1. Opening of the Meeting

EG on HIV, TB and Associated Infections Second Meeting Warsaw, Poland March 3-4, 2016

Reference HIV, TB&AI 2/3/1 Title Draft minutes of the Meeting Submitted by ITA in coordination with the Chair Requested action Comments1

March 3, Thursday

1. Opening of the meeting

Dr. Anna Marzec-Bogusławska, Director of the Polish National AIDS Centre, opened the meeting and welcomed the participants

Dr. Ali Arsalo, Chair of the Expert Group on HIV, TB and Associated Infections, thanked the hostess of the Meeting for the hospitality and welcomed the participants on his behalf to the 2nd meeting of the Expert Group under its new name, which highlights its focus on HIV, on TB/HIV and stand-alone TB (including drug resistant TB) and associated infections (e.g. viral hepatitis). Moreover, the EG has to prefer strategic activities that have an impact on policy changes and contribute to the efforts of other organizations working on the same topics.

Dr. Ali Arsalo told the participants about the three key elements of the Meeting: description of the current situation of the EG; planning of EG’s activities for the next 2 years; and sharing information from countries and organisations.

2. Introduction of participants and checking of the updated EG expert list

Since new nominations have been made by some countries and organisations, the participants introduced themselves (see Annex 1 for the complete updated list of EG members).

Mr. Dmitry Titkov, International technical Advisor for the HIV, TB & AI EG, noted, that the nominations of the EG’s Chair (Dr. Ali Arsalo), Vice-Chair (Dr. Anna Marzec-Bogusławska), and International Technical Advisors (Ms. Paula Tanhuanpää and Mr. Dmitry Titkov) were accepted by the EG members through the tacit acceptance procedure.

Dr. Pierpaolo de Colombani, Medical Officer from the WHO/Division of Communicable Diseases and Health Security, remarked that his primary field of work is related to tuberculosis, while his colleague, Dr. Irina Eramova, his alternate on the EG, is working on HIV and hepatitis. He also expressed his appreciation for the revised focuses of the EG, which includes TB not related to HIV co-infection and viral hepatitis, very common among risk populations for both HIV and TB as the people who use drugs.

Dr. Hans Blystad, Department of Infectious Disease Epidemiology/Norwegian Institute of Public Health, asked if the ECDC was invited on the Expert Group. Mr. Marek Maciejowski,

1 Text in red font implies prompt action from certain or all experts of the EG; text highlighted in yellow implies potential ideas for EG actions or projects

1 Director of the NDPHS Secretariat, explained that the ECDC is not a partner organisation for the NDPHS (as per clarification already received from the , while the European Commission is (and the ECDC is a EU’s agency), and it is the European Commission that should be contacted for this matter. But the NDPHS Expert Groups can always invite an ECDC representative, as well as other relevant organizations, to their meetings as invited experts. To facilitate the invitation process it would be best to know beforehand the name(s) of the expert(s) the EG would like to see at its meeting.

Mr. Dmitry Titkov will contact Mr. Marek Maciejowski for the procedural questions, and EG members are asked to propose names of the experts they find feasible to invite to the following meeting of the EG.

3. Adoption of the agenda

Changes were made to the agenda since Dr. Marc Lehmann, Chair of the Prison Health EG, was able to only be present on the first day of the Meeting, and it was decided to move item 6. “Presentation from Poland” and some sub-items from item 7 “Actual information concerning the HIV, TB and AI EG” to the next day, and instead dedicate more time to item 8 “HIV, TB &AI EG Action Plan development”.

4. EG’s new Terms of Reference

With reference to document HIV, TB & AI 2/4, Mr. Dmitry Titkov reported on the current situation with the adoption of the Terms of Reference for the EG. As agreed at the previous meeting of the EG in Tuusula/Finland in October 2015, two minor changes had been made to the document. On December 18, 2015, the revised ToR was distributed to the EG members for tacit acceptance, and the deadline (8.1.2016) remained unbroken. The EG-accepted document was sent to the NDPHS Secretariat to be communicated to the CSR for final acceptance.

Replying to the question of Dr. Pierpaolo de Colombani about why only prisoners were specifically mentioned in Objective 1 of the NDPHS Strategy 2020 (“Reduced impact of HIV, TB and associated infections among key populations at risk, including prisoners, through strengthened prevention and access to treatment”) and why only prison-related expected results (instead of other vulnerable groups of population for HIV, TB and AI) were assigned to the EG on HIV, TB & AI, the EG Chair replied that the prisoners were specifically stressed as a key population in the strategy writing process, and the decision about establishing a separate Prison Health Expert Group was made after the new NDPHS Strategy was written and adopted.

