Greece and Türkiye – pivotal countries in the global fight to defeat HIV

by Gus Cairns

On 16-17 October, EACS held the biennial Standard of Care for HIV and Co-infections meeting in Athens, Greece. The aim of the meeting was developing a common standard of HIV clinical care throughout Europe.

EACS’ decision to hold the 2024 meeting in Athens, Greece and to invite healthcare and community representatives from Türkiye and Greece to help organise it was timely. This region – the bridge between western and eastern worlds for millennia – has also become the world’s hotspot for HIV in terms of new infections.

The world’s annual total of HIV diagnoses fell by 39% between 2010 and 2023, UNAIDS reported at the AIDS 2024 conference in July, and by 59% in east and southern Africa. In contrast, in eastern Europe and central Asia, diagnoses rose by 20%, and they more than doubled in the Middle East and north Africa. In eastern Europe, of even more concern is that AIDS-related deaths had increased by 35% – showing that treatment was not reaching those who needed it most. Greece and Türkiye are respectively classed as being in western and central Europe by the World Health Organization – but what is happening on their borders is key to the future of the HIV epidemic.

Barriers to care in Greece

The Standard of Care is not a set of guidelines, which lists what the evidence tells us are the best treatments available. The Standard of Care instead aims to define targets for HIV testing, treatment, prevention, co-conditions and monitoring, and then use auditing as a tool to generate improved practice in European clinics, countries and regions as they compare their performance against themselves and each other.

People with HIV in Greece and Türkiye face barriers to a better standard of care that are both external, in terms of global events, and internal, in terms of structures in the healthcare system, and stigma within it. We will look at stigma in our second article from the meeting.

The way HIV services are structured within the Greek and Turkish healthcare systems are very different and have almost opposite results. Greece has only 16 HIV treatment centres, and 11 of them are located in Athens. If you have HIV and are living on a remote island, your HIV clinic may be a day’s journey away. Testing is free (though explicit consent is needed) and available in a variety of community settings, including migrant centres, though self-testing is not available.

The UNAIDS 95-95-95 target requires that 95% of people with HIV know they have it, 95% of those are taking antiretroviral therapy (ART) and 95% of them are virally suppressed, meaning 86% of all people with HIV are virally suppressed.

Professor Antonios Papadopoulos and Dr Konstantinos Protopapas, both of Attikon University Hospital in Athens, outlined the situation in Greece. Approximately 85% of people with HIV in Greece know their status and of those, 82% are linked to care and on ART. This process may take some time, though. In Greece, 55% of people start treatment within a month of diagnosis, while 26% have still not started treatment after three months (in the UK, for example, the corresponding figures are 75% and 12%).

Where Greece appears to fall behind the UNAIDS target most badly is in the proportion of people with HIV who have an undetectable viral load. This is 56% if we only count the proportion of people on ART with documented viral suppression, implying that the proportion of all people with HIV who are virally suppressed is only 39%.

But Dr Protopapas says the true proportion is nearer 86%, which is the number on ART who would be suppressed if undocumented viral load test results are also included. This would imply that that 61% of all people with HIV in Greece are virally suppressed.

He says: “According to the National Guidelines, viral loads should be done twice a year. The problem occurred during a five-year period, 2016-2021, when we could not perform the test, but since 2021 this has been resolved. We have had incomplete data entry during the past couple of years but we believe the 86% figure is accurate.”

He emphasised that the majority of people left behind the target are immigrants and people who inject drugs. On the second day of the conference, Dr Giota Lourida of Evangelismos Hospital in Athens presented an overview of HIV healthcare stigma and the challenges of HIV care in Greece, including staff shortages, HIV services not being provided at facilities for injecting drug users, and a lack of support services for migrants within the Greek healthcare system. She identified these as significant problems affecting HIV care.

A high proportion of new diagnoses in Greece are in key affected populations other than gay and bisexual men. In 2012, there was an HIV epidemic in drug users in Athens and more than half of all diagnoses were in injecting drug users that year. Since then there has been a smaller but significant increase in infections in drug users in Greece’s second-largest city, Thessaloniki. Swift action after the 2012 epidemic included setting up harm reduction services that quickly reduced onward HIV transmissions – diagnoses in injecting drug users were down to their previous level of 120-160 a year within two years. But that is still between 20 and 30% of all new diagnoses, which increased to 535 last year. For comparison, in a country with the population of the UK or France, that diagnosis rate would equal more than 3700 cases.

Migrants used to form about 10% of those diagnosed with HIV in Greece, but now 40% of new HIV cases are in people not born there. The majority of migrants acquire HIV after they have arrived in Greece.

The meeting heard a very moving testimony from a young west African woman (who asked not to be named) who had ended up in Greece after being trafficked from Türkiye. She gave an account of initially understanding she had tested HIV negative, getting shuttled between her HIV clinic and the medical service at her migrant centre, and constantly having to struggle to find basics such as bus tickets between one and the other. People with HIV in Greece are, unusually, entitled to a monthly benefit close to the national minimum wage regardless of their actual state of health, but undocumented migrants are not eligible.

