 and 2004. We consider regional and country differences in IDU HAART access; examine preliminary data regarding the injecting status of those initiating HAART and the use of opioid substitution therapy among HAART patients, and discuss how HAART might be better delivered to injecting drug users. Our data adds to the evidence that IDUs in Europe have poor and inequitable access to HAART, with only a relatively small improvement in access between 2002 and 2004. Regional and country comparisons reveal that inequities in IDU access to HAART are worst in eastern European countries.

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OBJECTIVE: To estimate access, activity and coverage of needle and syringe programmes (NSP) in Central and Eastern Europe and Central Asia. METHODS: Two data sets ('regional' and 'high-coverage sites') were used to estimate NSP provision (availability/number of sites), NSP utilization (syringes distributed/year), needle and syringe distribution (needles/syringes distributed/IDU/year), IDU reached (number/percentage of IDU contacted/year), regular reach (five or more contacts/month) and syringe coverage (percentage of injections/IDU/year administrable with new injecting equipment). RESULTS: Regional data set: results from 213 sites in 25 countries suggested that Czech Republic, Poland, Russia and Ukraine had > 10 NSP during 2001/2. Czech Republic, Kazakhstan, Latvia, Russia, Slovakia and Ukraine had >or= 10,000 IDU in contact with NSP. Ten countries reached >or= 10% of the estimated IDU population. The 25 countries distributed approximately 17 million syringes/needles. Eight countries distributed > 0.5 million syringes/year. Syringe coverage (assuming 400 injections/IDU/year) was < 5% in 19 countries, 5-15% in five and > 15% in Macedonia. Overall syringe coverage was 1.2% and when assuming 700 injections/IDU/year it decreased to 0.7%. Syringe coverage for the IDU population in contact with NSP was 60% in Croatia, Macedonia, Moldova and Tajikistan. Overall syringe coverage for the population in contact with NSP was 9.8%. High-coverage data set: Soligorsk, Pskov and Sumy's NSP reached 92.3%, 92.2% and 73.3% of their estimated IDU population, respectively (regular reach: 0.2%, 1.8% and 22.7%). The distribution levels were 47.2, 51.7 and 94.2 syringes/IDU/year, respectively. CONCLUSION: The evidence suggests suboptimal levels of NSP implementation, programme activity and coverage. This paper provides a baseline for development of indicators that could be used to monitor NSP. Strategies to increase coverage that may go beyond NSP are urgently required, as is research into understanding how NSP can contribute to better syringe coverage among IDU.

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In Europe today, HIV/AIDS prevention, treatment and care are needed more than ever. HIV incidence – steady in western and central Europe, and dramatically increasing in eastern Europe – remains a major challenge to public health in the 21st century. With more than 2 million people living with HIV/AIDS in the WHO European Region, no country has been spared. This book tells the story of HIV/AIDS in Europe from a broad variety of perspectives: biomedical, social, cultural, economic and political. The authors are leading experts from across the Region and include both the infected and the affected, be they doctors or former drug users, United Nations employees or gay men, public health researchers or community activists. They describe how, from the first documented cases in 1981 to the present era of antiretroviral management, controlling HIV in Europe has proven elusive. Yet while antiretroviral therapy lets many HIV-positive Europeans lead normal lives, the vast majority of the Region’s infected residents continue to face the disease unarmed. This volume not only analyses the past and surveys the present, but suggests how to move towards two fundamental goals: providing universal access to treatment and halting the spread of HIV/AIDS.

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In the 1990s, HIV/AIDS became a major threat to health, economic stability and human development in countries in eastern Europe and central Asia. Social, political and economic transition exacerbated the structural conditions that allowed HIV/AIDS to flourish as dramatic changes led to increasing drug injection, economic decline and failing health and healthcare systems. There is a need to address the professional and ideological opposition - even in countries considered to be fully functioning democracies - to evidence-based public health interventions like harm reduction, coupled with treating HIV/AIDS for all those in need, if countries are to provide a more effective response.

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