HIV/AIDS epidemiology and prevention policy in

FinlandMika Salminen

Kansanterveyslaitos – KTLNational Public Health Institute

Country Profile

• HIV-infection and AIDS are reportable diseases in Finland. Neither condition is classifi ed as a generally dangerous disease, which excludes the use of any compulsory measures in prevention or control.

• By law, both diagnostic laboratories and physicians report cases to the Finnish National Public Health Institute (KTL), which maintains the National Infectious Disease Registry (NIDR) for passive surveillance purposes.

• Voluntary targeted unlinked-anonymous studies are used to address prevalence in vulnerable groups.

• Blood donations are universally screened for HIV and all pregnant mothers are offered HIV testing (opt-out regimen in place since 1997).

Prevalence and Incidence• General population prevalence and incidence

of HIV and AIDS are low in Finland.– HIV prevalence rate of approximately 2 / 10,000

population*– HIV incidence rate of approximately 37 / million

population*

• HIV prevalence among vulnerable groups is higher:– Estimated HIV prevalence among MSM: 4.5% (2.6–7.3%, CI

95%) **– Estimated HIV prevalence among IDU: 1.4% (0.5–3.2%, CI

95%)

** based on passive surveillance data (2006)** based on cross sectionasectional unlinked-anonymous sampling data (2006 and

2005)

Flow of data and information in the national infectious disease register (NIDR), 1995 -

Main objectives of the HIV/AIDS prevention policy

• Prevention of new infections is the key target of policy measures. For those who become infected, there is guaranteed free access to medically indicated treatment and care.

• Support for full social empowerment of persons who have been infected to reduce their vulnerability is an essential part of prevention policies.

• Management of prevention activities through national coordination and a multidisciplinary public/private partnership approach.

Field of HIV prevention

MarginalisationRisks and ampifying factors

Lack of knowledge

Lack of tools

Unprotected sex

Unsafe bloodAnd tissue products

Mother to child

Intentionalrisktaking

Economic realities (sexwork)

Lack of understanding

Drugs and alcohol

Violence and useOf force

High prevalence

Financial resources for HIV/AIDS prevention

• The public financial resources allocated to HIV/AIDS prevention are divided between multiple actors and sectors.

• In many cases HIV/AIDS prevention activities are linked to general health prevention and education activities.

• There is no specific budget line for the purpose, and a comprehensive estimate of resources used for this purpose has not been made.

Risk perception and awareness

• Risk groups as a term give false pretence: ”If I do not belong to a certain group, I’m not at risk”

• Risks dependant on risktaking • AIDS/HIV prevention messaging fatigue

may over time lead to loss of awareness• Constant struggle to keep up awareness of

risks• Safe sex promotion has to be constantly

kept up with

1.Prevention of new infections is key

• Health education and promotion are the main modes of infuencing the development of the future epidemic

• Youth are the most important target group and gay and bisexual groups must also be reached.– Impact trough schools: health education as a subject for

pimary level grades 7-9 and secondary level 1-3– Includes sexual health and STD risks

• Prevention of both infection risks and drug use among Injecting drug users are equally important.

• Prevention of sexual transmission among youth needs new approaches

• Special attention need to be directed to prisons, socially marginalised group, immigrants and sex workers

• Prevention of MTCT must be as comprehensive as possible

School heath survey: 1

Kouluterveyskysely: Perusk. 8-9 luokka, ehkäisyvälineiden käyttö viim. yhd.

(20-23 % ollut sukupuoliyhdynnässa)

0102030405060708090

100

ei mitään kondomi e-pilleri kondomi jae-pilleri

jokin muu kondominkäyttö

yhteensä

Ehkäisyväline

Kä

ytt

öa

ste

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

School health survey 2

Kouluterveyskysely: Lukion 1-2 lk, ehkäisyvälineiden käyttö viim. yhd.

(41-49 % ollut sukupuoliyhdynnässä)

0102030405060708090

100

ei mitään kondomi e-pilleri kondomi jae-pilleri

jokin muu kondominkäyttö

yhteensä

Ehkäisyväline

Kä

ytt

öa

ste

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2. Health service role

• A comprehensive health and social service system is an essential part of HIV prevention

• For those living in Finland diagnostics, treatment, care and support are all free of charge, including ARV-treatment. Health service access is not tied to employment.

• The threshold to seeking AND offering HIV testing must be kept low, but strictly voluntary (excp. Blood & tissue donors).

• Anonymous testing outside the established health system fulfils an important role and must be supported.