5. Information by the NDPHS Secretariat

Mr. Marek Maciejowski, Director of the NDPHS Secretariat, expressed his hopes that the EGs will continue a solid approach in its work and produce expected results. Having Dr Marc Lehmann, Chair of the Prison Health EG, participate in the group’s meeting was a good sign that the activities of the EGs would be developed and implemented in the spirit of cooperation between the two Expert Groups which work towards the same objective, albeit from partly different perspective, and would bring mutual benefit.

The website of the NDPHS (www.ndphs.org) was recently updated and the EGs are asked to keep their respective pages updated systematically.

Mr. Marek Maciejowski thanked the EG for making a project idea to be submitted for ENI funding. The project idea, which had been approved by the CSR, will shortly be sent to the

2 European Commission for consideration along with two other project ideas developed by other EGs.

The NDPHS Secretariat submitted a project proposal to the Interreg Baltic Sea Region Programme for co-funding by the EU. The project proposal consists of work packages, of which three would be most interesting to the EGs: 1) to continue promotion of health and economic development – an effort, which has started already last year with the “Health is Wealth and Wealth is Health” study and event, 2) stakeholder consultation meetings, 3) a training on project development and implementation for EGs and stakeholders.

If the project proposal is approved, it may start around 1 July 2016 and will continue for 2 years. Currently the NDPHS Secretariat is planning a conference on policy-to-project-to-policy cycle to be held in late April 2016 in Copenhagen, Denmark, back to back with the CSR Meeting, and the EGs have been asked to send 1-2 persons per EG to participate, and consider recommending a speaker. More information about the event will be published on the event’s web page and disseminated to the EGs soon.

The NDPHS Secretariat informed about the 2nd call for applications to the Interreg Baltic Sea Region Programme 2014-2020. Out of three priority axes open for the call, priority 1 “Capacity for innovation” with specific topics of smart specialisation and non-technological innovation looking most relevant. For further detail please see:  the call announcement note (attached and available at: http://www.interreg- baltic.eu/fileadmin/user_upload/how-to- apply/2_call_step_1/Announcement_note_2nd_call.pdf);

 the Programme Manual (http://www.interreg-baltic.eu/fileadmin/user_upload/how-to- apply/1_call_step_1/1-3.Programme_Manual.pdf);

 all relevant documents for the first step of the call (http://www.interreg- baltic.eu/applying-for-funds/secondcallforapplications/2nd-call-step-1.html).

This information will also be published at the Infocorner of the NDPHS website (www.ndphs.org), in the section presenting funding opportunities.

Dr. Anna Marzec-Bogusławska referred to the HATBAI project proposal (developed with the EUSBSR Seed Money Grant) and asked the EG to keep the project proposal in mind when appropriate calls for applications open. This is a ready-to-go project proposal, which, if requested, can be split into smaller projects and modified. Dr. Anna Marzec-Bogusławska will send the final version of the HATBAI project proposal to Dmitry Titkov.

8. HIV, TB &AI EG Action Plan development

Mr. Marc Lehmann, Chair of the Prison Health EG (PH EG), presented the work plan’s matrix with the proposals for activities related to Expected Outcomes 5-7 of Objective 1. These expected results are clearly connected with the work of the PH EG. While most of the proposed activities lie within the responsibility and competence of the PH EG, some of them imply input from other EGs, including the HIV, TB & AI EG. Dr. Lehmann also noted that the prioritised issues of the PH EG are: communicable diseases, addictions (substance abuse), mental health, and continuity of care. Challenge is that the systems (prisons and prison health) are not running under the same structures (justice vs. health) and medical expertise to the prison system is needed from outside.

