EG on HIV, TB and Associated Infections First Meeting Tuusula, Finland October 28-29, Reference HIV, TB&AI 1 Title

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1 EG on HIV, TB and Associated Infections First Meeting Tuusula, Finland October 28-29, 2015 Reference HIV, TB&AI 1 Title Minutes of the Meeting Submitted by Dmitry Titkov, acting ITA Requested action For information October Opening of the meeting EG Chair Ali Arsalo opened the meeting and greeted the participants. He noted that as the change in the name of the EG was formally approved (from HIV/AIDS&AI to HIV, TB&AI, the meeting can be considered as the first one under the new name. He also informed the meeting that as Outi Karvonen leaves the post of the EG ITA. The Finnish Ministry of Social Affairs and Health proposed the candidatures of Mr Dmitry Titkov and Ms Paula Tanhuanpää (both from THL/Finland) to the vacant position. Besides, Finland also appointed experts to the HIV, TB & AI EG, who are Prof. Mika Salminen (THL) and Dr. Kristiina Salovaara (Filha ry). The opening was followed by the introduction round of the participants. Poland, Latvia and Estonia could not make it to the meeting due to various reasons. 2. Adoption of the agenda The agenda was adopted by the meeting. 3. Presentation by HivFinland (Ms Sini Pasanen, Executive Director) Sini Pasanen told briefly about the over 25-year long history and structure of the nongovernmental patient organisation, and also presented the key purposes of the organisation s operations. Following the introductory part, she shared information about one of the ongoing projects called SeksiPertti (Sexy Peter). The campaign is targeted at MSM and seeks to raise awareness about HIV and other sexually transmitted diseases, to fight stigma and generally to improve the life of people living with HIV. The project started with a survey, which was conducted in early summer 2015 and embraced 1100 respondents. Detailed information about the survey findings is available from the presentation published in the post-meeting section of the meeting s webpage at tuusula 1. Answering the question about HIV criminalization, the speaker told that at the moment there are two court proceedings in progress. According to the law, if a person has a positive HIV status, this person has to disclose this information to the partner and ensure the use of condoms. HIV tests are provided in the primary healthcare, student healthcare, NGOs, testing sites for immigrants, harm reduction facilities, and are also bought online for testing at home (not official tests). For HIV-testing there is Checkpoint. What we are missing in Finland, is 1 The presentations of all meeting s speakers are available from this link. 1

2 MSM-friendly health care clinics offering also other sexually transmitting diseases testing and counselling. The school subject on sexual and reproductive health does not include explicit information on sexual relations between men. 4. Implementation of the current NDPHS Strategy and the EU Strategy for the Baltic Sea Region; funding possibilities Mr Marek Maciejowski, Director of the NDPHS Secretariat, advised the audience about the approval of the new NDPHS Strategy (June 2015) and Action Plan accompanying the NDPHS Strategy (September 2015). The speaker presented brief information about the Strategy (vision, overall objective, cross-cutting themes, objectives, and guiding principles), which is estimated till 2020 to link it with relevant funding programmes, most of which are developed for the same spell of time. The Action Plan for the NDPHS Strategy was adopted in October 2015 by the CSR. Overall, the Action Plan s two key parts are: the description of horizontal results and activities, and activities to achieve the objectives of the Strategy. Objective No 1 of the Strategy falls foremost under the responsibility of the HIV, TB & AI EG. It was noted that hepatitis is missing from the Strategy. Although not specifically mentioned, hepatitis was kept in mind too. If the EG decides to have the wording modified and produces reasonable rationale for this to be done, the EG Secretariat will start necessary proceedings. The ultimate decision-making authority lies with the CSR. The Action Plan has very concrete expected results, which cannot be achieved via meetings, and they definitely require project work and activity by EG members in between the meetings. Another challenge is establishing links with the Prison Health EG, which was established in the last metres of the planning process. The EG Chair remarked that the first four bullet-points of the Action Plan have connection with the HIV/AIDS&AI EG. But now, as the Prison Health EG was established, the prison-related