3. PLWH as equal members of society

• Attitudes and knowledge among the general population must not become discriminatory against those living with HIV

• Legal measures must be put in place to prevent discrimination in all areas of life, including the health- care services, social and educational services

HIV/AIDS issues built into general legislation

• Constitution• Act on the Status and Rights of Patients• Primary Health Care Act• Act on Specialized Medical Care• Personal Data Act and Personal Data File

Decree • Communiable Disease Act and associated

decree • Act on the Protection of Privacy in Working

Life

Constitution

• Provides the basic protection against discrimination

• Protection against discrimination due to race, gender, sexual orientation, social and health status etc.– > no basis for discrimination in any setting due

to HIV infection– > HIV-infected have equal rights to work,

healthcare and all other governmental services– HIV-infected can work in all areas of society,

also within healthcare services

Primary healthcare

• Primary healthcare through municipal health centers– Responsible for preventive and health promotion

services– All primary care covered– Access to free of charge voluntary HIV testing and

councelling, VCT (subjective right of access regulated by ministerial decree)

– No automated screening groups, but testing offered routinely to expecting mothers

– Physician initiated most follow VCT

• Workers healthcare: parallel system paid by the employers

Specialised Healthcare

• Specialised care through hospital district central and university hospitals– Treatment and secondary care– Access to HIV/AIDS treatment and care is free

of charge for all legal residents (governed by HIV/AIDS belonging a category of fully covered diseases)

Law and ordinance on personal identity protection

• Information on personal identity even within the health care system is strongly protected

• Information cannot be shared between different service providers without explicit written consent of the client

• Information allowing identification of individuals cannot be shared with other authorities such as the police, insurance companies or even prison services

• Within the prison system, healthcare personnel cannot share information on prisoner health status with prison management or guards

• Workers healthcare services cannot share information on individual persons with employer

Law and ordinance on Infectious diseases

• Governs the classification of infectious diseases into reportable and non reportable categories

• Covers control measures available according to individual disease properties

• HIV/AIDS reportable, but no force measures applied (in contrast to i.e.Tuberculosis)

• Specifies certain responsibilities for the municipal prevention and health promotion services for example for the group of injecting drug users

Law (and ordinance) on Infectious Disease Control 1.1.2004 (free translation from Finnish)

• Law on communicable diseases 25.7.1986/583 (with changes 2004)

• Ordinance on communicable diseases 31.10.1986/786

• 6 § ....The municipal authority responsible for communicable disease control and as its sunbordinate, the municipal health care physician responsible for communicable diseases, must as a task specified by the Law on Communicable Disease also:

1) Organise communicable disease control activities in the municipal health care area, such as communicable disease information distribution, health education and health advice, including health advice services and exchange of injection equipment for injecting drug users as specified by the need for communicable disease control.

IDU health policy implementation• Establisment of a Network of Low Threshold

Health Service Centers (LTHSC) for IDU in Finland– Trust-based function: voluntary, not based on

beeing drug-free, personal information not recorded

– Close and accessible to target group– Services include smallscale healthcare provision,

councelling & guidance to detoxification, VCT & HIV-testing, vaccinations (tetanus, HBV, HAV), condom distribution and exchange of injection equipment

– Base for outreach work among IDU– Close collaboration with detox- and primary health

care services, social services and law enforcement

LTHSC Helsinki ”Vinkki”

Equipment for exchange

Exchange

Tests and Vaccinations

Impact on HIV- and Hepatitis epidemic in Finland

0

10

20

30

40

50

60

70

80

90

100

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

HIV

am

on

g ID

U

0

200

400

600

800

1000

1200

1400

1600

1800

2000

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

HIV

am

on

g ID

U

LTHSC –network inFinland-21 municipalities-> 30 sites

-2004 – statutory obligation formunicipalities toprovide services,Including inj.equipmentexchange

HIV

HCV

Number of LTHSC

0

5

10

15

20

25

30

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

HIV

am

on

g ID

U

LTHSC services 2000-2006

2000 2001 2002 2003 2004 2005 2006*

Working LTHSC

12 18 22 24 24 34 38

Clients 4 800 8400 9 300 9 300 10400 11 800

n. 12 000

Visits 32 900 44 500 55 300 70 600 83 400 80 500

n. 90 000

Equipment exchanged (syringes, needles, etc)

564 500

950 500

1,1 milj.

1,4 milj.

1,8 milj.

1,9 milj.

2.2 milj

2000 2001 2002 2003 2004 2005 2006*

Equipment sold through pharmacies

500000–

600000

419000

470000

486000

462000

620000

nk

Injection equipment exchange at LTHSC

Other access

* Preliminary data

Correlation btv. Intervention and outcome indicators

IDU-associated HIV-infection and equipment exchange

0 03 2 2 1 0 0

20

82

53

43

24

19

912

5

0

10

20

30

40

50

60

70

80

90

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Vuosi

An

nu

ally

re

po

rte

d c

as

es

0

500000

1000000

1500000

2000000

2500000

Eq

uip

men

t exch

an

ged

HIV

Exchanged S & N