In terms of the figures, although there has been international publicity about migrants flooding into Greece from Türkiye, most of them are Afghans, Syrians and Iranians – currently countries with low HIV prevalence. Most foreign-born people with HIV in Greece are from sub-Saharan Africa (30%, and over 50% of them women), central Europe (22%) and eastern Europe and central Asia (18%). People from north Africa and the Middle East only account for 6.1% of migrants with HIV.

As for the treatment cascade, even if as many people on ART with undocumented viral load results are undetectable as people with documented viral loads, still only 47% of HIV-positive people who inject drugs and 42% of migrants are virally suppressed.

So we can’t count on U=U (Undetectable equals Untransmittable) to bring down HIV infections in Greece, as yet. So how about PrEP? The answer is, there is almost none. The Greek Health Ministry approved the use of PrEP in September 2022 – but in practice it is not yet available.

Barriers to care in Türkiye

Dr Deniz Gökengin of the Ege University School of Medicine in Izmir presented the situation in Türkiye. In 2010, about 500 people a year were being diagnosed with HIV. This then started to rise exponentially, and in 2022 new cases reached 5200, meaning that for the first time the rate of new diagnoses in Türkiye outstripped the population rate in Greece, which has 12% of its population. Data from cohort studies found that 55% of cases were acquired via heterosexual sex and 27% via sex between men; Türkiye has not seen an epidemic in people who inject drugs like Greece.

While models show that, globally, HIV incidence – the rates of new HIV infections, regardless of diagnosis rates – halved between 2000 and 2020, incidence in Türkiye, though much lower in absolute terms, rose sixfold in men and fourfold in women, with the rate in women catching up in recent years.

Türkiye has a network of over 100 HIV care clinics and HIV testing services are widely available in hospitals, primary care centres, and via private labs. However, people don’t seem to be coming forward for testing. In terms of the 95-95-95 targets, once people are diagnosed 88% are linked to care and of them, 87% are virally suppressed. But it is estimated that only 41% of people with HIV in Türkiye know their status. This is strongly linked, firstly to the lack of a specific sexual health service and secondly to stigma, especially for key populations. There are only six specialist voluntary counselling and testing centres in the country, all in the big cities.

PrEP is in theory available in Türkiye but it is not reimbursed, while unfavourable price negotiations and exchange rates make even generic PrEP four times as expensive in Türkiye as in western Europe (the Lira has lost 83% of its value against the Euro since 2019). A local survey of men who have sex with men found that 41% were aware of PrEP, but only 1.7% were using it. Dr Gökengin’s centre opened a clinic for PrEP but found no takers for it. “No-one is using PrEP because the high price to be paid out of the pocket precludes its sustainability in the long term,” she says.

While much of the data to confirm it is missing, one factor or potential factor in the increase of HIV cases in Türkiye is the large number of migrants and refugees. Türkiye hosted the largest number of refugees and displaced persons in the world up until last year, when Iran, with a huge influx of Afghans fleeing the Taliban and economic collapse, overtook it. Most of them are 3.7 million Syrians fleeing civil war and who are “under temporary protection” (meaning that the Turkish government regulates their right to stay). Another 330,000 are refugees under international law. The Syrian civil war doubled the number of refugees in Türkiye, to 4.4% of the population. Overall, 16% of people with HIV living in Türkiye were born abroad.

The refugees are a young population – average age 22 – and 71% are women. Contrary to the images in the news, only 1.3% actually live in refugee camps – 98.7% live in towns, cities or ‘informal housing’. They are concentrated in nine southern provinces close to the Syrian border where they form 12.25% of the population as opposed to less than 5% in the other 91 provinces.

Significantly, only 0.008% – one in 12,500 people – have obtained a Turkish work permit, so most work illegally. It is unknown how many resort to sex work as there have only been small surveys of this population. A small study of 26 Syrian sex workers who were under temporary protection (14 trans women, eight cis women, four gay men) found that 81% had sex work as their sole source of income, 42% were using various drugs and 77% used alcohol.

There may be high rates of HIV and associated infections in this population, although this is unclear due to lack of testing. One survey of Syrian migrants in Istanbul found that 0.2% were HIV positive, which is similar to the general population. However, a scoping review of several studies of Syrian refugee women attending outpatient clinics nearer the border found that on average 2% had HIV, 2% hepatitis C and 4% chronic hepatitis B.

One piece of data suggested that investing in better testing and reporting could pay dividends. A model has shown that if testing rate in Türkiye was increased by 70%, there would be a subsequent decline of 85% in HIV incidence, solely due to the higher proportion with viral suppression.

EACS hopes to help Greece and Türkiye develop better services for people with HIV in these two countries that are pivotal in the fight to defeat HIV.

Many healthcare workers in Europe don’t know basic HIV facts, survey reveals

by Gus Cairns

A large survey of healthcare workers across Europe has revealed widespread ignorance about HIV transmission and prevention. A large minority were unaware that a person with an undetectable viral load cannot pass on HIV, while a majority were unaware of PrEP.