bullet-points should be negotiated with the newly established EG and either shifted under its responsibility or implemented in collaboration with the PHC EG. Also the EG Chair noted that the education for children should be relocated from the expected results to the activity level (under expected result No 3). When speaking about the funding opportunities, Marek Maciejowski mentioned the recently completed HIV prevention project funded from ENPI Regional East Programme to the NDPHS. This year the European Commission decided that the ENI s part of funding foreseen for the NDPHS would be granted for a project submitted by the NCD EG. The ENI funding will be made available to the NDPHS also next year. The EG can pick 1-2 expected results from the NDPHS Action Plan and propose that they be implemented as projects funded by the EU. The ENI focuses on collaboration with Russia, and the proposals to present to the EC must have clear relevance to EU s interests and bring concrete added value. Later this year Mr. Maciejowski will approach EGs to ask them for their ideas on how to spend 80, ,000 euros (1-3 years) allocated for the four priorities of the EU Baltic Sea Region Programme. Priority No 4 of the EU BSRP is relevant to the NDPHS in its capacity as a Policy Area Health Coordinator. 2

3 Norwegian funding is available for projects with Russian partners, although not anymore announced in the NDPHS Project Pipeline. One of the requirements is having a Norwegian organisation as a lead partner. Talks are being held with Russia s representatives as Russia is most likely to become part of the EU Baltic Sea Region Programme and allocate financial input for this purpose. It is hoped that Russia will be eligible beginning with the 2 nd call for proposals to be announced in a couple of months. Also, Russia had informed it might allocate funding to Russian partners for their participation in NDPHS projects. There is the European Social Fund, which has a lot of money, but imposes quite inconvenient (from the perspective of the NDPHS regional projects) requirements and restrictions. As for the ToR for Consultant project idea, prepared by the EG and submitted in summer 2015 but rejected by Brussels, one of the ways to proceed is to improve it and submit again with view to using the EU Framework Contract mechanism. Marek Maciejowski will send in November information to the NDPHS Expert Groups regarding ENI funding opportunity offered by the European Commission to the NDPHS for year 2016 and how the groups can possibly benefit from it. Afterwards the EG Secretariat will approach the EG members with the specific request on further actions regarding the re-application. 5. New ToR for the former HIV/AIDS&AI and change of the name The new name of the EG (from HIV/AIDS&AI to HIV, TB & AI) underlines the substance of the EG s activity and significance of the operational scope, and has reference to the CSR decision from the previous year and WHO comments. Overall Objective for the EG is No 1. The formulation logic is similar in all the EGs. Functions and expected results were formulated to ensure least dependence on external funding. Much emphasis is placed on sharing information. Also some expected results assume project-based work. Two extra functions were added in the relevant list continuation of close collaboration with the Barents HIV/AIDS Programme and the Barents TB Programme; as well as contribution to the implementation of the EU HIV Strategy and Russian Northwest Regional Strategy. Finland, as the Lead Partner, proposed Dr. Ali Arsalo as the Chair of the newly established EG, and Poland proposed Dr. Anna Marzec-Bogusławska as the Vice-Chair. The EG is to approve the proposed candidatures. It was commented that as the name of the EG was changed and activity scope enlarged, it may lead to the growth of the EG. Therefore, new working models could be explored, e.g. participants of the EG meetings could change depending on the priority topics of the meetings. As for working in between the meetings, the EG has never had problems with that. As before, countries cover costs of their respective experts, and annual reporting and annual planning approach remains. 6. Presentation on drug use in Finland Ministerial Adviser Elina Kotovirta, Ministry for Social Affairs and Health The current situation with drug use in Finland was presented, with data referring to a survey conducted in According to the survey, the public feels more accepting in terms of harm 3

