North America and Western and Central Europe .1 A largely stable epidemic

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Fig. 2.33 Number of people living with HIV, North America and Western and Central Europe, 1990–2010

Millions

3.0

1.0 2.0

0 2.5

0.5 1.5

Thousands

175

50

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Fig. 2.34 Number of people newly infected with HIV, North America and Western and Central Europe, 1990–2010

75 25 0 125 150 100

Thousands

125 100 75 50

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Fig. 2.35 Number of people dying from AIDS-related causes, North America and Western and Central Europe, 1990–2010

25 0

The HIV epidemic in North America and Western and Central Europe remains stable overall, with the incidence of HIV infection having changed little since 2004. An estimated 88 000 [56 000–150 000] people were newly infected with HIV in 2010, most of them in the United States of America. According to the United States Centers for Disease Control and Prevention, the HIV incidence in the United States has been relatively stable in the past few years, with between 48 600 and 56 000 people acquiring HIV infection annually

The total number of people living with HIV in North America and Western and Central Europe reached an estimated 2.2 million [1 900 000–2 700 000] in 2010, about one third (34%) more than the 1.6 million [1 400 000–1 800 000] in 2001 (Table 2.1, Fig. 2.33–

2.35). More than half (about 1.2 million) of the people with HIV in this region live in the United States.

The rising number of people living with HIV refl ects the wide-scale availability of antiretroviral therapy,

which has signifi cantly reduced AIDS-related mortality.

The number of people dying from AIDS-related causes has varied little since 2000 (despite the 34% increase in the number of people living with HIV) and totalled about 30 000 [26 000–37 000] in 2010.

The epidemic’s recent trends vary across this region.

The rates of diagnosed HIV cases doubled between 2000 and 2009 in Bulgaria, Czech Republic, Hungary, Lithuania, Slovakia and Slovenia and increased by more than 50% in the United Kingdom (116). In contrast, the number of people newly diagnosed with HIV decreased by more than 20% in Latvia, Portugal and Romania (116).¹

2.7.2 Unprotected sex between men is fuelling HIV transmission

Unprotected sex between men continues to be the main driver of HIV transmission in this region (116), with injecting drug use and unprotected paid sex being minor factors. In the United States, for example, men who have sex with men represent about 2% of the total population but account for 57% of the people newly infected (160,161). The HIV incidence in the United States increased during 2006–2009 among young men who have sex with men and especially among African-American men who have sex with men (159).

This epidemic pattern means that, across this region, men outnumber women among people living with HIV. In 2010, 26% of the people living with HIV in North America and Western and Central Europe were women, a proportion that has changed little since the late 1990s.

The HIV epidemics among men who have sex with men appear to be resurgent in North America and much of western Europe (162). In Western and Central Europe, the number of men who have sex with men newly diagnosed with HIV infection increased from 7601 in 2004 to 9541 in 2009 (116). The 3080 men who have sex with men newly diagnosed in the United Kingdom in 2010 was the highest annual number yet (163). Trends of increasing numbers of people living with HIV in this key population at higher risk are also evident in Belgium (164), France (165), Germany (166), the Netherlands (166), Slovenia (167) and Spain (168,169).

1 People who are newly diagnosed with HIV infection did not necessarily acquire HIV infection recently, nor does this refl ect the actual number of people newly infected. But where HIV testing coverage remains relatively consistent, trends in the numbers of people newly diagnosed with HIV can provide a useful picture of recent trends in the epidemic.

The HIV incidence among men who have sex with men in the United Kingdom is estimated to have increased from 0.5% [0.1–0.8%] in 2002 to 0.9% [0.5–1.3%] in 2007 (170). In France, about 50% of the men who have sex with men newly diagnosed with HIV infection between 2003 and 2008 had acquired infection recently (165).

In the United Kingdom, one quarter of the men newly diagnosed with HIV in 2010 had become infected 4–5 months before diagnosis (171). In the United States of America, the estimated number of men who have sex with men newly infected with HIV increased by 17%

from 2005 to 2008 in the 37 states with suffi cient data (172,173). In New York City, the HIV incidence in 2005–2008 more than doubled among men who have sex with men, and syphilis rates increased six-fold among those aged 18–29 years (174) – an indication of increased sexual risk-taking (175). Similar trends have been reported in Canada (176). This underscores the need for ongoing prevention efforts, especially ones tailored for young men who have sex with men.

