Integrated Strategy for HIV, Hepatitis B and C and Other Sexually Transmitted Infections

 
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Integrated Strategy for HIV, Hepatitis B and C and Other Sexually Transmitted Infections
Integrated Strategy for HIV,
Hepatitis B and C and Other Sexually
Transmitted Infections
 
 
       Integrated Strategy for HIV, Hepatitis B and C and Other Sexually Transmitted Infections                                               3
	
  
       Foreword
	
  
                                                                                   diseases. At the same time, hepatitis B and C are
       Changes in sexually                                                        becoming more significant, both nationally and
       transmitted and blood                                                      internationally, because of their prevalence, of the
                                                                                  serious health consequences to which they lead
       borne infections                                                           (including cirrhosis and cancer of the liver), as well as
	
  
                                                                                  of new treatment that is available. HIV, hepatitis B
       Anyone can come into contact with a sexually transmitted
                                                                                  and C, as well as other sexually transmitted infections,
       or blood borne infection during his or her lifetime. There
                                                                                  have comparable transmission routes, and hence have a
       is therefore a need to make appropriate services available
                                                                                  higher incidence in similar groups. They are therefore
       in line with age and circumstances which contain
                                                                                  being addressed jointly in an Integrated Strategy.
       infections and minimise impacts on both the individual
       and on society. This starts with immunisation during                       	
  
       childhood, and continues through education and                             Sexually transmitted infections already formed part of the
       prevention in youth and adulthood, to age-independent                      previous HIV/AIDS strategy. It has however not yet been
       diagnostic and treatment services, as well as healthcare in                possible to create the same public awareness of these
       old age.                                                                   infections. Unlike with HIV, the numbers of new sexually
	
                                                                                transmitted infections such as syphilis have risen rapidly
                                                                                  in recent years, both in Germany and in neighbouring
       With the 2005 German HIV/AIDS strategy, the Federal
                                                                                  European countries. Chlamydia or human
       Government successfully laid the foundations for keeping
                                                                                  papillomaviruses (HPV) are particularly prevalent among
       HIV infections at a low level in Germany. At the same
                                                                                  young women and men. Many sexually transmitted
       time, the Government’s high level of international
                                                                                  infections can be treated and cured very well, but if
       commitment helped to reduce the number of new HIV
                                                                                  untreated they can cause serious health problems such as
       infections worldwide.
                                                                                  cancer or infertility. Greater attention and awareness
	
                                                                                therefore need to attach to the risks of and the protection
       As a result of the progress that has been made in terms of                 available against these and other sexually transmitted
       therapy, HIV infections can be regarded as a chronic                       infections, and groups of the population need to be
       disease in Germany today, unlike in the 1990s. People                      reached with prevention, testing and care services in a
       with HIV who commence antiretroviral therapy early more                    targeted manner. This is the approach followed by the
       seldom suffer side-effects, have fewer symptoms, and are                   Strategy. In particular for juveniles and young adults, age
       generally well integrated into everyday life and work.                     and target group specific interventions should be regularly
       Despite all these efforts, HIV is diagnosed late among one-                offered, addressing the various aspects of sexuality,
       third of people in Germany. Roughly 13 % of those who                      sexually transmitted diseases, the associated risks and
       are infected in Germany are unaware of their infection.                    protection. At the same time, there is a need to increase
       Serious health consequences and deaths caused by AIDS                      the acceptance of various sexual orientations and living
       could be avoided by earlier diagnoses and treatment. In                    environments. Thresholds are to be lowered when it
       order to safeguard the achievements which have been                        comes to seeking information and medical advice.
       made to date, and to sustainably contain HIV/AIDS,                         	
  
       engaging in an ongoing commitment and adjusting the
                                                                                  With its “demand-orientated”, “integrated” and
       approach is therefore indispensable. The early recognition
                                                                                  “cross-sectoral” core concepts, the Strategy forms the
       of HIV infections and treatment needs to be enhanced and
                                                                                  framework for the sustainable, successful containment of
       prevention activities expanded.
                                                                                  HIV, hepatitis B and C and other sexually transmitted
	
                                                                                infections. This integrated approach is pioneering. It
       New scientific knowledge underpins the approach of                         constitutes a forward-looking orientation towards the
       viewing HIV not in isolation, but in connection with other
       sexually transmitted and blood-born
                            	