4 to the use of cannabis than to tobacco or immoderate use of alcohol. Also, according to the survey, smoking marihuana occasionally is more acceptable than before. More and more people think that marihuana and cannabis should be legalized. The popularity of needle exchange grows, and the number of new HIV infections among IDUs is on decline. The full presentation is available at the webpage of the meeting. 7. HIV/AIDS&AI Action Plan The EG Chair prepared and distributed a work plan matrix, which can serve as the basis for planning the EG s work for He noted that out of four expected results, No 3 is projectoriented and requires extra funding, and regarding expected result No 4 the EG could make more use of the information collected for wider dissemination. The EG Secretariat will come back to the EG members with more specific questions regarding the actions to be carried out in Afterwards, the EG members proposals for activities in 2016 can be synthesized by the EG Secretariat into the 2016 work plan of the HIV, TB and AI EG. The work plans of EGs are expected to be approved at the spring meeting of the Committee of Senior Representatives. 8. Development and facilitation of HIV/AIDS&AI EG projects Building capacity in prevention of HIV and associated infections among youth at high risk NDPHS Secretariat (lead) Mr. Marek Maciejowski made a short review of the recently completed project. The project produced methodological material, which has been posted on the project partners websites. The guidelines produced by the project include statistics and findings of a survey conducted among children and adolescents in difficult life situations and migrants in Russia. Also, best practices were collected from different countries. Dr Nechaeva briefly reviewed the document and pointed out that the survey had been conducted with legal and regulatory errors, therefore, the findings are not valid due to, at least, the facts that the under-age children were interviewed without informed consent and presence of their legal representatives and there was no permission of the ethical committee, etc. The Russian members of the EG were asked to provide in writing their comments so that corrections could be done to the electronic version of the guide and thus high quality of the product was ensured. After consultations at national level, the Russian representatives at HIV, TB & AI EG were advised to report to the EG Chair and the NDPHS Secretariat that at request of Russian senior representatives to remove the publication in question from NDPHS website at 25 th CSR, the decision of removal was approved by the CSR. The proposal of considering of putting the publication back to the site with a list of errors is a mandate of CSR. EU Joint Action on HIV and Co-infection Prevention and Harm Reduction (HA- REACT) EG ITA Ms. Outi Karvonen made a concise review of the progress and current situation. The project officially started on October 1 but was not yet kicked-off. The EG is expected to be present at the Advisory Board of the project. Besides, many of the EG members participate in the project. 4

5 Barents HIV and TB Programmes EG ITA Only Norway continues to finance bilateral cooperation with Russia. Finland ends up the coordination of the Barents HIV Programme in December 2015, and no other country is willing to take over the coordinator role. Negotiations are being held now that the HIV, TB & AI EG ITA could take responsibility for organising one Barents HIV Programme s meeting a year. Formally, the Republic of Komi (Russia) is the chair of the Programme. As for the Barents TB Programme, it will have its following meeting on November 21. The coordination is being done by Norway (Dr. Zaza Tsereteli). 9. Tour-de-table Relevant actual information and news from countries and organisations The situation with HIV, TB and associated infections in Norway was presented. Generally, the situation is changing for the better, except gonorrhoea and syphilis. Due to increased refugee traffic, some growth will likely be seen, but not drastic as the refugees are not coming from countries with very poor HIV or TB situation. All asylum seekers undergo X-ray testing for TB and risk assessment of needs within 2 weeks after arrival. New low threshold facilities were established. A PrEP policy and new strategy for hepatitis B and C are under construction. The complete presentation is available at the webpage of the meeting. EG Chair proposed that each speaker would conclude their presentations afterwards with three bullet points concerning main problems, possible recommendations, and needs for improvement. These bullet points would be collected, summarised and later submitted for the CSR and other relevant bodies. The participants accepted this proposal. October Presentation on Hepatitis C infection surveillance in Finland in Dr Markku Kuusi, THL Information on hepatitis from the National Infectious Diseases Register (NIDR) collected