The HepHIV 2023 Madrid conference: A call to action for political leadership in reaching the sustainable development goals on earlier testing and linkage to care for HIV, viral hepatitis, and sexually transmitted infections
Daniel Simões and Dorthe Raben shared first authorship.
Abstract
Introduction and Objectives
The HepHIV 2023 Conference, held in Madrid in November 2023, highlighted how Europe is not on track to meet the United Nations (UN) sustainable development goals and Joint UN Programme on HIV/AIDS (UNAIDS) targets. This article presents the outcomes of the conference, which focus on ways to improve testing and linkage to care for HIV, viral hepatitis, and other sexually transmitted infections. HIV-related stigma and discrimination, a major barrier to progress, was a key concept of the conference and on the agenda of the Spanish Presidency of the European Union.
Methods
The HepHIV 2023 organizing committee, alongside the Spanish Ministry of Health, oversaw the conference organization and prepared the scientific programme based on abstract rankings. Key outcomes are derived from conference presentations and discussions.
Results
Conference presentations covered the obstacles that HIV-related stigma and discrimination continue to pose to access to services, models for data collection to better monitor progress in the future, and examples of legislative action that can be taken at national levels. Diversification of testing approaches was also highlighted, to reach key populations, (e.g. migrant populations), to increase testing offered in healthcare settings (e.g. emergency departments), and to account for different stages of epidemics across the region.
Conclusion
With a strong call for intensified action to address the impact of HIV-related stigma and discrimination on testing uptake, the conference concluded that strengthened collaboration is required between governments and implementers around testing and linkage to care. There is also an ongoing need to ensure sustainable political commitment and appropriate resource allocation to address gaps and inequalities in access for key populations and to focus on the implementation of integrated responses to HIV, viral hepatitis, and sexually transmitted infections.
INTRODUCTION
The number of new HIV infections and AIDS-related deaths has declined over the last decade in the European Union (EU)/European Economic Area (EEA) and globally, but new infections are still rising in the World Health Organization (WHO) European Region, with the Eastern part of the region continuing to see increasing epidemics of HIV, viral hepatitis, and tuberculosis (TB). Approximately one in five people living with HIV in the WHO European Region remain undiagnosed [1, 2]. Late presentation for care has not declined significantly, signalling that testing programmes are not sufficiently effective. Addressing this is critical for the health of individuals and for the region to achieve the sustainable development goal of ending the HIV/AIDS epidemic by 2030.
In addition, more than 10% of people living with HIV report experiencing HIV-related stigma and discrimination in healthcare and community settings, hampering prevention, testing, and treatment efforts and indicating that further work is required to reach the goal of ‘zero stigma’ [3].
To address these ongoing challenges, since 2007, the EuroTEST initiative has hosted eight European conferences focused on optimal testing and earlier care. This short paper reports from the latest HepHIV 2023 conference, which took place in Madrid, 13–15 November, in conjunction with the Spanish Presidency of the EU. The conference focused on progress and implementation of integrated testing, new technologies, and ensuring equity in the delivery of services for HIV, viral hepatitis, and sexually transmitted infections (STIs). Attendees discussed innovative strategies and technologies for prevention, earlier testing, and linkage to care and partner notification for key populations, especially migrants and mobile populations. The conference also particularly focused on the impact of stigma and strategies to mitigate it – a topic that was made a political priority area under the Spanish EU Presidency.
METHODS
An organizing committee of 23 experts from 22 Spanish and other European organizations was assembled (2022–2023) to oversee the conference organization and prepare the scientific programme. The programme was structured into five plenary sessions, four abstract-driven sessions, three poster sessions (including six poster categories), and five side meetings. Speakers for the plenary sessions were selected by the organizing committee, whereas the content of the abstract-driven sessions was determined through peer review of submitted abstracts.
Key outcomes arising from the conference presentations and discussions were summarized in the closing session, through participant evaluation with pre-defined questions available in the conference app and are presented in this short report.
In parallel, in preparation for the Spanish Presidency of the Council of the EU (July–December 2023), the Spanish Ministry of Health (Division for Control of HIV, Sexually Transmitted Diseases, Viral Hepatitis, and Tuberculosis) placed the elimination of stigma and discrimination associated with HIV as a political priority and arranged a high-level meeting entitled “HIV and human rights: Political action to achieve ZERO Stigma” in Seville on 15 September 2023.