  
       4                              8    Integrated Strategy for HIV,
                                                                    Integrated
                                                                        Hepatitis
                                                                               Strategy
                                                                                  B andfor
                                                                                        C and
                                                                                           HIV,
                                                                                              Other
                                                                                                Hepatitis
                                                                                                    Sexually
                                                                                                          B and
                                                                                                              Transmitted
                                                                                                                C and Other
                                                                                                                          Infections
                                                                                                                            Sexually Transmitted Infections
	
                             	
  
	
                             	
  
	
                             	
  
	
                             	
  
                                                                                       pillars of the successassociatedthat has been
                                                                                                                                   withachieved     to date,   and C viral load
                                      2. Medical
       containment of HIV, hepatitis B and C as well as other
       sexually transmitted infections which both takes                                form principles in thecontributes
                                                                                                                                          a heightened
                                                                                                                                    to heightened
                                                                                                                        implementation
                                                                                                                                                            hepatitis
                                                                                                                                                       infectiosity.
                                                                                                                                            of the Strategy.     The This explai
                                      knowledge and
       advantage of the shared features, and allows for specific                                                  heightenedknowledge
                                                                                       Strategy focuses on imparting                hepatitis Cand co-infection
                                                                                                                                                      expandingrates observed
       requirements that ensue from individual infectious                              skills in order to set the         stage for
                                                                                                                  particular          people
                                                                                                                                  among        to deal withmen who have sex
                                                                                                                                            HIV-infected
       diseases.                      developments                                     sexually transmitted men.   infections responsibly, and to
	
                               Early initiation of HIV treatment                     encourage them to take     	
   up the prevention and healthcare
       Sexually transmittedOn        the basis
                                  diseases  are of  new study
                                                 associated    withdata,
                                                                                       services offered.
                                                                           the HIV guidelines
                                                                       shame
                                                                                                                  Increasing drug resistance
                                 currently are
       and stigma. Those concerned          recommend
                                                frequentlytreatment
                                                               marginalised            	
  
                                                                           to be commenced        early, as       When it comes to gonorrhoea, the number of case
                                                                                                                  rising worldwide in which antibiotics have no eff
       and made the subjectsoon        as possible after
                                  of discrimination.     Onlytheifdiagnosis.
                                                                    it is      This prevents
                                                                                       Data from  a research and          surveillance provide us with a
                                 reduction   in the  immune     status,    and serious  related                   because       of resistance. This makes it more difficul
       possible to create an atmosphere within society which                           sound basis today for planning and refining evidence-based
                                 diseases  aretoavoided.    Effective                                             treat the gonorrhoea. Without a successful therapy
       counters this will it be    possible      effectively    counterantiretroviralprevention
                                                                                            therapy and treatment           services, and for adjusting the
                                 considerably    reduces    the HIV      transmission  risk,    and hence         infection can pass to other organs. Inflammatory
       their spread.                                                                   measures in line with changing behaviour. Together with its
                                 also has a preventive effect. Early diagnosispartner      and treatment          processes
                                                                                                   countries, Germany             in the genital
                                                                                                                              is striving           area also
                                                                                                                                            to achieve          increase the risk
                                                                                                                                                           the goal
	
  
                                 contribute to the reduction of AIDS.                  that has been set by the international community in the 2030therapies d
                                                                                                                  transmission.        The   failure  of  chlamydia
       All the relevant players      need  to work    together    at  all levels                                  antimicrobial        resistance
                            	
                                                         Agenda for Sustainable             Development,      namelyisto  currently
                                                                                                                                                          ensure being debated
       in order to implement the Strategy. The Federation, the                                                    	
  
                                 HIV as a chronic disease                              healthy lives and to promote well-being for all at all ages. It
       Länder, local self-government, public health offices, civil
                                 Progress in the therapy has enabled people with       was HIV       in as a part Mutual
                                                                                                agreed            of this Goalinfluences               of co-infections
                                                                                                                                     to end the epidemics        of
       society organisations, community led-initiatives, the                                                      Data
                                 Germany to have a similar life expectancy asAIDS            thoseand
                                                                                                   whotuberculosis       by and  studies
                                                                                                                             2030,         show
                                                                                                                                     as well       that
                                                                                                                                               as to     some sexually transm
                                                                                                                                                     combat
       medical profession, long-term carers, as well as stake-                                                    infectionsaccessoccur to prominently      in specific groups b
                                 are not infected. An HIV infection can therefore      hepatitisbe and ensure universal                       services and
       holders in the judiciary, education and labour affairs, are                                                the     transmission     routes   are  the  same
                                 regarded as a chronic disease today. However,                this
                                                                                       information       relating to sexual and reproductive health              andor similar. T
       called upon. The official structures which are available                                                   of     infection   depends    on  sexual    behaviour.   Some s
                                 requires life-long therapy and needs to be closely    rights (SRHR). In order to reach these goals, and not to
       are used as a platform for the implementation of the                                                       practices,      such   as anal   sex,  entail  higher  transmiss
                                 monitored by medical staff since people with                HIV have
                                                                                       endanger      the successes that have been achieved, greater
       Strategy, and are modified where appropriate as the
                                 a considerably heightened risk of cancer, as efforts    well asandof a holistic risks.
                                                                                                                     approachAt the
                                                                                                                                  willsame   time, other
                                                                                                                                        be needed     in thesexually
                                                                                                                                                               years totransmitted
       process advances. All players are invited to take part.                                                    infections such as gonorrhoea or syphilis increase
                                 heart and vascular diseases.                          come on the part of all concerned.
	