between 1995 and 2013 was presented. The register contains now some 20,000 cases. The complete presentation is available at the webpage of the meeting. In the Q&A session the speaker underlined that hepatitis C poses a major health problem despite all efforts. The current treatment policy is that the hepatitis C patient should quit drug injecting before the treatment is administered. But the policy may shortly change. Also, the strategy of treatment of HIV+HepC cases can change soon as new medicines come to the market and prices go down. At the moment, hepatitis C is being treated mainly at central hospitals gastroenterology units, in some health care districts at infectious disease units. The Norway s new strategy on hepatitis could be used in renewing the Finland s policy. 11. Presentation by Pro-tukipiste Development Coordinator Erja Aalto from Pro-tukipiste organisation gave presentation The health and welfare of erotic, escort and sex workers in Finland: Key learnings from training peers as voluntary study assistants. The survey was carried out in September 2012 to March 2013 and was driven by scarce knowledge about health and wellbeing of sex and erotic workers in Finland and globally, as existing research focuses mainly on street sex workers. As 5

6 access to public health services in Finland requires a social security number, the proportion of those who had access (according to the survey) was 67%. In terms of the gender distribution of the respondents, 84% were women, 7% were men, 3% were trans people, and the rest did not disclose their gender in the questionnaire. The complete presentation is available at the webpage of the meeting. Tour-de-table continues (started previous day) The HIV situation in Finland was presented by Dr. Markku Kuusi (THL). Overall, the situation is stable in the last 6 years. Sexual contacts are the dominant transmission route (71%). International travelling is a major risk factor for Finns to acquire the infection (about 60%). Finland has HIV Strategy for on key high risk populations but so far little impact is seen from its implementation. The complete presentation is available at the webpage of the meeting. The Lithuanian situation with HIV, TB and associated infections was presented by Dr. Saulius Caplinskas, Director of the Lithuanian Centre for Communicable Diseases and AIDS. In 2013, there were an estimated prevalent TB cases (range ), which is equivalent to 51 (39 65) cases per population. Considering downward trend observed during last decade, it seems feasible that the Millennium Development Goal (MDG) target of a 50% reduction by 2015 against a baseline of 1990 will not be reached. The highest TB prevalence (2013): Romania 83.5, Lithuania 57.4 and Latvia 44,7l. Multidrug resistant (MDR) TB was reported for 4.1% of cases with drug susceptibility testing (DST) results (2.6% of new pulmonary TB cases and 17.0% of previously treated pulmonary cases) and continues to be most prevalent in the three Baltic countries. In Lithuania, the incidence of syphilis and gonorrhoea is decreasing. Despite low testing volumes, the incidence of chlamydia is increasing. Over the last two years, sexual contacts were the predominant transmission route for HIV. Incidence of acute Hepatitis B and C are decreasing, only a few cases are reported. No data is available for chronic VHB and VHC. The complete presentation is available at the webpage of the meeting. The speaker informed the meeting about the Vilnius Communicable Diseases Summit, which is to take place on June 29 to July 1, The event could be a good opportunity to enhance visibility of the EG. The EG expressed interest in the received information. The involvement of the EG into the conference lies entirely in the authority of the EG and must be clearly linked with the Action Plan. The EG needs to formulate a task for the EG towards the Conference, and Dr. Saulius Caplinskas was asked to prepare a proposal on how the EG could contribute and deliver it to the EG Secretariat for further actions by the EG members. The information sheet about the Communicable Diseases Summit is available on the webpage of the meeting in the post-event documentation section. The HIV, TB and AI situation in Sweden was presented by Dr. Torsten Berglund from the Public Health Agency of Sweden. The situation is characterized by stable incidence at 469 cases/year on average in the last five years, most foreign-born. Heterosexual transmission is dominant. 95% of HIV patients receive ART. Before 2006 there were only 2 low threshold 6

