INTERNATIONAL COUNCIL OF NURSES (ICN) _____ 2005 ____________________________________________________ HIV/AIDS IN THE EUROPEAN UNION Overview In the European Union, the AIDS epidemic shows no signs of declining. In Western Europe, in spite of the availability of HIV testing, treatment and care, the number of newly reported HIV cases has doubled from 1995 to today. 1 In addition, more women are diagnosed with the virus, from 25% in 1997 to 38% in 2002. 2 There is also worrying evidence of antiretroviral drug resistance among some HIV-infected individuals. In the Baltic states, the number of infected people is low, but HIV is currently spreading at an alarming pace. In Latvia, Lithuania and Estonia, up to 80% of people infected with HIV are under 30 years of age. 3 In Central Europe, most of the new infections have been recorded in Poland, with a prevalence of 11% in 2000. 4 In the Czech Republic, Hungary, Slovenia and Slovakia, risk behaviours prevail and efforts are made to maintain effective preventive measures. Causes of the upward trend In many European countries, HIV/AIDS prevention, education and treatment programmes either do not exist or have not been maintained. In high-income countries, the availability and promise of antiretroviral (ARV) treatment may have caused complacency among people and a decline in prevention efforts. In Western Europe, although sex between men and injecting drug use remain prominent factors in the epidemic, more people are becoming infected through unprotected heterosexual intercourse. In some countries, infection rates among female sex workers have increased. In addition, there is evidence that younger people are engaging in unsafe sex practices. According to one European survey, Swedish female teenagers use condoms the least. 5 In the Baltic States, social and economic changes and unfavourable living conditions have caused a dramatic increase of injecting drug use among young people. Risky sexual behaviour is also gaining ground Latvia, Lithuania and Estonia. Throughout Europe, migrants from high HIV prevalence countries comprise a large share of newly diagnosed cases. The majority of these migrants are unaware of their HIV status. Most people seek medical help only when they become ill or pregnant. In addition, in many countries, there is a lack of trained health care workers to deal with all aspects of the HIV/AIDS epidemic. 6 Many individuals at risk of, or living with, HIV are subject to stigma and discrimination. These factors prevent people from disclosing their HIV status and seeking treatment, which can heighten the spread of the disease. The range of actions Urgent action is needed to reduce the vulnerability of people at risk and provide better access to treatment and care for those who are ill. A comprehensive response should include the following key elements: • Prevention and education Awareness campaigns and behaviour change programmes are crucial for halting the spread of HIV. Public information should be linguistically and culturally relevant to targeted populations. Young people need to be empowered to face the discrimination, stigma and denial of HIV/AIDS. Schools are an ideal setting to initiate stigma-reduction and anti-discrimination measures. Education programmes should be gender-specific and culturally sensitive. For example, young women may need to acquire assertiveness and negotiation skills to avoid unwanted or unprotected sex. Young men may need interpersonal skills to listen to what young women are saying. 7 Teaching HIV prevention to boys and girls in the same classroom encourages them to talk openly about HIV and sexuality. 8 Education and prevention efforts should be tailored to the specific needs of people, including vulnerable groups such as injecting drug users and men who have sex with men. 9 In the Baltics, for example, there is an important need to reduce the risk of HIV transmission among drug users. Local health services should be equipped to distribute clean needles and syringes to injecting drug users. To prevent HIV-positive births, family planning services should be well integrated to prevention and testing services. 