                                                                                                                of HIV transmission because of infections, irritati
                            	
                                                                                    injuries to the oral, intestinal or genital mucosa. S
       The safeguarding of Hepatitis             B immunisation
                                 sexual rights and     the acceptance of and new
                                                                                                                  syringes and other equipment entails a high level
       diversity, as well as the     self-determination
                                 treatments                  of the for hepatitis C
                                                     available                                                    of hepatitis B and C transmission in the group of
       individual and personal       responsibility
                                 Increasing   hepatitisto B
                                                          respect    and
                                                              immunisation      rates among children,             users. Co-infections with HIV and hepatitis virus
       protect oneself and others,
                                 as wellare
                                          as major
                                             amongprinciples
                                                       people with of the
                                                                        a heightened risk of                      accelerate the respective progression of the diseas
       Strategy. The inclusion of the self-help institutions,                                                     more frequently and more quickly lead to serious
                                 infection, can prevent the spread and the occurrence of
       empowerment and participation are central                                                                  consequences of the disease.
                                 chronic hepatitis B in future. The treatments available for
                                      hepatitis B are highly laborious so far. They only alleviate                	
  
                                      the symptoms and reduce the incidence of related diseases.                  Long-term effects of sexually trans
                                      New therapy options for hepatitis B are expected to                         infections underestimated
                                      emerge in the coming years. Thanks to new therapies with                    Sexually transmitted infections can generally be t
                                      fewer side-effects, more effective, rapid treatments are                    and cured very successfully. As they frequently h
                                      available to cure hepatitis C.                                              symptoms, or the symptoms also subside if left un
                               	
                                                                                 and the infections even heal themselves in some c
                                      Sexual transmissibility of hepatitis C                                      they are too seldom recognised at present. Untrea
                                      New study data have shown that hepatitis C can be                           infections can have serious consequences. HPV is
                                      transmitted not only via blood, but also sexually. This                     of cervical cancer, which is prevalent among wom
                                      mainly affects HIV-positive men who have unprotected                        Among men, HPV can lead to anal cancer or to a
                                      anal sex, or who engage in high-risk sexual behaviour. An                   carcinoma of the penis. Untreated syphilis can ca
                                      HIV and hepatitis C virus co-infection is usually                           serious after-effects which can even be life threat
 
       Integrated Strategy for HIV, Hepatitis B and C and Other Sexually Transmitted Infections    5
	
  
       Table of contents
	
  
       Changes in sexually transmitted and blood borne infections                                  3
	
  
       I. Developments and
       challenges in Germany                                                                      6
	
  
       1. Data and facts – epidemiological trends                                                  6

       2. Medical knowledge and developments                                                       8

       3. New challenges caused by behaviour changes                                               9

       4. Gaps in prevention, testing and care                                                     9

       5. Stigmatisation and discrimination                                                       11
	
  
       II. The goal of the Strategy                                                               12
	
  
       III. Areas of action                                                                       13
	
  
       1. Creating an enabling environment                                                        13

       2. Further expansion of demand-orientated services                                         14

       3. Refining integrated prevention, testing and care services                               16

       4. Promoting cross-sectoral networking and cooperation                                     20

       5. Further expanding the knowledge base and data utilisation                               20
	
  
       IV. International contributions                                                            22
	
  
       1. Europe                                                                                  22
	
  
       2. Global                                                                                  22
6                                   8   Integrated Strategy for HIV,
                                                                 Integrated
                                                                     Hepatitis
                                                                            Strategy
                                                                               B andfor
                                                                                     C and
                                                                                        HIV,
                                                                                           Other
                                                                                             Hepatitis
                                                                                                 Sexually
                                                                                                       B and
                                                                                                           Transmitted
                                                                                                             C and Other
                                                                                                                       Infections
                                                                                                                         Sexually Transmitted Infections