7 centres in the country with needle and syringe exchange for IDUs, but as the law changed 4 more appeared, and 4 more will start working in The TB situation is characterized by decline in cases among people born in Sweden and rise among people born abroad. Gonorrhea and syphilis are on the rise, particularly among MSM. Sweden has adopted new national recommendations for management and treatment of bacterial STIs; national guidance on health promotion and prevention of hepatitis and HIV among IDUs; new Swedish recommendations about follow-up time after HIV exposure (6 weeks follow-up with lab based combo test for HIV-1 and 8 week follow-up with rapid tests for HIV-1 the recommendations are also published and available on-line in English in journal Infectious Diseases 2. The complete presentation is available at the webpage of the meeting. The TB situation in Russia was presented by Prof. Olga Nechaeva, Head of the Federal Centre for TB monitoring and control. The speaker underlined that TB is a wave-wise infection, and although the wave is on decline now, the new wave can be worse from the quality side (co-infections, etc.). It is estimated that by 2020, 2/3 will be MDR cases and every fourth will be HIV-co-infected. Among the age group of 18 to 44, the dominant causes of death are CVDs and cancers but HIV and TB hold the third place. Adherence to treatment is weak, and there are discussions now about establishing forced treatment and isolation. As 20% of the nation is tested for HIV, there is no data on how many IDUs are among them. But all drug users placed on records are tested for HIV. The complete presentation in Russian and the summary in English are available at the webpage of the meeting. The HIV, TB and AI situation in Germany was presented by Dr. Ulrich Marcus from the Robert Koch Institute. At the moment, a new strategy for HIV, STI and hepatitis is being drafted. The document will be ready in March Diagnosis will be a keystone, and new guidelines for HIV testing have been published, with the follow-up duration reduced from 12 to 6 weeks. For the upcoming update of the HIV treatment guidelines it is expected that any CD4 count limit will be dropped. Germany reports data to the ECDC, and unknown causes only amount to 10-20%. According to estimates, there are 83,000 people living with HIV in Germany, 70,000 diagnosed with HIV and 58,000 of them are under ART. The PrEP knowledge among MSM has been poor in a survey conducted end of Readiness to consider taking PrEP was moderate (~22% of participants), but this has to be interpreted with caution considering the poor knowledge. The leading reported transmission routes for hepatitis C are drug injecting and sex contacts between men, affecting primarily men with HIV infection. Besides, prisons pose a big threat for hepatitis C, especially if sentences are long and frequent, and if the prisoner injects drugs. TB incidence grew from 5,2 to 5,6 in the last two years due to increased immigration and shared shelters (proportion of TB patients born abroad has increased from 42% in 2001 to 63% in 2014). There are MDR cases but not XDR. Mr Boris Sergeyev, from the IOM s Moscow Office, told about the migrants role in the TB situation in Russia. According to estimates, 3,7 million immigrants work in Russia illegally. In Moscow, migrants add 15% to the TB prevalence, and in St-Petersburg 26%, but as Russia is a country with high TB prevalence, they contribute just 3% to the overall picture. According to Russian laws, if a foreigner has positive HIV and TB status, this person has to be deported. This decreases migrants motivation to be tested for infectious diseases, while those working illegally undergo no medical evaluation whatsoever. The idea which is now being discussed is to have health examinations in the countries of origin as disease detection in there provides an opportunity for early treatment while not being associated with the threat of deportation

8 A study named Migrants in St Petersburg: Socio-Economic Background, Prevalence of Behavioral Risks With Respect to Infectious Diseases and Factors Influencing Their Decisions to Seek Medical Help in Russia was implemented together with Institute of Sociology of RAN, St. Petersburg Tuberculosis Institute and FILHA by the support of the Consulate General of Finland in St. Petersburg. The report of the study has been published Next meeting Poland would be happy to host the EG meeting in autumn 2016, and Russia was proposed as the site for the spring 2016 meeting. The latter question will be negotiated by between the EG Secretariat and Russian members of the EG. The most preferable time for the meeting would be early March. 12. Any other business No other questions were raised. 13. Closing of the meeting The EG Chair thanked the participants for good work and announced the meeting closed. 3 Journal of Public Health, (2015) 23: , DOI /s