10 Women of childbearing age and their partners should have complete access to these services. For pregnant HIV-infected women, careful obstetric management, ARV treatment and counselling should be made available. Peer education and training programmes for health care professionals should be a priority. Standards for infection control and blood supply safety should serve as a basis for HIV/AIDS prevention in all health care systems. • Counselling and testing Testing and counselling is the gateway to treatment and prevention. To reduce the spread of HIV, testing and counselling should be made available to all, particularly to pregnant women, migrants and excluded populations. • Treatment and care Early, affordable and safe treatment options should be made available to the increasing number of people who need them. Expanded access to treatment can result in people discovering their HIV status and strengthening prevention efforts. • Surveillance and research Monitoring and evaluation systems are vital in providing public health information with respect to the epidemic and trends over time. Research activities that aim at understanding the disease and developing new and effective drugs and vaccines should be encouraged. • Building partnerships In order for prevention and treatment programmes to reach individuals, the legal, social and economic disadvantages of groups at risk must be addressed. At community and national levels, changes in laws and policies can help mitigate the worst effects of harassment and discrimination. For people living with AIDS, equitable employment policies are critical. A comprehensive response to the spread of HIV/AIDS requires active partnership within the European Union and neighbouring countries. Political leaders should join forces with public and private sectors, international organisations, charities and other groups. To guarantee fair access to treatment, pharmaceutical companies must be part of the AIDS response. Adequate funding and resources are essential components to the fight against HIV/AIDS. Health information for HIV-positive people HIV-positive people should know the difference between HIV and AIDS. 11 They should understand how people become infected. Some HIV infected people stay healthy for months or years, but can still transmit the virus to others. Some get flu-like symptoms such as fever, headache, sore muscles and joints, stomachache, swollen lymph glands or skin rash. With any unexplained symptoms or possible exposure to HIV, testing should be considered. HIV testing looks for HIV antibodies in the blood, saliva or urine. If tested too early, some HIV infected people may not obtain positive results. For accurate results, testing should be done two and six months after exposure. A positive test result does not mean that a person has AIDS. Depending on HIV symptoms and test results (viral load and T-cell count), a person may need to take ARV medication. ARV medication does not cure AIDS, but can slow down the growth of the virus. Individuals who are taking ARV medication can still transmit the virus to others. There are many types of ARV medication. For best results, a combination of two or three types of medication is recommended. ARV medication can cause side effects, some of which can be severe. ARV also interacts with other medications, recreational drugs, herbal products or certain foods and can cause serious illness. Interrupting treatment can cause the virus to develop resistance to ARV. ARV therapy should only be stopped if recommended by a health care professional. There are special considerations for the treatment of pregnant women, adolescents, drug users and people with infections like hepatitis and tuberculosis. Pregnant women with HIV can reduce the risk of infecting their babies if they take ARV medication and do not breast-feed. Short-term ARV treatment taken only during labour and delivery can eliminate the risk of transmitting HIV to a newborn. Some mothers may be advised to take ARV medication during pregnancy, labour and delivery. To stop the spread of the disease, HIV-positive people should not partake in the same activities that caused them to become infected. In addition, HIV-positive people need to protect themselves in order to stay well. Any additional sexually transmitted infections or infections from a different strain of HIV can increase the progression of HIV towards AIDS. Practicing sexual abstinence or fidelity, using male and female condoms, not sharing drug injection equipment, protecting open sores, eyes and mouth from contact with blood and counteracting stigma and discrimination are important risk reduction issues. For HIV-positive individuals, good nutrition, physical exercise and adhering to medication and food safety practices are important lifestyle factors. Smoking, drugs and alcohol should be avoided because they can weaken the body’s immune system, making individuals more prone to infections. Informed HIV-positive people know what to expect from the medical care in their community. They can take a more active role in planning their own health care and work in partnership with their health providers. Being informed about their rights in society, they are better equipped to challenge discrimination and stigmatization. ___________________________________ 1. Commission of the European Communities (2004), ‘Coordinated and integrated approach to combat HIV/AIDS within the European Union and in its neighborhood’, Brussels, Belgium. 