I. Developments
       2. Medical   and                                                                                        associated with a heightened hepatitis C viral load
                                                                                                               contributes to heightened infectiosity. This explai

challenges  in Germany
       knowledge  and                                                                                          heightened hepatitis C co-infection rates observed
                                                                                                               particular among HIV-infected men who have sex
           developments                                                                                        men.
                                                      Stabilised new HIV indection infection rates
1. Data andEarly
              factsinitiation of HIV treatment
                         –                            The  Federal
           On the basis of new study data, the HIV guidelines              Increasing
                                                                    Government  has  been  drug
                                                                                                rates
                                                                                                  resistance
                                                                                          promoting  HIV
epidemiological         trends
           currently recommend                        prevention
                                 treatment to be commenced                 When
                                                             early,campaigns
                                                                    as       since 1987. Overall, there is athe
                                                                                  it comes to gonorrhoea,       number of case
                                                                                                              high
                      soon as possible after the diagnosis. This prevents   level ofa knowledge inrising Germanyworldwide
                                                                                                                       about in HIVwhich
                                                                                                                                       and antibiotics
                                                                                                                                            AIDS and have no eff
Improved
Improves data  data reduction
                      availability
                      availianility
                                  in the immune status, and serious protective                         because     of  resistance.
                                                                            related measures. Antiretroviral therapies have            This  makes
                                                                                                                                                beenit more difficul
HIV, hepatitis B anddiseases    areasavoided.
                       C, as well      other sexually                         therapy in Germanytreat
                                                Effective antiretroviralavailable                        sincethethe
                                                                                                                   gonorrhoea.
                                                                                                                      1990s. More    Without
                                                                                                                                         and morea successful therapy
                      considerably    reduces   the  HIV     transmission   people
                                                                            risk, and with
                                                                                        henceknown     infection
                                                                                                      HIV           can pass
                                                                                                             infections    are   to other organs.
                                                                                                                                 receiving    anti-    Inflammatory
transmitted infections, are caused by a heterogeneous
                      also has                             Early diagnosisretroviral                   processes     in  the  genital
                                                                                          treatment. Roughly 90 % of those who are      area  also   increase  the risk
group of pathogens which     cana be
                                   preventive   effect.
                                      transmitted    by sexual               and treatment
                                                                                                       transmission.      The    failure  of  chlamydia     therapies  d
contact, and in some contribute    to theas
                       cases via blood     reduction    of AIDS.
                                              well as from      the         undergoing treatment have viral loads which are fully
                                                                            suppressed. The estimated  antimicrobial
                                                                                                                number resistance
                                                                                                                           of new HIV    is currently
                                                                                                                                            infectionsbeing debated
mother to the child during pregnancy, birth or
breastfeeding.        HIV as a chronic disease                              has  stabilised    since  2006    at an  elevated     level,  after  it had
Whilst some pathogens Progress   in theknown
                           have been     therapyforhas    enabled
                                                     a long                 fallenHIV
                                                               time,people with      steeply           Mutual         influences
                                                                                         in until the end of the 1990s. There were         of    co-infections
                      Germany     to have   a similar
other infections such as HIV and hepatitis C were not    life expectancy    3,200
                                                                           as  thosenewwho             Data and
                                                                                            HIV infections          studies
                                                                                                               in 2014         show1).
                                                                                                                          (Figure      that  some sexually transm
                                                                                                                                          Roughly
                      are  not infected.   An  HIV    infection
discovered until the 1980s. On the basis of surveillance           can      84,000
                                                                       therefore   be people    with   infections
                                                                                                      HIV    were    occur
                                                                                                                    living    prominently
                                                                                                                             in  Germany      atinthe
                                                                                                                                                   specific groups b
                      regarded as asurveys
                                       chronicfordisease                    end
                                                            today.ofHowever, this of  2014.   Almost   the  transmission
                                                                                                        three-quarters      ofroutes
                                                                                                                                people  are  the
                                                                                                                                          with    same
                                                                                                                                                 HIV     or similar. T
data and of target group-specific                   the groups
                      requires                                              belong    to  the group    of
                                                                                                      of   infection
                                                                                                          men    who    depends
                                                                                                                        have   sex   on
                                                                                                                                     withsexual
                                                                                                                                           men.   behaviour.   Some s
men who have sex with      men, life-long
                                 injecting therapy     and needs to be closely
                                             drug users,
                      monitored     by medical                                                         practices,    such   as  anal   sex,  entail  higher  transmiss
migrants from Sub-Saharan      Africa,   as well staff
                                                  as sexsince    people with HIV have
                                                            workers,
                                                                                                       risks. At the same time, other sexually transmitted
concrete data and information are available on HIV andcancer, as Increased
                      a considerably     heightened     risk  of             well as of
                                                                            Increased          significance
                                                                                                significance          of hepatitis
                                                                                                                      of   hepatitis        B
                                                                                                                                            B andand    CC increase
                                                                                                       infections such       as gonorrhoea       or syphilis
                      heart
other selected sexually      and vascular
                          transmitted        diseases.
                                        or blood   borne                    Hepatitis B and C areofcurrently           gaining inbecause
                                                                                                                                      significance    both
                                                                                                           HIV transmission                    of infections,   irritati
infections to adjust and improve prevention, counselling                    nationally and internationally          because     of  their  prevalence,
                                                                                                       injuries to the oral, intestinal or genital mucosa. S
and treatment servicesHepatitis        B immunisation and new
                         for these groups.                                  of the serious health syringes
                                                                                                       consequences        (including
                                                                                                                   and other              cirrhosis
                                                                                                                                  equipment            anda high level
                                                                                                                                                 entails
                      treatments available for hepatitis                         C
                                                                            cancer                     of hepatitis B and C transmission in the group of
                      Increasing hepatitis B immunisation rates among children,                        users. Co-infections with HIV and hepatitis virus
      6.000
      6,000           as  well as  among    people   with    a heightened  risk  of                    accelerate     the respective progression of the diseas
                      infection, can prevent the spread and the occurrence of                          more frequently and more quickly lead to serious
                      chronic hepatitis B in future. The treatments available for                      consequences of the disease.
                                                                                            Men   whodie
                                                                                            Männer,    have
                                                                                                          Sexsexmitwith   men haben
                                                                                                                     Männern
      5,000
      5.000           hepatitis B are highly laborious so far. They only alleviate
                      the symptoms and reduce the incidence of related diseases.
                                                                                            People  whoLong-term
                                                                                            Injizierende  inject  drugs effects of sexually trans
                                                                                                          Drogengebrauchende

