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EUROBulletin eFeature

Professor Jens Lundgren

The Sexual Health & HIV Policy EUROBulletin was delighted to secure an interview with Dr Jens Lundgren, Professor of Viral Diseases at the University of Copenhagen and Chief Physician at Department of Infectious Diseases at Rigshospitalet, Copenhagen. Professor Lundgren has more than twenty years experience of leading major international research on infectious complications in people living with HIV and transplant recipients. In 1994 he established CHIP, the Centre for Health & Infectious Disease Research, a Global Centre of Excellence in Health, which is recognised as a World Health Organization Collaborating Centre for HIV and Viral Hepatitis. Until last year he was co-chair of the HIV in Europe initiative and is still an active member of its steering committee. In this interview, Professor Lundgren shares his views on some of the biggest current challenges for HIV work in Europe and reflects on treatment and prevention developments that are likely to have a significant impact on policy and practice across Europe and beyond.

What do you see as the biggest HIV or AIDS-related challenge in Europe today?
Getting everyone diagnosed and on treatment. There are two key aspects of this; too many people with HIV live undiagnosed, and, in many cases, health systems are not set up to handle the spectrum of care needed to keep people on treatment, including linking them to HIV  care. The situation varies by country, but in general, there is insufficient retention of people on treatment; people need a combination of proper medication and care, and a health system that can deliver that. The cornerstone of a responsive healthcare service is one that ensures that people are retained in the system, and don't drop out. Obviously it is impossible to retain everyone in care, but we need to optimize the chances for retention.

Do you feel optimistic about the likelihood that it will be addressed effectively?
Yes; I'm optimistic about this. Health policy has to be based on rational thinking; this is particularly the case for communicable diseases. Doing nothing is not an option. We have to find the necessary funding, and there are many ways of arguing for it, from emphasizing the human suffering involved, drawing attention to the staggering amount of new infections every year that the absence of necessary services would generate, to the wisdom of making the investment because ultimately it's cost effective.

What are the most significant challenges for HIV work in Europe?
Principally the wide variation in the way the epidemic manifests itself across the continent; the challenges in Moldova aren't the same as those in Madrid. But we need a concerted effort to harmonise clinical approaches; we need testing and benchmarks for treatment and care to be consistent across Europe. The European Centre for Disease Prevention and Control (ECDC) can only recommend and advise; it doesn't have the power to insist on what approaches are adopted. Individual countries need to learn from each other to improve the quality of their programmes; we need indicators and benchmarks that will help us to do this effectively.

EuroSIDA, as a large prospective observational cohort study of more than 18,791 patients followed in 107 hospitals in 37 European countries plus Israel and Argentina, is a good example of this. The main objective of the study is to follow the long-term clinical prognosis for HIV-infected patients living in Europe and to assess the impact of antiretroviral drugs on that. The study has demonstrated the value of clear indicators; WHO uses its data. Evaluating what works is really important; we need to do more of that, and countries need to be open about sharing data, and learning from each other. We have examples of what such work can achieve; Estonia, faced with major issues in mounting an effective HIV response, reorganised its health system in the light of data and lessons learned from other programmes.

Are we doing enough, particularly in the field of HIV education and prevention to safeguard the sexual health of young people?
We've been a bit ignorant about that, and we haven't appropriately addressed the sexual health concerns that do exist. This is partly a reaction to the early, fear-based campaigns, and partly because public health authorities are reluctant to talk about the sexual health of young people. We need a more targeted approach; I would argue that we haven't learned enough from the early experience of education and prevention programmes.

Tell us about the most exciting initiative you're involved with at the moment.
I'm particularly proud of the recent research from the Strategic Timing of AntiRetroviral Treatment (START) study - the first large-scale randomised clinical trial to establish that early treatment is beneficial to the HIV-positive person. These results support treating everyone irrespective of CD4 cell count. All global guidance has changed in the light of the findings from this study.

I'm also enthusiastic about the Optimising Testing and Linkage to Care for HIV across Europe (OptTEST) project, a study being managed by HIV in Europe together with CHIP, which aims to develop strategies to improve early diagnosis and care of people with HIV across Europe. I'm optimistic that OptTEST has the potential to make HIV testing policy and practice more rational.

How accurate is our knowledge about HIV status - to what extent is undiagnosed HIV a problem in Europe? 
We have a number of models that help to estimate HIV prevalence, and they are becoming more sophisticated. Ongoing work at UCL (University College London), together with ECDC and WHO, has resulted in fairly robust models, but they are still to be fully applied across the continent. Effective use of modelling is a critical part of a rational public health response to HIV; modelling different intervention scenarios is an important tool for policy-makers.