The activities proposed by Mr. Marc Lehmann for the HIV, TB & AI EG solicited a lively discussion and comments:

3 - Dr. Pierpaolo de Colombani asked what is the “optimal international standard for TB resistance monitoring in prison settings” mentioned in Expected Outcome 5: shouldn’t the standards be the same both in and outside the prison settings (principle of equivalence)? Besides, the TB monitoring is already held by the WHO Regional Office for Europe jointly with the ECDC. - Different agencies use different tools, and we need to define which tool we will use and how we will share the collected information. But a more important question is what info we want to collect - It was noted that the activities proposed for Expected Outcomes 5-7 look quite operative instead strategic, as the EG is requested to work. - In many countries the prison health is subordinate to the ministries of justice, not health. And therefore it may be hard to come in contact with the prison healthcare. Inviting ministries of justice into the work through the CSR could be a way to facilitate the activity. There is already a well-established network of health in prison lead by WHO named Health in Prison Project (HIPP) that may be used (Germany still not participating in this network). - EGs should do something that the others do not do. A lot of data is produced by the WHO, ECDC, and the EGs should be careful not to duplicate others. - Hepatitis in prisons, continuity of care after release from prison, transfer of the prison healthcare from the jurisdiction of the ministries of justice to the ministries of health – those might be the priorities for EG consideration, according to Dr. Pierpaolo de Colombani

Concluding the discussions the Chair of the HIV, TB&AI EG Dr. Ali Arsalo proposed that Expected Outcomes 5-7 will be included into the revised version of the work plan’s matrix and submitted to the EG members for their written comments. Dr. Ali Arsalo remarked that both EGs have to make their own reports, they have their own responsibilities under Objective 1 with some clearly belong to the HIV, TB&AI EG and some to the PH EG. This creates a good chance to identify activities which the both EGs can conduct together and with involvement of other EGs. As an example of a joint deliverable for three EGs (HIV, TB&AI; PH; and ASA) he mentioned a joint document with recommendations and advice for decision-makers, particularly from the ministries of justice.

Afterwards, the EG moved to discuss the possible actions for Expected Outcomes 1-4 of Objective 1:

 Background for discussion

Dr. Ali Arsalo, Chair of the EG, reminded the participants of the work plan’s development process. The activities should support the achievement of the expected results and outcomes, which are fixed in the Action Plan for the NDPHS Strategy 2020. The EG’s work plan should be designed for two years, i.e. till the end of 2017. But some elements, included in the document, could be meant for the longer period (till 2020) or for 2018-2020. The first draft of the EG’s work plan matrix was presented at the first Meeting of the HIV, TB&AI EG in October 2015 and modified afterwards. The new version for discussion was proposed to the Meeting participants (HIV, TB&AI 2/8).

 Expected Result 1

The proposed activity is very much based on the project idea for the Statement Follow-Up (ref. HIV, TB&AI 2/7/C). Yet, it is evident that the requested funding, if the project idea is accepted, will be made available in autumn 2016 at earliest.

Dr. Hans Blystad, Norwegian Institute of Public Health, proposed to prepare a simple questionnaire form based on the provisions of the Statement to be replied by the EG

4 members. The survey would help collect basic information from the NDPHS Partners with relation to the Statement. The questionnaire may also include references to other relevant documents, e.g. ECDC 2016 Dublin Declaration and document “Towards TB elimination…”. Yet, the questionnaire should not be very long and time-consuming, and should regard scarce human resources some EG member-organisations may have. The EG leadership will draft a questionnaire and submit it to the EG experts for comments.

Dr. Pierpaolo de Colombani noted the recently adopted and published WHO Consolidated Guidelines on integrating collaborative TB and HIV services within a comprehensive package of care for people who inject drugs2, which include the very latest recommendations on viral hepatitis and on the provision of ART regardless of CD4 cell count. The EG experts could work on dissemination and facilitation of the implementation of the guidelines in their countries and take it as an activity in their work plan.

The following comments have been made:

An LFA workshop could be organised for NGOs and health professionals on how to do case management for different specific medical conditions (case studies). Dr. Ali Arsalo asked Dr. Saulius Čaplinskas, Dr. Hans Blystad and Dr. Anna Marzec-Bogusławska to formulate their ideas for the workshop.

The proposed joint discussion and cross-sectoral visits could be for the next period, i.e. 2018- 2020.

Dr. Pierpaolo de Colombani noted that the WHO might be interested in having an overview of countries’ organization of TB control within the Ministries of Health, as governance for TB is different in different countries.

Dr. Monica Ideström from the Public Health Agency of Sweden made a comment about the possibility to advocate the use of tools developed in the EU Joint Action project – Quality Action to help HIV preventive projects review and improve their work. This also relates to Expected Result 4.

Dr. Ulrich Marcus, Robert Koch Institute/Germany, referred to the CHAFEA’s tender forecast for Quality of HIV/AIDS/STI, viral Hepatitis and tuberculosis prevention and linkage to care, which is expected to be announced in 2016.