                      New therapy options for hepatitis B are expected to Heterosexuals                infections underestimated
                                                                                            Heterosexuelle
      4,000
      4.000                                                                                            Sexually transmitted infections can generally be t
                      emerge in the coming years. Thanks to new therapies with
       der Infizierten
            infections

                      fewer side-effects, more effective, rapid treatments are                         and cured very successfully. As they frequently h
                      available to cure hepatitis C.                                                   symptoms, or the symptoms also subside if left un
      3,000
      3.000
                                                                                                       and the infections even heal themselves in some c
    of HIV

                      Sexual transmissibility of hepatitis C                                           they are too seldom recognised at present. Untrea
Anzahl

      2,000
      2.000           New study data have shown that hepatitis C can be                                infections can have serious consequences. HPV is
No.

                      transmitted not only via blood, but also sexually. This                          of cervical cancer, which is prevalent among wom
                      mainly affects HIV-positive men who have unprotected                             Among men, HPV can lead to anal cancer or to a
      1,000
      1.000           anal sex, or who engage in high-risk sexual behaviour. An                        carcinoma of the penis. Untreated syphilis can ca
                      HIV and hepatitis C virus co-infection is usually                                serious    after-effects which can even be life threat

                         0
                         0
                             1975

                                        1980

                                                        1985

                                                                        1990

                                                                                        1995

                                                                                                        2000

                                                                                                                         2005

                                                                                                                                        2010

                                                                                                                                                     2014

                                                                                Yearder
                                                                               Jahr  of Infektion
                                                                                        infection
Figure 1: Estimated total number of new HIV infections in Germany from 1975 to 2014 by transmission groups
Source: Epidemiologisches Bulletin 45/2015, pp. 478
 