2. UNAIDS (2004), ‘AIDS epidemic update December 2004’, North America, Western and Central Europe, viewed 13 June 2005, www.unaids.org. 3. UNAIDS (2004), ‘AIDS epidemic update December 2004’, Eastern Europe and Central Asia, viewed 13 June 2005, www.unaids.org. 4. Health and Consumer Protection of the Commission of the European Communities (2003), ‘Euro Surveillance. European Communicable Disease Bulletin’, vol. 8, no. 3, March 2003. 5. The Body: The Complete HIV/AIDS Resource, HIV/AIDS Newsroom archives from June 8, 2004, www.thebody.com. 6. Commission of the European Communities (2004), Ibid. 7. AVERT (2004), HIV/AIDS Education and young people, viewed 13 June 2005, www.avert.org/aidsyoun.htm. 8. Schenker II and Nyirenda JM (2002), Preventing HIV/AIDS in Schools, International Academy of Education, International Bureau of Education, Educational Practices Series – 9, SADAG, Bellegarde, viewed 13 June 2005, www.ibe.unesco.org. 9. UNAIDS (2004), ‘Report on the global AIDS epidemic’, Executive Summary, June 2004 10. Best K (2004), Family Planning and the Prevention of Mother-to-Child Transmission of HIV, Family Health International (2004), April 2004, viewed 13 June 2005, www.fhi.org 11. AVERT (2004), Ibid. Additional source for health information: AIDS.ORG. www.aids.org _____ 2003 ____________________________________________________ THE WHO 'TREAT 3 MILLIONS BY 2005' (3X5) INITIATIVE Background HIV/AIDS is the greatest health crisis the world faces today. In two decades, the pandemic has claimed nearly 30 million lives. An estimated 40 million people are now living with HIV/AIDS, 95% of them in developing countries, and 14,000 new infections occur daily. The burden of HIV/AIDS, including the death toll among health workers, is pushing health systems to a state of collapse. Of the 6 million people who currently need antiretroviral therapy (ARVs) in developing countries, fewer than 8% are receiving it. This should change now that the prices of ARVs, which put them beyond the reach of low-income countries, have dropped sharply. A worldwide political commitment, led by people living with HIV/AIDS, has mobilized communities and governments to provide ARVs as a matter of human right. New mechanisms such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and other initiatives have been launched, reflecting an exceptional level of political will and unprecedented resources for the HIV/AIDS battle. This exceptional response and political will must now be translated into urgent action to expand access to ARVs. One such action is the 3x5 Initiative. The 3x5 Initiative The 3x5 Initiative sets out how life-long ARVs can be provided to 3 million people living with HIV/AIDS in poor countries by the end of 2005. Prevention will remain an important element of 3x5, as access to ARVs will encourage people to know their HIV-status and seek treatment. The 3x5 Initiative encompasses a comprehensive strategy linking treatment, prevention, care and support for people infected and affected by HIV/AIDS. The goal of the 3x5 Initiative (1) The goal of the Initiative is to help prolong survival and restore quality of life for individuals with HIV/AIDS. In addition, it contributes to the ultimate goal of universal access to antiretroviral therapy as a human right for those in need of care within the context of a comprehensive response to HIV/AIDS. Guiding principles (2) Urgency. Immediate action is required to avert millions of needless deaths. The HIV/AIDS treatment emergency demands new resources, redeployment of resources, streamlining of institutional procedures and a new spirit of teamwork. The centrality of people living with HIV/AIDS. The Initiative clearly places the needs and involvement of people living with HIV/AIDS at the centre of all of its programming. Life-long care. Antiretroviral therapy is for life and the world community has a responsibility to ensure uninterrupted supply of medicines. Country ownership. It is essential that the programme and its activities be under country ownership. The Initiative will strive to avoid duplicating existing country-level coordination mechanisms and to build a sustained response. Treatment and human rights. The Initiative will advance human rights in line with the Universal Declaration of Human Rights, and in accord with WHO Constitution in seeking the attainment of the highest possible standards of health, and other UN commitments. Under 3x5, special attention will be given to protecting and serving vulnerable groups in prevention and treatment programmes. Partnership and plurality. The Initiative and its activities are based on partnerships and networks that maximize the contribution of all stakeholders in a given country Complementarity. The Initiative will strive to ensure complementarity by integrating planning and funding within existing programmes and activities. Learning, innovation and sharing. Capturing and disseminating lessons across countries and regions in a rapid manner is essential to