The HATBAI project proposal has much in common with the content of the Expected Result 3 and therefore should be kept at hand.

It was proposed to assess the prison population with the increased risk for drug-associated infections.

The training for the prison healthcare authorities planned in autumn 2016 within the JA HA- REACT, could be employed for activities under this Expected Result

2 http://www.who.int/tb/publications/integrating-collaborative-tb-and-hiv_services_for_pwid/en/. The document is available both in English and Russian.

5 All received ideas and proposals will be compiled into the next version of the work plan’s matrix and distributed to the EG members on the 11th March at latest for their further comments.

6. Presentations from Poland

Poland is a country with low HIV prevalence, with about 1,000 new HIV cases diagnosed each year. Mostly HIV is transmitted via sex contacts – 54% MSM, 26% hetero, and 12% bi, while drug injecting as a transmission route is next to zero (2014).

Case registration is overloaded with duplication, which is estimated at 30%. The late diagnosis rate with CD4 at less than 200 is 50%.

Pregnant women are offered HIV and syphilis testing, and 30% take the tests.

In Poland, people often travel to other cities to get treatment because of the fear of stigma.

The Polish Institute of Public Health/Department of Hygiene is responsible for the epidemiological surveillance (i.e. data collection), not the Polish National AIDS Centre.

Poland has the system of individualised treatment (since 2003), which also includes prisoners.

The recommended CD4 rate for initiating ARV treatment is 350, but in practice all clients are included, even with higher counts. ARV treatment is funded by the Ministry of Health, not insurance funds. The voluntary counselling and testing service are not very popular in the country.

The society in general and many doctors in particular still believe that drug use is the way to contract HIV infection, and many people do not expect they may have HIV and therefore do not undergo testing. Those who take tests prefer to do this in connection with the blood donation.

According to the Polish laws, only HIV can be reported anonymously, but not hepatitis or STIs, but the National AIDS Centre tries to include these conditions in the HIV testing. The politicians promise to change the laws, but so far nothing happens.

Anonymous HIV testing is only for those above 18 years old; otherwise the parental permission is needed.

Poland is not the best example of services integration.

The National AIDS Centre observes a rise in STIs among MSM and adolescents (syphilis, gonorrhoea, and chlamydia) with new localisations of syphilis appearing. This incline is aggravated by the lack of monitoring of STIs and hepatitis, and the specialists do not know how many diagnosed people turned for treatment.

Quite many people buy tests and medication online because pharmacies ask for prescriptions.

The society and mass media oppose targeted communication towards MSM and condom promotion, talking about condoms is socially unacceptable.

PrEP is to be 100% covered by patients, and now doctors prescribe Truvada.

6 The treatment success for HIV+TB is pretty low, and the reasons are few: people disappear or die from other reasons because the patient population is quite senior. But this questions still requires deeper analysis.

Both HIV and TB tests are offered, and if both positive, then TB is treated first. The treatment is done at infectious disease clinics. Only 1% of TB patients know their HIV status.

The full presentations can be found at the webpage of the Meeting at: http://www.ndphs.org/? mtgs,hiv_tb&ai_2__warsaw

The presentation was commented by data from Germany, where 4,5% of TB patients are HIV positive, and over 50% of TB patients know their HIV status. Germany (as well as Sweden) now deals mostly with TB-finding in migrants, while the infection develops rapidly in older people. In Germany, there are two notification systems, one is name-based and the other is anonymous, and they cannot be connected. As noted by Dr. Pierpaolo de Colombani, the EG could create a case on how to connect the two notification systems.

7. Actual information concerning the HIV, TB and AI EG

A. HIV, TB and AI EG’s Progress Report 2015

The draft progress report of the EG for 2015 (HIV, TB&AI 2/7/A) was prepared by Ms. Outi Karvonen, former ITA for the EG. The document was uploaded to the webpage of the Meeting at http://www.ndphs.org/?mtgs,hiv_tb&ai_2__warsaw. The EG members were asked to get acquainted with the document and provide their comments until 18 March.

B. Information from the recent EG Chairs and ITAs Meeting

Ms. Paula Tanhuanpää, ITA for EG on HIV, TB&AI, reported on key questions covered at the EG Chairs and ITAs Meeting conducted a week before in Gdansk.

The EG Meeting discussed the annual work planning versus biannual planning and the decision was made in favour of the biannual planning approach.

The EGs’ work plans are to be submitted at least 3 weeks before the CSR Meeting.