RESULTS
The HepHIV 2023 conference was attended by 185 participants from 32 countries. Of the attendees, 41% were community representatives; 22% were policy-makers/public health institution representatives; 16% were clinicians; 8% represented social scientists, epidemiologists, or statisticians; and 13% represented other groups. The scientific programme included research and interventions selected from 55 abstracts submitted from 16 countries.
Stigma and discrimination in accessing testing services for HIV, viral hepatitis, TB and STIs
As part of the Spanish Presidency, and in alignment with the vision of the Spanish Ministry of Health, a main theme of the conference was to understand and discuss current data and evidence of stigma and discrimination as a barrier to testing. Presentations highlighted the need to address HIV-related stigma and discrimination as a key structural barrier preventing Europe from meeting the sustainable development goal and Joint United Nations Programme on HIV/AIDS (UNAIDS) targets. Several presenters addressed the importance of political support to take action to address HIV-related stigma, providing examples of good practice in reviewing and updating national legislation to remove HIV-related discriminatory laws and regulations in Spain [3-6]. For example, legislative reforms implemented in Spain removed some medical reasons for exclusion from public employment (HIV, psoriasis, coeliac disease, and diabetes mellitus), which were still valid for exclusion from employment in state security forces, armed forces, customs surveillance bodies, and the penitentiary in 2023. Other reforms include Comprehensive Law 15/2022 of July 12 on equal treatment and non-discrimination, which for the first time now states that serological status cannot be used a reason to treat a person differently at the national level. The Sports Law 39/2022 also introduced measures in favour of equality and against any type of discrimination, making reference to discrimination due to HIV, and guaranteeing access to sport for any person. Finally, Royal Decree 426/2023 removed a requirement for a person to have an HIV-negative status to have and use weapons to provide private security services. This modification eliminates the barrier for people with HIV to provide armed private security functions [7-10].
HIV-related stigma in healthcare settings was also reported and documented, with clinicians describing the consequences of people being unable to access services. The persistent lack of data around HIV stigma is being addressed at European and national levels with surveys coordinated by the European Centre for Disease Prevention and Control (ECDC) in collaboration with the European AIDS Clinical Society and a forthcoming survey conducted by the World Hepatitis Alliance on stigma related to viral hepatitis [3]. Discussions also raised the missed opportunities to diagnose individuals who do not appear to be “at risk” for HIV, where stigma is among the reasons that people are not offered tests. Finally, it was recommended to always use person-centred language to avoid contributing to stigma (Peoples First Charter) [11].
Integrated testing and integrated services
Several sessions discussed good practices of integrated testing interventions in different settings, with good examples from the United Kingdom, Portugal, France, Australia, and Spain [12]. The Fast Track City initiative was highlighted as a good model for enhancing cross-programme and cross-sector collaborations. It is important to be aware that situations vary widely across the European Region, requiring diversification and tailoring of testing approaches to local contexts. In some settings that are close to reaching the targets, such as London, it should be acknowledged that the closer we get to elimination, the harder and more costly it will be to find the remaining cases and secure funding and political commitment.
A well-documented challenge to implementation of integrated testing programmes is the silo-based nature of programmes (in terms of planning, delivery, and funding), competing clinical priorities, and national policies that are not always updated to account for the latest evidence and recommendations around integration.
Presentations and sessions discussed screening for blood-borne viruses in emergency departments as a highly effective, feasible, and cost-effective intervention in high-prevalence areas. Evidence shows that these programmes tend to identify people who are older, more ethnically diverse, and at a later stage of infection [2]. For these programmes to become successful, there needs to be a focus on optimizing pathways for effective linkage to care and to retain motivation of emergency department doctors with competing clinical priorities [12-15]. The positive outcomes from these pilot studies led to England's Department of Health recommending and funding routine opt-out testing in emergency rooms in London and other areas with high HIV prevalence as part of the national HIV Action Plan [16].
Reaching migrants and mobile populations with services
A special session discussed lessons learned from testing implementation in migrant and displaced populations across Europe, including during the Ukrainian crisis. Migrants account for a significant proportion of people newly diagnosed with HIV in Europe (48% in the EU/EEA in 2022, defined as originating from outside the country in which the diagnosis was made). Although transmission occurs post-migration for many, a significant proportion have also been infected and/or diagnosed in another country before arrival (16.6% in the EU/EEA in 2022), largely reflecting the influx of people from Ukraine, a country with a high prevalence of HIV [2, 9]. Stigma, discrimination, racism, and legal barriers are the primary barriers to healthcare access for migrants. Presentations highlighted how non-governmental organizations in Ukraine and Poland have played a major role in facilitating and providing access to testing and treatment for Ukrainian refugees.