Obviously we have huge variations in populations affected by HIV in Europe; in the North and West of the continent, men who have sex with men are most affected, whereas in Eastern and Central Europe, the epidemic is currently most highly concentrated among injecting drug users and their sexual partners. We need to look closely at the possible effects of the current refugee crisis; surveillance activity is needed to scientifically quantify the extent to which HIV might be coming in via this route.

Undiagnosed HIV is the key to explain continued transmission of HIV across the continent. Most persons diagnosed and retained in care are on treatment that markedly reduces their infectiousness.

What do you see as the major challenges related to access to treatment? In particular, to what extent do you see this as a financial issue?
Again, that depends on where you are, although the key question remains the same - does the health system create an environment that enables people to access treatment? In places where access to services is free of charge, but there is no link to care, or the environment isn't conducive to people wanting to use them, they won't. Where people are not accessing services, even if, theoretically, those services are available, that can end up being the functional equivalent of no access. The financial crisis of 2008 led to a demolition of health services in some regions of Europe that was particularly severe in some Southern European countries. But in Eastern Europe, the problem isn't necessarily driven by lack of finances. In general, those countries are quite good at diagnosing HIV; about 25 million HIV tests are made in Russia every year. The challenge is getting those infected linked to and retained in care. For the most part, countries want to provide medication, but, due to factors such as criminalisation and stigma attached to, say, drug addiction, people are unable to access that medication. These factors are not predominantly financial; for example where there is resistance to changing policies on drug use, you won't see harm reduction programmes.

What recent developments in the field of HIV/STI prevention, diagnosis and treatment strike you as being the most interesting?
I'm enthusiastic about the PROUD and Ipergay study findings that pre-exposure prophylaxis (PrEP) effectively reduces the risk of HIV transmission for men who have sex with men. It is fairly clear that the current approach is not working sufficiently well, and we need new additional tools to limit transmission. The evidence base for PrEP is now clear; I would like to see countries move quickly to introduce this approach. PrEP isn't for everyone, but for some people with lifestyles that render them vulnerable to HIV infection, it represents a major advance.

How do you feel about the challenge represented by HIV co-infection with Hepatitis?
As far as I'm concerned, the real co-infection concern is tuberculosis (TB). In some parts of Eastern and Central Europe especially, drug resistant TB is a major worry, and we don't have a plan to deal with that. The lack of leadership in addressing co-infection with TB is an additional concern.

Can you give us examples of where you have seen HIV-related stigma and discrimination tackled effectively?
I can't really say that I've seen that yet. In some countries stigma manifests itself very clearly: people get beaten up. In more tolerant countries, that may not happen, but people are still reluctant to disclose their HIV status, which is often a sign that such stigma, while less obvious, still continues to exist. Political leaders are missing a message here; people see themselves as tolerant, living in a tolerant society, while I am seeing patients with HIV who don't feel they can disclose their status. Policy makers should tackle this, but don't dare to. In Hungary it's difficult to be gay, as it is in Russia. I would like to see HIV-positive people treated like everybody else; too many people still do not accept the reality that many people living with HIV are physically active and are doing well.

Are you aware of any European-wide sexual health/HIV initiatives in the pipeline that we should be aware of?  
HIV in Europe is doing a good job of bringing together data, policies and practices from across Europe; OptTEST and EuroCoord are two other examples of good collaboration, as is the European AIDS Clinical Society (EACS). We need to improve European-wide collaboration and co-operation, and the ability to learn from each other; what happens in individual member states matters, and the European structures in place, such as ECDC, have relatively limited ability to generate evidence-based change.

If you had one message for HIV practitioners in Europe today, what would it be?
Show empathy. Actually I've got two; the second is 'base your practice on good evidence'.

What messages do you have for policy-makers in the field of HIV/AIDS in Europe today?
- Build policy on good evidence-based guidance;
- Don't do things that cannot be logically justified; HIV is too serious to allow that to happen;  
- Fear must not impede rational policy and decision-making; policy-makers need to be aware that technical experts without vested interests are available and willing to guide policy and practice in this important area.

The eFeature interview was conducted by Karen Newman on behalf of MEDFASH.

The content of all eFeatures represents the views and opinions of the authors. MEDFASH does not necessarily share or endorse the views expressed within them.

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