       Integrated Strategy for HIV, Hepatitis B and C and Other Sexually Transmitted Infections                                                    7
	
  
       of the liver), and of new medication that is available.                    High prevalence of other
                                                                                                       othersexually
                                                                                                            sexually
       There are at least 300,000 people in Germany who are                       transmitted  infections
                                                                                  transmitted infections
       infected with the hepatitis B and hepatitis C virus,
                                                                                  Data on other sexually transmitted infections such as
       respectively. More than 2,300 hepatitis B and 5,800
                                                                                  syphilis indicate a considerable rise in the trends of some
       hepatitis C infections were diagnosed in Germany in
                                                                                  of these infections. Roughly 5,700 syphilis infections
       2014. Hepatitis B and C are particularly prevalent
                                                                                  were reported in 2014, the majority of whom were men
       among people who use drugs intravenously or also
                                                                                  (Figure 2). Chlamydia and human papillomaviruses
       nasally, as well as among prison inmates, HIV-positive
                                                                                  (HPV) are particularly prevalent among young women
       men who have sex with men, and among people from
                                                                                  and men in Germany. The DEGS Study carried out by the
       high prevalence countries.
                                                                                  Robert Koch Institute estimated prevalences of 4.5 %
                                                                                  among 18- to 19-year old women and of 4.9 % among 25-
                                                                                  to 29-year old men. The prevalence of high-risk HPV
                                                                                  types among non-immunised women aged between 20
                                                                                  and 25 was 34 % in a study on the prevalence of HPV in
                                                                                  Germany, (Delere et al. BMC Infectious Diseases 2014,
                                                                                  14:87).
	
  
                          7,000
                          7000                                                                      	
  
	
                                                                                                  Men
                                                                                                    Männer              Women
                                                                                                                        Frauen            Total
                                                                                                                                          Gesamt
                          6,000
                          6000
	
  
                          5,000
                          5000
	
  
              Meldungen

                          4,000
                          4000
	
  
       No. of reports

                          3,000
                          3000
	
  
       Anzahl

                          2,000
                          2000
	
  
                          1,000
                          1000
	
  
                             0
                                  2001   2002   2003
                                                2003   2004   2005   2006     2007    2008
                                                                                      2008        2009   2010
                                                                                                         2010    2011     2012     2013
                                                                                                                                   2013     2014
	
  
                                                                Yearder
                                                                Jahr of the report/diagnosis
                                                                        Meldung/Diagnose
	
  
       Figure 2: Syphilis reports in Germany by sex and year of diagnosis, Report data in accordance with the Protection Against Infection Act
       (Infektionsschutzgesetz) 2001-2014
       Source: Epidemiologisches Bulletin 49/2015, pp. 515-527
                           	
  
       8                             8   Integrated Strategy for HIV,
                                                                  Integrated
                                                                      Hepatitis
                                                                             Strategy
                                                                                B andfor
                                                                                      C and
                                                                                         HIV,
                                                                                            Other
                                                                                              Hepatitis
                                                                                                  Sexually
                                                                                                        B and
                                                                                                            Transmitted
                                                                                                              C and Other
                                                                                                                        Infections
                                                                                                                          Sexually Transmitted Infections
	
                            	
  
	
                            	
  
	
                            	
  
	
                            	
  
       2. Medical2. Medical                                                           associated with a heightened
                                                                                                           associated
                                                                                      contributes to heightened
                                                                                                                     hepatitis
                                                                                                           contributes
                                                                                                                       with a C
                                                                                                                 infectiosity.
                                                                                                                               heightened
                                                                                                                                 viral load,hepatitis
                                                                                                                        to heightened
                                                                                                                               This explains
                                                                                                                                              which C viral load
                                                                                                                                        infectiosity.
                                                                                                                                               the This explai
       knowledgeknowledge
                  and       and                                                       heightened hepatitis C
                                                                                                           heightened
                                                                                                             co-infection
                                                                                                                        hepatitis C co-infection
                                                                                                                            rates observed   in    rates observed
                                                                                      particular among HIV-infected
                                                                                                           particular among
                                                                                                                       men who HIV-infected
                                                                                                                                  have sex withmen who have sex
       developments
                 developments                                                         men.                 men.
       Early initiation Early
                            of HIV initiation
                                       treatmentof HIV treatment      	
             	