effectively and rapidly scaling up. Ethical standards. The Initiative will identify options for an ethical approach to meeting 3x5 targets Equity. The Initiative will make special efforts to ensure access to antiretroviral therapy for people who risk exclusion because of economic, social, geographical or other barriers. Accountability. The Initiative will support the development of national accountability among policy-makers, providers, people receiving therapy and all stakeholders. The strategic framework Treating 3 million people by the end of 2005 will require concerted, sustained action by many partners. To chart the direction and to show what WHO itself will be doing to accelerate action, WHO has developed an initial strategic framework. The strategic framework for emergency scaling up of antiretroviral therapy contains 14 key strategic elements. These elements fall into five categories – the pillars of the 3x5 campaign:  global leadership, strong partnership and advocacy  urgent, sustained country support  simplified, standardized tools for delivering antiretroviral therapy  effective, reliable supply of medicines and diagnostics  rapidly identifying and reapplying new knowledge and successes. Pillar one Scaling up of ARVs will contribute to strengthening of health systems. The crisis in the health workforce facing many countries has implications both for the 3x5 Initiative and for the viability of health systems. Expansion of human resources for health is a critical need. WHO and 3x5 partners will work with countries to find and implement solutions that can quickly fill gaps while laying the groundwork for long-term sustainability. Key actions would include: intensified recruitment for specific tasks; overcoming fiscal constraints related to public sector hiring; recruiting both young people and experienced people into health work; increasing community input; initiating large-scale in-service training focused on antiretroviral therapy; and expanding pre-service training. Issues of recruitment, funding, training, appropriate incentives and retention of health workers will require a broader cross-sector dialogue, involving health and non-health ministries, trade unions and the private sector. (3) Beyond 2005 The 3x5 Initiative does not end in 2005. Antiretroviral therapy does not cure HIV infection and must be taken for life. When properly managed, it can transform AIDS into a chronic disease similar to diabetes or hypertension. However, withdrawing or ending treatment will lead to the recurrences of illness and with it the inevitability of premature death. Lifelong provision of therapy must be guaranteed to everyone who has started antiretroviral therapy. Thus, 3x5 is just the beginning of antiretroviral therapy scale-up and strengthening of health systems until almost all of the more than 40 million people now infected with HIV have access to ARVs. (1) WWW.who.int (2) WHO (2003), Treating 3 million by 2005: Making it Happen. The WHO Strategy. Geneva: WHO. (3) WHO, ibid. _____ 2001 ___________________________________________________ ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) ICN Position ICN deplores the stigma and marginalisation of people living with HIV/AIDS and the disastrous social and health consequences of this stigma, and calls for competent, compassionate care. National nurses associations, employers and nurses have a responsibility to:  Ensure all health care providers have access to up-to-date information about HIV/AIDS, its mode of transmission, prevention, counselling and guidelines for safe practice.  Ensure that nurses are competent to provide care and counselling to patients and health care providers. This includes knowledge of universal precautions and acceptance of their ethical and moral duty to care for people living with HIV/AIDS.  Secure a safe environment, including protective equipment and materials, that permits adequate care to people living with HIV/AIDS and ensures protection of nursing personnel from exposure to HIV as well as other blood borne diseases such as hepatitis B and C.  Lobby governments and others, including drug manufacturers, to make antiretroviral therapy (ART) accessible to people living with HIV/AIDS. Background Acquired Immunodeficiency Syndrome (AIDS) is a global public health threat that continues to increase the burden of disease. World-wide there are over 36 million people living with HIV/AIDS and this number continues to increase. ICN is particularly concerned about the growing prevalence of HIV infection in women, young people and other vulnerable populations. Lack of access to services, low socio-economic status and societal values that tolerate violence, sexual abuse and other violations of women’s rights continue to fuel the epidemic in women. Irrational and discriminatory treatment of people living with HIV/AIDS continues to be reported in