2.7.3 HIV infection trends are showing signifi cant racial, ethnic and socioeconomic disparities

In the United States of America, the increase in HIV diagnoses has been especially marked among black men who have sex with men, especially those who are young (177,178). National behavioural surveillance data for 2008 showed a 28% HIV prevalence among African-American men who have sex with men versus 18% among Hispanics and 16% among whites (179).

Those racial and ethnic disparities are mirrored also in the overall HIV epidemic in the United States (180), with blacks disproportionately affected. Despite representing less than 14% of the country’s total population, African-Americans accounted for half the people diagnosed with HIV infection in 37 states in 2005–2008 (181,182). Blacks have an estimated 1 in 22 lifetime risk of receiving an HIV diagnosis versus 1 in 170 for whites and 1 in 52 for Hispanics (181).²

Socioeconomic divides appear to be equally important in the epidemic in the United States. A study in 23 cities found an average HIV prevalence of 2.1% among heterosexual residents of high-poverty areas (183).

The HIV prevalence was inversely related to annual household income – the lower the income, the higher

2 Lifetime risk refers to the probability, at the day of birth, that an individual will be diagnosed with HIV infection at some point during his or her lifetime.

the HIV prevalence. HIV prevalence did not differ by race or ethnicity in that population. The researchers concluded that poverty may account for some of the racial and ethnic disparities found in HIV prevalence rates for the overall population in the United States – 46% of African-Americans and 40% of Hispanics live in high-poverty areas versus just 10% of whites (184).

In Canada, meanwhile, Aboriginal people continue to be overrepresented in the HIV epidemic. Although they comprise less than 4% of Canada’s population, they accounted for 8% of the total number of people living with HIV and almost 13% of the people newly infected in 2008 (185). Injecting drug use was the probable cause for most of the Aboriginal Canadians newly infected (66% versus 17% for all Canadians) (185).

Immigrants living with HIV have become a growing feature of the epidemics in several countries in Europe.

In Western and Central Europe, 49% of the people newly diagnosed with HIV infection acquired through heterosexual transmission originated from countries with generalized epidemics (in sub-Saharan Africa, the Caribbean and Asia) (116). In the United Kingdom, for example, two thirds of the heterosexuals newly diagnosed with HIV infection in 2009 had probably acquired HIV infection, mainly in sub-Saharan Africa (186). However, the number of diagnoses among people infected heterosexually outside the country has decreased in the United Kingdom since 2003 (186), and diagnoses among people who most likely were infected inside the United Kingdom have risen (from 210 in 1999 to 1150 in 2010) (171).

The decline in the rates of new infections among people who inject drugs in western Europe and parts

of central Europe appears to be continuing and has been attributed to harm-reduction services (187). Injecting drug use continues to drive the epidemic in Estonia, which has the highest national HIV prevalence among adults in all of Europe (1.2%). The HIV incidence among new injectors has declined signifi cantly since 2005, however. The estimated HIV incidence among people who inject drugs in Tallinn (Estonia), for example, slowed from 18 to 8 per 100 person-years between 2005 and 2009, a period when the needle and syringe programme expanded signifi cantly (188).

Injecting drug use also appears to be fuelling the more recent epidemic in Poland, where 18% of people who inject drugs tested in 2009 in eight regions were living with HIV (189). However, the absolute numbers of people who inject drugs newly diagnosed with HIV infection have decreased (from 201 in 2004 to 39 in 2009) (116). In Greece, the 113 people who inject drugs newly diagnosed with HIV in the fi rst seven months of 2011 was almost nine times higher than the average annual number of people who inject drugs diagnosed in the previous decade (190).

Considering the overall scale of the epidemic in this region, the estimated number of children living with HIV is very small: slightly more than 6000 [3500–

8000] in 2010. This refl ects both the centrality of sex between men in the epidemic and the extensive provision of services that can prevent the mother-to-child transmission of HIV. Remarkably few mother-to-children younger than 15 years have been newly infected with HIV (<500) or died from AIDS-related illnesses (<500) in this region in 2010.

2.8 Middle East and North Africa