  
       On the basis of new study
                           On thedata,
                                  basisthe
                                         ofHIV
                                           new guidelines             Increasing drugIncreasing
                                               study data, the HIV guidelines             resistancedrug resistance
     currently recommendcurrently
                                treatmentrecommend
                                             to be commenced
                                                          treatment early,         When early,
                                                                       to beascommenced    it comesas to gonorrhoea,
                                                                                                            When it comes
                                                                                                                        the number
                                                                                                                               to gonorrhoea,
                                                                                                                                       of cases isthe number of case
     soon as possible aftersoon the diagnosis.
                                     as possibleThisafterprevents
                                                           the diagnosis.
                                                                    a              rising worldwide
                                                                            This prevents a             in which
                                                                                                            rising antibiotics
                                                                                                                   worldwide     have
                                                                                                                                 in which
                                                                                                                                        no  effect
                                                                                                                                             antibiotics   have no eff
     reduction in the immune  reduction
                                   status,inand
                                              theserious
                                                   immunerelated                   because
                                                               status, and serious related    of resistance.because
                                                                                                              This  makes
                                                                                                                      of resistance.
                                                                                                                            it more   difficult
                                                                                                                                       This   makes
                                                                                                                                                 to    it more difficul
     diseases are avoided.diseases
                               Effective areantiretroviral    therapyantiretroviraltreat
                                              avoided. Effective                         the gonorrhoea.treat
                                                                                     therapy                 Without
                                                                                                                  the gonorrhoea.
                                                                                                                       a successfulWithout
                                                                                                                                       therapy,athesuccessful therapy
     considerably reducesconsiderably
                               the HIV transmission
                                               reduces the  risk,
                                                               HIVandtransmission
                                                                       hence       infection
                                                                                   risk,       can pass to infection
                                                                                         and hence           other organs.
                                                                                                                       can pass
                                                                                                                             Inflammatory
                                                                                                                                  to other organs. Inflammatory
     also has a preventivealso effect.
                                    hasEarly
                                        a preventive
                                                diagnosis effect.  Early diagnosisprocesses
                                                             and treatment                      in the genital
                                                                                    and treatment           processes
                                                                                                                area also
                                                                                                                        in increase
                                                                                                                           the genitalthearea
                                                                                                                                           riskalso
                                                                                                                                                of HIV
                                                                                                                                                     increase the risk
     contribute to the reduction
                              contribute
                                      of AIDS.
                                            to the reduction of AIDS.              transmission.    The  failure
                                                                                                            transmission.
                                                                                                                  of chlamydia
                                                                                                                            The   failure
                                                                                                                                  therapies of due
                                                                                                                                               chlamydia
                                                                                                                                                    to      therapies d
	
                       	
                                                        antimicrobial resistance antimicrobial
                                                                                                                is currentlyresistance
                                                                                                                               being debated.
                                                                                                                                         is currently being debated
       HIV as a chronic
                     HIVdisease
                           as a chronic disease                                       	
                        	
  
       Progress in the therapy
                            Progress
                               has enabled
                                     in the people
                                            therapywith
                                                    has enabled       Mutual
                                                        HIV in people with HIV ininfluences
                                                                                        Mutual
                                                                                            of co-infections
                                                                                                influences of co-infections
       Germany to have a similarGermany life to
                                              expectancy
                                                have a similar
                                                           as those    expectancy asData
                                                                  life who             thoseandwhostudies show Data
                                                                                                                  thatand
                                                                                                                        some
                                                                                                                           studies
                                                                                                                               sexually
                                                                                                                                     showtransmitted
                                                                                                                                              that some sexually transm
       are not infected. An HIV are not
                                     infection
                                          infected.
                                                  canAntherefore
                                                         HIV infection
                                                                   be                infections
                                                                           can therefore   be occur prominentlyinfectionsinoccur
                                                                                                                              specific
                                                                                                                                    prominently
                                                                                                                                        groups because
                                                                                                                                                     in specific groups b
       regarded as a chronicregarded
                                 disease today.
                                            as a chronic
                                                    However,
                                                           disease                   the
                                                                thistoday. However, this transmission      routes
                                                                                                               the are
                                                                                                                    transmission
                                                                                                                        the same   or
                                                                                                                                    routes
                                                                                                                                       similar.are The
                                                                                                                                                   the  same
                                                                                                                                                        risk or similar. T
       requires life-long therapy
                                requires
                                      andlife-long
                                            needs to therapy
                                                       be closely                    of
                                                                and needs to be closely infection     depends  of
                                                                                                               on  infection
                                                                                                                    sexual  behaviour.
                                                                                                                               depends     on
                                                                                                                                            Some
                                                                                                                                               sexual
                                                                                                                                                    sexual
                                                                                                                                                        behaviour.   Some s
       monitored by medicalmonitored
                                  staff sincebypeople
                                                  medicalwith
                                                            staff
                                                               HIV since
                                                                      have           practices,
                                                                         people with HIV have      such  as anal
                                                                                                               practices,
                                                                                                                  sex,  entail
                                                                                                                            suchhigher
                                                                                                                                  as  anal
                                                                                                                                         transmission
                                                                                                                                             sex,  entail   higher transmiss
       a considerably heighteneda considerably
                                       risk of cancer,
                                                   heightened       as of cancer, as risks.
                                                          as wellrisk                 well asAtofthe same time,risks.
                                                                                                                    other
                                                                                                                       At the
                                                                                                                           sexually
                                                                                                                               same transmitted
                                                                                                                                      time, other sexually transmitted
                                                                                     infections such as gonorrhoea
                                                                                                               infectionsor such
                                                                                                                               syphilis
                                                                                                                                   as gonorrhoea
                                                                                                                                          increase the or syphilis
                                                                                                                                                           risk     increase
       heart and vascular diseases.
                                heart and vascular diseases.
                                                                                     of HIV transmission of    because
                                                                                                                   HIV transmission
                                                                                                                          of infections,because
                                                                                                                                             irritations
                                                                                                                                                      of infections,
                                                                                                                                                           and        irritati
	