many countries, with violations of their rights to employment, housing, education and even health and nursing care. Maintaining the quality of life of people with HIV/AIDS is possible mainly through extensive, competent and compassionate nursing care. Yet, the provision of care for persons living with HIV/AIDS is raising health and occupational concerns for nurses and other health care workers. Furthermore, nurses need to examine their own personal attitudes and stereotypes toward people living with HIV/AIDS as these can compromise compassionate care. Due to economic difficulties, countries may be unable to allocate appropriate resources for care of people living with HIV/AIDS. Thus, health services in these countries lack the proper facilities, personal protective equipment, and other materials to care for people living with HIV/AIDS. The use of antiretroviral therapy (ART) has greatly improved the health and quality of life of people living with HIV/AIDS. However their high cost has made them inaccessible to many, especially in developing countries. HIV/AIDS has been declared a serious threat to national security and to economic development. ICN urges member national nurses' associations to:  Actively participate in sensitising and educating the public about HIV/AIDS.  Take measures to combat violence against women including rape, sexual abuse, child prostitution and trafficking.  Work to protect the basic human rights of people living with HIV/AIDS, their families, the public and nurses who care for those living with HIV/AIDS. Adopted in 1989 Revised in 2001 _____ 2000 ________________________________________________ IMPACT OF HIV/AIDS ON NURSING/MIDWIFERY PERSONNEL ICN Position Exposure of nursing/midwifery personnel to HIV/AIDS must be minimised. Measures need to be taken to prevent the transmission of HIV and other blood borne pathogens in health care settings, including reduction of the incidence of needlestick and other sharps injury. Employers, national nursing/midwifery associations and individuals have a responsibility to see that nursing/midwifery personnel: Have access to information on prevention of HIV and other blood borne infections such as Hepatitis B and C. Have access to guidelines, policies and protocols regarding occupational exposure to HIV/AIDS, Hepatitis B and C and other workplace issues. Have a safe work environment while providing quality care, including sufficient supplies and protective equipment. Have access to appropriate post-exposure follow-up care and monitoring, including immediate first-aid and documentation. Who are HIV-positive, and regardless of how they became infected, have access to confidential counseling and be allowed to work with duties modified, where appropriate, so the risk to their patients or themselves is reduced. Who are HIV-positive are protected from discrimination such as job or housing loss. Background: HIV/AIDS is a growing public health problem with complex social and behavioural issues related to protection, prevention of transmission and care for nursing and midwifery personnel caring for people living with HIV/AIDS. The social stigma associated with HIV, the disease's long period of ‘invisibility’ and the determination of whether infection was related to behavioural risks such as sexual transmission or occupational exposure, add to the complexity of HIV/AIDS in the workplace. The widespread emergence of other infectious disease such as tuberculosis (TB), and the significant prevalence of Hepatitis B and C have increased the potential for occupational exposure by nurses/midwives, necessitating appropriate supplies and protective personal equipment and consistent use of universal precautions. Preventive measures to be taken include: Using universal precautions Availability and rational use of personal protective equipment and supplies Cutting down on unnecessary injections, laboratory work and episiotomies Proper transport and disposal of sharps, blood specimens, biowaste and soiled linen Creating a less stressful work environment for nursing and midwifery personnel. The intensive nursing care demands of persons with HIV/AIDS and the real or perceived risks and stressful work environment, can have a detrimental impact on the profession, including burnout, a high drop-out rate and fewer recruits. This could result in a nursing/midwifery shortage and in turn affect the quality of care. Measures for addressing the stress and burnout issues should be developed and integrated into care delivery systems. Work-related incidence is still unclear, due to lack of research-based data such as longitudinal tracking of HIV/AIDS exposure in the workplace, and underreporting of needlestick and other sharps injury or splashes. _____ 1999 _______________________________________________ MOBILISING NURSES FOR HIV/AIDS Prevention and Care The HIV infection continues to spread