Although doctors were on the whole better informed than other healthcare workers, 51% of the physicians who answered the survey were either unaware of PrEP or had inaccurate knowledge of it.

The survey, jointly conducted by the European Centre for Disease Control and Prevention (ECDC) and the European AIDS Clinical Society (EACS), also found that a minority of healthcare workers were reluctant to treat people with HIV; this was often due to lack of training or outdated views on transmission, but also at times due to directly stigmatising attitudes towards people with HIV.

The findings of the study were presented to the EACS Standard of Care for HIV and Co-infections in Europe meeting in Athens on 17th October. It follows on from a survey of the experience of stigma among people living with HIV, which was presented at the 2022 Standard of Care meeting in Brussels (see this report for the full findings).

In that survey, 23% of respondents had said that they “worried about being treated differently” if they disclosed their HIV status to healthcare staff, and 12% said they had avoided healthcare appointments in the last year because of that worry.

Teymur Noori of ECDC, who collaborated with EACS on the survey, presented the findings. It was distributed to 54 countries in Europe and central Asia, in 38 languages, between September and December 2023; 18,430 people replied, a large number for this sort of survey. Nearly three-quarters (74%) of respondents were female and a quarter male; 35 people (0.3%) defined as non-binary.

Forty-four per cent of respondents were doctors and 22% were nurses. The other one-third ranged from other specialists such as radiographers and dentists to admin workers and students. Fifty-eight per cent said they worked in a hospital and 17% in a primary care centre.

Only 7% worked in a dedicated HIV department. Thirty per cent were located in an infectious disease department or other inpatient hospital facility, while 13% worked in surgery or in an A&E department. A quarter worked in primary care or another outpatient facility.

Perhaps the most revealing survey results were of respondents’ basic knowledge of HIV facts. The survey asked respondents whether they agreed with, disagreed with or didn’t know the answer to three statements about U=U, PEP, and PrEP. They were:

• U=U: People living with HIV who are on effective treatment and have an undetectable viral load cannot transmit the virus sexually.
• PEP: Taking a short course of HIV medicines after a possible exposure to HIV prevents the virus from taking hold in your body.
• PrEP: Someone who does not have HIV can take HIV medicines to prevent them from getting HIV.

“I disagree” and “I don’t know” were both classed as incorrect answers.

A quarter of respondents gave no correct answers to the three questions – not many fewer than the 31% who gave three correct answers.

People tended to give more correct answers to the U=U and PEP questions. Sixty-one per cent answered the U=U question correctly (69% of doctors), and 56% the PEP question (67% of doctors). But levels of knowledge of PrEP were considerably lower, with only a minority of 41% knowing about PrEP, and even a minority of doctors (49%).

The only workplace setting where more people knew about PrEP than not was community centres, where 53% knew and replied correctly about it. Only 46% of hospital workers were aware of PrEP, and only a third of people working in primary care. In contrast, two-thirds of hospital workers answered the U=U question correctly, and a bare majority (52%) of workers in primary care.

Understandably, those who cared for more people with HIV were more likely to have correct knowledge. Of healthcare workers who were not aware of having cared for any HIV-positive patients or clients in the last year, 23% answered the PrEP question correctly, versus 89% of those who had seen more than 100 people with HIV.

The survey asked about incorrect or out-of-date knowledge of HIV transmission, especially during medical procedures. About a quarter of respondents (23%) were “worried” dressing wounds of a person with HIV, and 27% when drawing blood. Twenty-six per cent said they still used double gloves when working with a person with the virus.

The survey also asked whether people “preferred not to” provide services for four different key populations with HIV: transgender women and men, sex workers, men who have sex with men and people who inject drugs. This varied by geographical region, with scarcely any respondents in western Europe not wanting to work with the first three categories and 6% preferring not to work with people who inject drugs, whereas in eastern Europe 15% preferred not to work with the first three categories and 21% not with drug users.

Among the people expressing aversion to working with HIV-positive patients or clients, the reasons for these preferences ranged from the practical (“I haven’t had training”, with 50% of respondents giving this reason for not working with drug users and 49% with transgender people), through outdated or exaggerated risk perception (“They put me at risk”, with 43% giving this reason not to work with drug users and 38% with sex workers) to straightforward disapproval (“This group engages in immoral behaviour”, with 50% giving this as the reason not to work with men who have sex with men and 45% with sex workers).

When asked if they had observed stigmatising behaviour in other healthcare workers, 30% said they had heard discriminatory remarks, 22% had witnessed reluctance to care, and 19% said they had witnessed non-consensual disclosure of a person’s HIV status to a third party.

Teymur Noori concluded: “This study underscores the importance of implementing targeted interventions aimed at different healthcare facilities and healthcare professions to combat HIV-related stigma and discrimination.”

The full report of the ECDC/EACS survey, HIV Stigma in the Healthcare Setting, can be accessed here.