The EG are asked to submit the annual reports before the end of March according to the template from the previous year.

C. Project idea on Statement follow-up: brief overview and current situation

Mr. Dmitry Titkov, ITA for the EG, reported on the situation with the project idea on the follow- up of the implementation of the NDPHS Statement on HIV/AIDS and tuberculosis in the ND area (HIV, TB&AI 2/7/C). The project idea is based on the proposal developed in summer 2015 and submitted to the EU/ DG NEAR but rejected. In December 2015 – January 2016 the project idea was further developed in consultation with the NDPHS Secretariat. In February 2016 the project idea was approved by the CSR along with other two project ideas. Consequently, the three project ideas aiming at the ENI funding channeled through European Commission’s DG NEAR will be submitted to the European Commission.

D. Information about the relevant on-going projects (EU’s Joint Action on HIV and Co-Infection Prevention and Harm Reduction; AIDS Action Europe – Clearing House)

Mr. Dmitry Titkov, ITA for the EG, presented information about the ongoing EU’s Joint Action on HIV and Co-Infection Prevention and Harm Reduction. Purpose of HA-REACT: Improved

7 capacity to respond to HIV and co-infection risks and provide harm reduction with specific focus on people who inject drugs (PWID) in the EU. There are 18 Associate Partners from 23 countries, and three focus countries – Latvia, Lithuania (ND area) and Hungary. The official start was on the 1st October 2015. The Kick Off Meeting was in Vilnius 14th January 2016, together with the 1st Meeting of the Advisory Board and 2nd Meeting of the Steering Committee. The website launched at http://www.hareact.eu/en. Next key activity is the round of logframe workshops for the WPs, starting from mid-February. Poland is closely involved in the implementation of the Joint Action, particularly WP6 and WP8. The full presentation of the Joint Action is uploaded to the post-meeting documents at http://www.ndphs.org/? mtgs,hiv_tb&ai_2__warsaw.

HIV/AIDS Clearinghouse, AIDS Action Europe’s database of HIV/AIDS related resources and materials uploaded by contributors (ref. HIV, TB&AI 2/7/D/Info 1 and Info 2). It is a platform to learn and share experiences and practices, and documents. There are 1,360 publications at the moment.

In January, the launch of a brand new Clearinghouse website, providing epidemiologic and scientific data, advocacy materials and community-driven information shared for and by members and partners in Europe and Central Asia, as well as the wider public. It is an interactive online platform now optimised for mobile devices, making it easier to access HIV/AIDS good practice resources on the go.

You can access the Clearinghouse through our AAE website that is at the moment, while still work in progress, re-designed. The articles are organised by date of publication and the extensive archives can be searched easily by theme. You can filter by key populations, regions and topics. You can log in on the Clearinghouse and submit your HIV/AIDS good practice materials. You can also edit or delete your previous uploads. By creating your own account you can reach out to other members and partners who are active in the field of HIV/AIDS prevention work in Europe and Central Asia.

E. Barents HIV and TB Programmes

The Barents Programme for HIV/AIDS prevention and control for the period 2015-2019 is developed within the framework of cooperation in the Barents Euro-Arctic Region. The Steering Committee (SC) of the Barents HIV Programme and the SC consultant prepared the programme. The Joint Working Group on Health and Social Issues adopted the programme on 23 April 2015. The following five priority areas for the region: 1. HIV prevention in key groups 2. HIV prevention in the general population including at workplace 3. Integrating alcohol and HIV prevention and control programmes and policies 4. Strengthening national coordination and capacity to respond HIV and AIDS 5. Strengthening international cooperation in HIV/AIDS prevention and control The full text of the Barents HIV Programme 2015-2019 is available in English and Russian at: https://www.barentsinfo.fi/beac/document_database/Sub-group-docs.aspx?id=HIV- AIDSProgramme. The last meeting of the Steering Committee of the Barents HIV Programme held in November 2015 in St-Petersburg. The minutes are available at https://www.barentsinfo.fi/beac/document_database/Sub-group-docs.aspx?id=HIV- AIDSProgramme. A new Chair is coming – Dr. Nikolai Belyakov, director of the Russian Northwestern AIDS Centre.

