At the end of last year I attended the European Association of AIDS Care (EANAC)
conference in Zurich, Switzerland, and followed this with a visit to a German AIDS Care
organisation in Berlin. This pan-European odyssey gave me some useful insights into some
of the issues surrounding human immunodeficiency virus (HIV) in this part of the world.
From an epidemiological perspective, HIV has always been an interesting phenomenon,
affecting the Northern and Southern hemispheres in entirely different ways. Even within
Europe there is a clear North-South divide; in Northern Europe (except Scotland), the two
primary routes of transmission remain sex between men (though this is reducing) and the
sharing of IV drug ‘works’. In Southern Europe (eg. Italy and Spain) HIV is more
concentrated within the drug using groups, with sexual activity running a poor second as
the prime route of transmission. This context, of course, presents different challenges to
health care workers – the already complex lifestyles of IV drug users are strained to
breaking point by the addition of an HIV infection.
Much of the conference addressed Swiss initiatives; and it was clear that they are
certainly pro-active about their health education campaigns. During the 1980s, a huge
programme of public education (albeit under pressure from gay activists) was initiated
(the largest ever in Swiss history) to educate the population about the HIV, and how to
reduce the chance of infection. Not a gravestone or a ‘Death’ figure in sight
(the flawed images promoted by the UK government in the 1980s). Instead, succinct and
direct material was disseminated that resulted in a marked reduction in the number of new
cases of HIV. Another key factor that dominated the conference was the changing
architecture of the HIV population across Europe – successful anti-viral treatment
resulting in a marked reduction in morbidity and mortality, less in-patient admissions,
and an increasing number of ‘well’ HIV positive people in the community. The
acute has become the chronic, and paradoxically this has exposed some of the more complex
contexts in which HIV occurs, particularly amongst drug users, who tend to fall outside of
the usual cycle of diagnosis-treatment-remission.
Berlin has always conjured up for me images of baroque buildings, gothic lettering, and
Cabaret. I travelled from Zurich to Berlin by train, and the most scenic part of
the journey was the Bavarian section from the Swiss-German border north of Zurich to
Munich. The Austrian alps loomed over the train like disapproving aunties in wedding hats.
13 hours after leaving Zurich, I rolled into Berlin’s Zoo station – 2 hours late
(who says the Germans trains run on time?), with only a rough idea of the direction of my
hotel. Fortunately it turned out to be only half a mile away, though midnight in Berlin is
not the best time to look like a visitor; following the advice of the Rough Guide,
I walked purposefully in (largely) the right direction, and was there in 10 minutes. Achim
Weber, of Deutsche AIDS-hilfe, was my host in Berlin. The German HIV scenario
mirrors the rest of Northern Europe. As in the UK and Switzerland, HIV care is moving into
the community and he in-patient units that 10 years ago were full of people with serious
opportunistic infections are now closing. Out patient departments are providing a broad
spectrum of palliative care, and are also supporting people with ‘new’ diseases,
such as lymphoma, now appearing as a result either of the anti-viral treatment, or longer
periods of survival. Interestingly, the recent election of Gerhard Schroeder is perceived
as a precursor to the liberalisation of traditionally conservative attitudes towards
people with HIV and the constellation of associated issues including drug users and gay
rights. Prejudice and ‘gay-bashing’ is not uncommon on Berlin, however, and
certain parts of the city are no-go areas for gays, as well as tourists and anyone who
looks ‘different’. One unfortunate result of integration is easier access to the
West for the powerful neo-Nazi groups residing the north east of the city (in old East
Berlin) – an area I was advised to avoid. This intolerance also affects the Turkish
population (numbering 250000 in Berlin); arson attacks on workers’ hostels have been
well covered in the UK press.
Issues for the future? Resistance to treatment is the spectre haunting all Western HIV
units, and medical research is currently exploring ways of ‘salvaging’ the
immune systems of those individuals who do develop resistance. But this is only part
(albeit a prominent part) of the picture. Collaboration across Europe, facilitated by
European HIV organisations, is imperative, so that HIV care services can share ways to
maximise the quality of care delivery to this still vulnerable group.
As will all epidemics, particularly those as mercurial as HIV, the epidemiological
architecture tends to change over time, with a shift from an epidemic phase to a state
where the infection is endemic. This is likely to happen over the next 10 or so years in
Europe and the West, though it may take much longer elsewhere, especially in parts of the
world where the virus is still in a pandemic phase (and perhaps, rarely for the 20thC, a
‘plague’ stage, in which mortality is reaching 50%).
As the endemic stage is reached, HIV is likely to mirror the incidence of TB earlier
this century, tending towards the ‘fault lines’ of society. In our time the poor
and the disenfranchised are those most at risk of infectious diseases, which flourish in
conditions where people are disempowered, forced through circumstance to live in close
proximity to others, and are physically and socially disengaged from the matrix of
society.
Lastly, I’d like to thank Achim Weber of Deutsche AIDS-hilfe for
facilitating my visit to Berlin. He was gracious and helpful, and translated where
necessary to ensure my ignorance of the German language did not hinder the benefits of my
visit.