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HIV situation in Finland

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HIV/AIDS epidemiology and
prevention policy in Finland
Mika Salminen
Kansanterveyslaitos – KTL
National 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
Risks and
ampifying
factors
Intentional
risktaking
Lack of knowledge
Lack of understanding
Lack of tools
Violence and use
Of force
Marginalisation
High prevalence
Unprotected sex
Mother to child
Unsafe blood
And tissue products
Economic realities
(sexwork)
Drugs and alcohol
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
Käyttöaste
Kouluterveyskysely:
Perusk. 8-9 luokka, ehkäisyvälineiden käyttö viim. yhd.
(20-23 % ollut sukupuoliyhdynnässa)
100
90
80
70
60
50
40
30
20
10
0
ei mitään
kondomi
e-pilleri
kondomi ja jokin muu
e-pilleri
Ehkäisyväline
kondomin
käyttö
yhteensä
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
School health survey 2
Käyttöaste
Kouluterveyskysely:
Lukion 1-2 lk, ehkäisyvälineiden käyttö viim. yhd.
(41-49 % ollut sukupuoliyhdynnässä)
100
90
80
70
60
50
40
30
20
10
0
ei mitään
kondomi
e-pilleri
kondomi ja
e-pilleri
Ehkäisyväline
jokin muu
kondomin
käyttö
yhteensä
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 ARVtreatment. 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 healthcare 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 & HIVtesting, 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
Number of LTHSC
30
LTHSC –network in
Finland
-21 municipalities
-> 30 sites
25
HIV among IDU
20
15
10
5
0
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Year
HIV
-2004 – statutory
obligation for
municipalities to
provide services,
Including inj.equipment
exchange
100
90
80
HIV among IDU
70
60
50
40
30
20
10
0
1995
1996
1997
1998
1999
HCV
2000
2001
2002
2003
2004
2001
2002
2003
2004
2005
Year
2000
1800
1600
HIV among IDU
1400
1200
1000
800
600
400
200
0
1995
1996
1997
1998
1999
2000
Year
2005
LTHSC services 2000-2006
Injection equipment exchange at LTHSC
2000
2001
2002
2003
2004
2005
2006*
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*
500000–
600000
419000
470000
486000
462000
620000
nk
Working LTHSC
Other access
Equipment sold
through
pharmacies
* Preliminary data
Correlation btv. Intervention and outcome indicators
IDU-associated HIV-infection
and equipment exchange
90
2500000
82
HIV
80
2000000
Exchanged S & N
53
1500000
50
43
40
1000000
30
24
20
19
20
500000
12
9
10
3
0
0
5
2
2
1
0
0
2006
2005
2004
2003
2002
2001
2000
Vuosi
1999
1998
1997
1996
1995
1994
1993
1992
0
1991
0
Equipment exchanged
60
1990
Annually reported cases
70
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