F. Vilnius Communicable Disease Week – update

26 June – 1 July (Sunday to Friday) http://www.vilnius-summit.eu/

8 The objective of the Vilnius Communicable diseases week (ref. HIV, TB&AI 2/7/F) is to present and discuss evidence-based policies, guidance, approaches and best practice examples of tackling communicable diseases from across the region. Vilnius Communicable Diseases Week will be a joint continuation of the five traditional scientific-practical meetings on communicable diseases:

• European Conference on Clinical and Social Research on AIDS and Drugs • 2nd Open Europe Conference “Europe and HIV/AIDS: New Challenges, New Opportunities” • XIII Annual Conference of the Baltic Network against Life-threatening viral infections (BAN) • 2nd European Conference on Antimicrobial Resistance and Infection Prevention • 3rd National Communicable Diseases Conference

Among the topics:  HIV/AIDS, tuberculosis and associated infections (viral hepatitis and sexually transmitted infections)  HIV/VH/TB co-infection in the European context  The newest research of hepatitis B/C prevalence in Europe and opportunities for new response  EU and international collaboration in tackling communicable diseases (market of best practices)  Response to challenges of drug use-related infections (primary prevention, harm reduction, early diagnosis, prison issues, etc.)  Education of children, youth and target groups (personal hygiene, safe food processing, risk taking, sexual education, among others)

Dr. Saulius Čaplinskas, EG member and organizer of the event, invited the EG members to contribute to the event. Dr. Ali Arsalo, Chair of the EG, and Dr. Hans Blystad, EG member from Norway, will take part in the event. An invitation will also be sent to Dr. Marc Lehmann, Chair of the Prison Health EG.

G. Update of the EG’s web page on the ndphs website

Since new guiding policies and plans came into force and changes in the structure of the NDPHS it required the update of the NDPHS website. A contractor was selected, who proposed a revised layout and asked for updates from the EGs of their respective webpages. In late January the updated text for the Front Page of the EG’s page was submitted (HIV, TB&AI 2/7/G). The list of the EG members is available at the webpage of the EG (http://www.ndphs.org/?hiv-tb-ai_eg#members) and is up-to-date.

9. Tour-de-table

Russia Dr. Olga Nechajeva, Federal Research Institute for Health Organisation and Informatics of the MoH of Russia presented the situation with TB control among migrants in Russia. All in all, 17 million people migrated to Russia in 2015, of whom only some 8 million people have been placed on the records of the migration service. Only 10% of the migrants received a work permit. The biggest migrant traffic in 2015 was from Ukraine (2.6 million), Uzbekistan (2 million), and Tajikistan (1 million). The TB incidence in Central Asia and Ukraine is higher than in Russia, but only 3,000 cases have been detected, while some 7,000 remain undetected, as many migrants are illegally employed and avoid public healthcare services.

9 Economic migrants have to undergo a health checkup but do this reluctantly due to the fear of deportation and stigma. In 2013, TB was the reason for deportation in 45% of all deported people, HIV – 37%, STIs – 18%. Annually, 26-27% of foreign citizens diagnosed with TB in Russia undergo treatment in Russian TB facilities.

Russia’s legal framework for TB prevention and treatment needs modernization. New guidelines on TB control among migrants were published in 2015 to fill in the gaps. TB is now included into the voluntary health insurance scheme for labour migrants. Besides, if a person with HIV status has first-line relative living in Russia (a spouse, children, parents), this person cannot be deported, unless the person breaches the Russian laws for the infection transmission.

The complete presentation in Russian and abridged presentation in English can be found at http://www.ndphs.org/?mtgs,hiv_tb&ai_2__warsaw among the post-meeting documents.

In the discussion which followed the presentation it was suggested that the EG should take the migrants and refugees as a special topic of work. Many ND countries have similar problems with undocumented and uninsured migrants, and the situation with communicable disease incidence and prevalence among them is not known.

Germany Dr. Ulrich Marcus from the Robert Koch Institute reported on the situation with integration of services for key populations in Germany and recent epidemiology.

Generally, the integration of services looks functional in Germany, and a client has a free choice of healthcare provider. HIV care providers can diagnose and treat hepatitis, TB and STIs, as long as they are competent to do this. The opioid substitution treatment is separated from the HIV services. HIV testing is possible, but not the care. During pregnancy, testing for HIV, HBV, Syphilis, Chlamydia, and Gonorrhea is recommended. Testing for HIV is still not universal (estimated coverage ~90%).

The testing sites provide mainly HIV testing and increasingly STI testing, but for treatment clients are referred to specialised practices since treatment provision requires a doctor, and low-threshold service do not usually have resources to keep a doctor on staff.