The session also highlighted the urgent need for inclusive health policies and scale-up strategies for delivering HIV testing, prevention, and treatment tailored to migrant populations. Healthcare policy must account for the need for earlier testing and treatment for migrants during the full migration process (pre, during, post).
Outcome of conference evaluation and call to action
In total, 27% (n = 51) of conference participants responded to the conference evaluation: 92% of respondents agreed that the overall conference was useful and informative, 96% agreed that it was relevant to their field of work and/or current research, and 94% were satisfied with the whole conference and felt it met their expectations. The overall impression of the presentations from the scientific programme was positive, with 96% indicating that the scientific programme was interesting and informative and 92% saying that the presentation topics were appropriate. There was consensus that the scientific programme covered a variety of disease areas (90%) and had a wide range of geographical representation (88%).
HepHIV 2023 concluded with a Call to Action with six areas for action in the field of earlier and integrated testing for HIV, viral hepatitis, STI, and TB (Table 1).
| We, the participants of the HepHIV 2023 conference, call on all stakeholders in the European region to work together towards the 2030 Sustainable Development Goals for HIV, viral hepatitis, sexually transmitted infections (STIs) and tuberculosis (TB) by implementing the following actions: |
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DISCUSSION AND CONCLUSION
The HepHIV 2023 conference provided a platform to discuss the actions necessary for Europe to achieve the targets set for HIV, hepatitis, STIs, and TB. It specifically highlighted the need to invest in a systematic and coordinated approach to measuring the impact of stigma on the offer and uptake of testing in community and healthcare settings and to implement interventions to address it. The conference called for efforts to be intensified in designing culturally competent prevention; in providing testing and care services for migrant and displaced populations; in removing access barriers; and to improving epidemiological surveillance, monitoring, and evaluation to inform evidence-based decision-making and programme development.
The key points and results from the Spanish high-level meeting were discussed during the conference and are reflected in the technical document “Stigma and discrimination associated with HIV: The challenge”, prepared jointly by the Ministry of Health, the ECDC, WHO Europe, UNAIDS, and the Sociedad Española Interdisciplinaria del Sida (SEISIDA), and reviewed by more than 20 leading national and international institutions [6]. The document provides a roadmap for countries in the EU to combat HIV-related stigma and discrimination in various dimensions, including legal reforms, access to health care for the most vulnerable populations, addressing public service discrimination, promoting educational initiatives, and coordinating between political authorities and communities. The document was subsequently presented in the European Parliament on World Aids Day, 1 December 2023.
Several actions preceded the focus of the Spanish EU Presidency on stigma. Since 2018, Spain has focused on legislative actions, including the Social Pact for Non-discrimination and Equal Treatment associated with HIV 2018, and joining the UNAIDS global partnership of action to eliminate all forms of stigma and discrimination associated with HIV – the second European country to do so.
The conference Call to Action reflects outcomes from the HepHIV 2023 Madrid conference and covers key topics presented and discussed during the conference. It is not intended to be exhaustive, nor does it cover everything addressed within each thematic area.
The success of the Spanish Ministry of Health in having the topic of HIV-related stigma and discrimination included on the national and European agenda demonstrated the need for further strengthening of collaboration between governments and implementers around testing and linkage to care. This will ensure sustainable political commitment and appropriate resource allocation in the future, and can serve as a model for other countries.
The conference participants called for European HIV, hepatitis, STI, and TB-specific actions to be integrated into national roadmaps and strategies and designed and implemented in multi-sectorial collaborative approaches across the region. Having a clear strategy linked with adequate resources and mobilizing all stakeholders is the only way that, as a society, we can ensure every single person has access to the healthcare services they need and that we reach the 2025 and 2030 international goals to help eliminate these threats.
AUTHOR CONTRIBUTIONS
All authors contributed to writing the manuscript on behalf of the HepHIV 2023 conference organizing committee and the EuroTEST steering committee. DR and DS led and coordinated the writing process while other authors provided specific content on the various sections. All authors commented on the manuscript and approved the final manuscript.
ACKNOWLEDGEMENTS
This article was written by the authors on behalf of the HepHIV 2023 conference organizing committee and the EuroTEST steering committee.