around the world. In a number of countries AIDS is the leading cause of death in young people. It is increasingly affecting women. Estimates by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO) indicate that over 30 million people world-wide have been infected with HIV and almost 14 million people have died due to the disease. The majority of people infected with HIV die within a decade, unless they have access to treatment. New HIV infections occur at a rate of about 16 000 people a day, of whom approximately 7 000 are children. At present HIV/AIDS is among the top ten causes of death world wide, and if current levels of infection continue, it is expected to rise into the top five soon. (UNAIDS/WHO Report, 1998) Most HIV infections occur in developing countries where resources to provide care and treatment for people living with HIV/AIDS are scarce. About 21 million (86%) of people with HIV/AIDS live in sub-Saharan Africa and Asia. It is estimated that 6.4 million people are currently living with HIV in Asia. HIV infection is also rapidly rising in Eastern Europe. In Latin America HIV infection is rising in some countries and declining or stable in others. In many industrialised countries, HIV infection is falling or remaining stable. Spread of HIV infection HIV transmission involves complex cultural, behavioural and economic forces. Poverty, illiteracy and violence often force people to engage in unsafe sexual practices. As well, the “invisible” nature of HIV infection fuels the epidemic in that the carriers infect others without realising that they themselves are infected. The common causes of HIV transmission include the following:  Unprotected sex between men and women  Unprotected sex between homosexual men  Intravenous drug use and sharing of needles  Commercial sex work  Blood transfusion  Mother-to-child transmission In rare circumstances, HIV infection can spread in health care settings to patients/clients or health care providers, through needle stick or injury with other sharps (ICN, 1996). The Rising HIV infection rate in women shows that heterosexual transmission is becoming more common. Often economic, social and gender inequity put women at risk of HIV infection, as their power to negotiate for safe sex is undermined. The presence of other sexually transmitted diseases (STDs) also increases the risk of HIV infection. Antiretroviral drug therapy (ART) has postponed the development of AIDS and prolonged the life of people living with HIV. However, ART remains inaccessible to developing countries due to its high cost. ART has also reduced the rate of mother-to-child transmission in countries that have access to drugs. Actions by National Nurses Associations (NNAs) and others It is important that nurses and others are up to date with the HIV/AIDS situation in their country, the mode of spread, access to care and treatment. Nurses need to use facts and figures to lobby for increased access to prevention, treatment and a continuum of care for people living with HIV/AIDS. NNAs, nurses, governments and organisations can: 1. Dispel myths and misinformation: Network with the media and other health professionals to provide information, education and communication to combat ignorance, fear and stigma associated with HIV/AIDS. 2. Lobby policy makers: Advocate for access to prevention, counselling, care and treatment, and political commitment to mobilise resources, including access to ART. 3. Safeguard human rights: Stimulate dialogue on respect for human rights, support voluntary testing and treat people living with HIV/AIDS like other people with a chronic disease. 4. Reduce transmission: Provide education on safe sex, abstinence, condom accessibility and empowerment of women through education, economic rights and access to condoms. Disseminate information materials. 5. Increase capacity for care: Provide training and supervision of family members in home care, strengthen health systems capacity to prevent and care, mobilise community resources and donor agencies. 6. Target Vulnerable populations: Focus preventive efforts on those that are at high risk of HIV infection including commercial sex workers, homosexual men, intravenous drug users, street children and homeless people. 7. Promote a continuum of care: Advocate for compassionate nursing care, prevention, access to drugs and referral services to hospital and community facilities. NNAs should be part of an expanded response to mobilise the nursing workforce for prevention, counselling, care and treatment of HIV/AIDS. ICN/99/10 For further information please contact ICN at icn@icn.ch References International Council of Nurses (1996), Reducing the Impact of HIV/AIDS in Nursing/Midwifery Personnel, ICN, Geneva. UNAIDS, WHO (1998), Report on the global HIV/AIDS epidemic, June 1998, UNAIDS/98.10-WHO/EMC/VIR/98.2-WHO/ASD/98.2. www.UNAIDS.ch www.WHO.ch