The HIV infection was on increase in 2000-2006, then the situation stabilised, with a clear rise following in the last 2-3 years, which is related to the rise in migration. HIV testing is offered to migrants but it is obviously not a priority for them. The testing system is not designed to bring people into care.

The registration of HBV grew drastically in 2015, while the situation with HCV remains steady.

Syphilis has also been rising since 2010. Now about 6,000 cases are recorded, of whom most are MSM from large cities. The syphilis testing is problematic, and screening cannot be offered as screening. Chlamydia and gonorrhoea testing is not fully reimbursed to the provider.

Asylum seekers face different mandatory screening policies in different federal states. Access to health care is regulated differently in different federal states. Hepatitis B is screened by some federal states among refugees, and Hepatitis C is not. TB screening among refugees is a nationwide recommendation. Undocumented migrants and people without valid health insurance have no legal access to expensive treatments. The complete presentation is available at http://www.ndphs.org/?mtgs,hiv_tb&ai_2__warsaw among the post-meeting documents.

10 Sweden Dr. Monica Ideström, Public Health Agency of Sweden, reported on the HIV, TB, hepatitis and STIs situation in Sweden. Approximately 6,800 people are now living in Sweden with the HIV status. HIV was the only infection on decline last year.

HIV: Quite stable situation during the last 5 years with about 450-470 reported cases per year. >80% of all cases are infected abroad (before immigration or during visits abroad) and the endemic cases (people infected in Sweden) are decreasing during the last 5 years, probably due to high coverage of ART (>90% of all diagnoses cases are on effective ART). TB: The TB increase is not unexpected, since about 90% of those with tuberculosis in Sweden have been infected in another country and immigration increased significantly in 2015. Hepatitis C: The incidence has leveled out at a level of ca 2000 reported cases per year during the last 10 years. >40% of the cases are reported as IDU, but ca 50% of cases are reported as “unknown” route of transmission. Acute Hepatitis B: Increasing rates of acute HBV during the last few years. Ca 60% of the acute cases are infected in Sweden. Heterosexual transmission most common followed by IDU. Only a few MSM-cases (3 msm 2015). Syphilis: Increasing trend during the last 5 years, mainly due to a sharp increase in MSM (+50% 2015 vs 2014). Chlamydia: Incidence has leveled out at an annual level of ca 37 000 cases during the last 7 years. Ca 22% of all cases in the age group 15-19 years (decreasing trend during last 5 years in teenagers) and 60% of the cases in the age group 20-29 years. Gonorrhea: Continuing huge increase during the last years – The incidence has doubled since 2015 compared with 2010. Mainly due to a sharp increase in MSM but also an increase in women has been observed. Since 2010 the number of tests for gonorrhea has increased 3 times (from ca 75 000 tests / year to 250 000 tests /year) as an effected of introduction of combo NAT tests for Chlamydia and gonorrhea in most clinics.

MSM2013 – a study about sex, HIV and health among men who have sex with men in Sweden, was published in 2016. The report describes the results from a web-based survey conducted on the web community Qruiser in October 2013. The report is based on responses from 2 373 respondents.

The county councils have an obligation to offer a health examination for all asylum seekers. Ca 40 % undergo health screening. Testing for HIV, STI, TB and hepatitis are offered but voluntary. Foreign origin is a risk factor for late HIV diagnosis in Sweden. All diagnosed with HIV and TB get free care and medication. Also undocumented have that right.

In 2015, the Public Health Agency of Sweden published a “Guidance for health promotion and preventive work with hepatitis and HIV directed at people who inject drugs”. The objective is to support regional and local actors who in their work come in contact with PWID.

The national NSP coverage is insufficient. The background is legal and political. But there is now an ongoing process to change restrictive laws and policies. OST is available for PWID in low-threshold health care settings but with restrictive policies.

All pregnant women, with migrant women included, regardless of legal status, must be offered testing for syphilis, HIV and Hepatitis B when visiting Maternal Health Care. TB testing will be offered to women from countries with high risk. All women who are first time pregnant are also offered a test for Chlamydia. More than 90 % accept the offer. Maternal Health Care is free of charge.

The presentation also included information about the National information campaign, which ran late 2015 to raise the knowledge about life with HIV today. That treatment in Sweden

11 today is so effective that the risk of transmission of infection is minimal. The purpose of the campaign was to reduce stigma and discrimination.

The complete presentation is available at the webpage of the Meeting at http://www.ndphs.org/?mtgs,hiv_tb&ai_2__warsaw among the post-meeting documents.