HepHIV 2023 conference organizing committee: Ann K. Sullivan, Chelsea & Westminster Hospital, United Kingdom; Alejandro Bertó Moran, National non-governmental organization (NGO)/patient representative. Coordinator of ADAHARA and founder Seville Check Point, Seville, Spain (local conference co-chair); Arkaitz Imaz, Spanish Society of Infectious Diseases (SEIMC) and Bellvitge Hospital, Barcelona, Spain (local conference co-chair); Ben Collins, ReShape/International HIV Partnerships, United Kingdom; Cary James, World Hepatitis Alliance, United Kingdom; Daniel Simões, GAT, Portugal (co-chair); Denis Onyango, Africa Advocacy Foundation, United Kingdom; Elena Vaughan, University of Galway, Ireland; Erika Duffell, European Centre for Disease Prevention and Control (ECDC), Sweden; Julia Del Amo, Director of the HIV, STIs, Viral Hepatitis and Tuberculosis Control Division, Ministry of Health, Spain (local conference co-chair); Jordi Casabona, Center for HIV/STI Epidemiological Studies of Catalonia (CEEISCAT), Spain; Jürgen Rockstroh, Department of Medicine I, University Hospital Bonn, Germany (co-chair); Lella Cosmaro, Fondazione LILA Milan, Italy; Teymur Noori, European Centre for Disease Prevention and Control (ECDC), Sweden; Magdalena Ankiersztejn-Bartczak, European AIDS Treatment Group (EATG), Poland; Maria Buti, EASL, Spain; Milan Mishkovikj, ELPA, Macedonia; Ricardo Baptista Leite, UNITE Parliamentarians Network for Global Health, Portugal; Roberto Pérez Gayo, Correlation Network/C-EHRN, The Netherlands; Stefan Baral, Johns Hopkins Bloomberg School of Public Health, USA; Thomas Seyler, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Portugal; Tom Platteau, Institute of Tropical Medicine, Department of Clinical Sciences, Antwerp, Belgium; Viatcheslav Grankov, WHO Regional Office for Europe, Denmark.
EuroTEST steering committee: Ann K. Sullivan, Chelsea & Westminster Hospital, United Kingdom; Ann-Isabelle von Lingen, European AIDS Treatment Group (EATG), Belgium; Ben Collins, ReShape/International HIV Partnerships, United Kingdom; Brian Gazzard, Chelsea & Westminister Hospital, United Kingdom; Cary James, World Hepatitis Alliance, United Kingdom; Daniel Simões, Grupo de Ativistas em Tratamentos (GAT), Portugal; Daniela Rojas Castro, Coalition PLUS, France; Ferenc Bagyinszky, AIDS Action Europe, Germany; Francesco Negro, University Hospitals Geneva & European Association for the Study of the Liver (EASL), Switzerland; Igor Karpov, Belarus State Medical University, Belarus; Irith De Baetselier, Institute of Tropical Medicine, Department of Clinical Sciences, Antwerp, Belgium; Jack S. Lambert, University College Dublin (UCD), Ireland; Jens Lundgren, University of Copenhagen; CHIP, Copenhagen, Denmark; Johanna Brännström, Department of Infectious Diseases, South Hospital & Institute of Medicine, Karolinska Institute, Stockholm, Sweden; Jordi Casabona, El Centre d'Estudis Epidemiològics sobre les Infeccions de Transmissió Sexual i Sida de Catalunya (CEEISCAT), Spain; Jürgen Rockstroh, University of Bonn, Germany; Kira Grazava, TB Coalition Europe, Ukraine; Lella Cosmaro, Lila Milano, Italy; Liudmyla Maistat, Medicines Patent Pool, Switzerland; Magnus Unemo, WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Örebro University Hospital, Sweden; Mojca Matičič, University Medical Centre Ljubljana, Slovenia; Nikos Dedes, Positive Voice, Greece; Nino Tsereteli, Center for Information and Counselling on Reproductive Health – Tanadgoma, Georgia; Rajul Patel, Southampton University Hospitals, Southampton & International Union against Sexually Transmitted Infections (IUSTI), United Kingdom; Tom Platteau, Antwerp Institute of Tropical Medicine, Belgium; Valerie Delpech, Public Health in Northern New South Wales, Australia; Yazdan Yazdanpanah, ANRS Maladies Infectieuses Emergentes, France.
Observers to the EuroTEST steering committee: Anastasia Pharris, European Centre for Disease Prevention and Control (ECDC), Sweden; Stela Bivol, Viatcheslav Grankov and Marcelo Naveira, WHO Regional Office for Europe, Denmark; Thomas Seyler, European Monitoring Centre for Drugs and Drug Addiction (EMDCCA), Portugal.