In the discussion that followed the presentation Dr. de Colombani noted that a WHO workshop will be organized on 10-11 May 2016 in Catania, Italy on TB and migration, where the identification of groups at risk and which methodology to use for TB screening will be discussed among other topics.

Lithuania Dr. Saulius Čaplinskas from the Lithuanian Centre for Communicable Diseases and AIDS presented information from Lithuania. The presentation had exhaustive information about the regulatory framework on provision of diagnostic and therapeutic services for various conditions and in different settings. Altogether, 2,535 HIV cases have been recorded in the country since 1988, with 157 new cases registered in 2015. About 580 people are on ARV therapy, which is free of charge, and the dominant transmission routes for HIV now are drug injecting and heterosexual contacts.

Pregnant women are offered HIV and syphilis tests twice during the pregnancy period.

TB patients are screened for HIV. TB/HIV care services are integrated. TB prevention and control response is coordinated by the MOH. TB programme implementation activities are coordinated by the health care institution – Santariskes Clinic of the Vilnius University (TB care department). The share of MDR TB stays at high level.

The harm reduction programme includes testing for STI, HIV, TB, VHB and VHC. HIV, HCV and syphilis testing for OST patients is an incentive service, which is compensated from the resources of the Compulsory Health Insurance Fund.

As of January 1, 2015, 585 persons were receiving OST but the termination rate is high due to different factors.

In 2015, a study on prevalence of drug-related infections among IDUs at the low-threshold centre was conducted, which revealed that the markers of HCV were found with 77% of the PWID-clients, HIV – 12,5%, and HBV – 10,5%.

In the prison settings, tests are offered for HIV, syphilis, gonnorhea, VHB, VHC, and TB. HIV/AIDS/TB/STI/VH treatment, care, prevention in prisons setting is coordinated by Prison Department under the Ministry of Justice. The key problems in the prison system are deficit of qualified personnel, higher VAT for medication compared with the civilian healthcare, long waiting list for consultation and procedures.

The complete presentation is available at http://www.ndphs.org/?mtgs,hiv_tb&ai_2__warsaw among the post-meeting documents.

Norway Dr. Hans Blystad from the Norwegian Institute of Public Health reported on the situation in Norway.

HIV rate dropped among the MSM. Home testing is planned for introduction nationwide by NGOs. The 90-90-90- target is likely already reached. The PrEP will be in place in 2016 and provided free of charge. The new Hepatitis Strategy was drafted and moved to the ministry,

12 but still no reply came from the ministry. The municipalities in Sweden are responsible for organizing health examinations among migrants. TB: while the proportion of TB cases of foreign origin is increasing, this is compensated by a decreasing of the cases among native population. TB was not observed a common disease among the refugees coming to Norway.

The complete presentation is available at http://www.ndphs.org/?mtgs,hiv_tb&ai_2__warsaw among the post-meeting documents.

10. Next meeting

Russia agreed to host the next meeting of the EG. One of the options is to organise the meeting on 19 October in St-Petersburg back-to-back with International Congress on HIV and immunosuppressions, which is to take place on 17-18 October.

But at the last EG Chairs and ITAs Meeting the EGs were asked to conduct their meeting in late August – early September. The Russian representatives will be asked to consider this change in the dates and explore their possibilities for hosting the meeting.

Alternatively, Norway expressed its readiness to host the next meeting of the EG.

11. Any other business

Dr. Olga Nechaeva, Federal Research Institute for Health Organisation and Informatics of the MoH of Russia presented the project proposal from Russia to be funded for Russian money entirely, which may start already in 2016. The project proposal is included into the post- meeting documentation at http://www.ndphs.org/?mtgs,hiv_tb&ai_2__warsaw

The EG took note of the presented information and will follow up the progress. As agreed with the Dr. Nechaeva, the EG can contribute to the project planning and implementation with advice and consultations.

Dr. Anna Marzec-Bogusławska asked the EG members to provide information on who will represent their respective countries at the High-Level Meeting in New York on 10-12 June 2016. She asked to send her information within the next 10 days.

She also regretted that Dr. Ali Arsalo is not present at the HIV/AIDS Think Tank meetings, as the structure could benefit from Dr. Arsalo’s input and the NDPHS could draw more visibility and attention.

12. Closing of the meeting

Dr. Ali Arsalo, Chair of the EG, thanked the participants for the good work and declared the Meeting closed.