                         	
                                                        injuries to the oral, intestinal
                                                                                                               injuries toorthe
                                                                                                                              genital
                                                                                                                                 oral,mucosa.
                                                                                                                                        intestinalSharing
                                                                                                                                                     or genital mucosa. S
       Hepatitis B immunisation Hepatitis B and     immunisation
                                                           new               and new syringes and other equipment
                                                                                                               syringes andentails
                                                                                                                                other
                                                                                                                                    a high
                                                                                                                                       equipment
                                                                                                                                              level ofentails
                                                                                                                                                         risk a high level
       treatments available     treatments for hepatitis
                                                    available    C for hepatitis         C
                                                                                     of hepatitis    B and C transmission
                                                                                                               of hepatitis Binand theCgroup
                                                                                                                                          transmission
                                                                                                                                                 of drug in the group of
       Increasing hepatitis BIncreasing
                                  immunisation hepatitis
                                                    ratesBamong
                                                           immunisation
                                                                    children,rates among
                                                                                     users.children,
                                                                                             Co-infections withusers.HIV
                                                                                                                       Co-infections
                                                                                                                            and hepatitis withviruses
                                                                                                                                                 HIV and hepatitis virus
       as well as among people  as well
                                     withasaamong
                                               heightened
                                                      peoplerisk
                                                               with                  accelerate
                                                                  of a heightened risk   of         the respective
                                                                                                               accelerate
                                                                                                                     progression
                                                                                                                             the respective
                                                                                                                                    of the disease
                                                                                                                                                progression
                                                                                                                                                       and of the diseas
       infection, can preventinfection,
                                  the spread canand
                                                  prevent
                                                     the occurrence                  more frequently
                                                           the spreadofand the occurrence       of        and more frequently
                                                                                                                       quickly lead andto more
                                                                                                                                           seriousquickly lead to serious
       chronic hepatitis B inchronic
                                 future. hepatitis
                                           The treatments
                                                      B in future.
                                                              available
                                                                     The treatments
                                                                          for        consequences
                                                                                      available for of the consequences
                                                                                                               disease.          of the disease.
     hepatitis B are highlyhepatitis
                                laboriousB so
                                            arefar.
                                                 highly
                                                    Theylaborious     so far. They	
   only alleviate
                                                            only alleviate                                    	
  
     the symptoms and reduce  the symptoms
                                     the incidence
                                                and reduce
                                                      of related
                                                               the diseases.      Long-term
                                                                   incidence of related      diseases. effectsLong-term of sexually  effects transmitted
                                                                                                                                                   of sexually trans
     New therapy optionsNew    for hepatitis
                                     therapy Boptions
                                                 are expected
                                                         for hepatitis            infections
                                                                  to B are expected         to          underestimated
                                                                                                              infections underestimated
     emerge in the comingemerge years. in
                                        Thanks
                                           the coming
                                                  to newyears.
                                                           therapies   withto new Sexually
                                                                  Thanks             therapiestransmitted
                                                                                                  with        Sexually
                                                                                                                  infectionstransmitted
                                                                                                                               can generallyinfections
                                                                                                                                                 be treated
                                                                                                                                                          can generally be t
     fewer side-effects, more fewereffective,
                                      side-effects,
                                               rapidmore
                                                       treatments
                                                             effective,           and     cured
                                                                    are rapid treatments are      very  successfully.
                                                                                                              and     curedAs very
                                                                                                                                they successfully.
                                                                                                                                      frequently     have
                                                                                                                                                       As  they
                                                                                                                                                            no frequently h
     available to cure hepatitis
                              available
                                     C. to cure hepatitis C.                      symptoms,        or  the symptoms
                                                                                                              symptoms,    alsoorsubside
                                                                                                                                   the  symptoms
                                                                                                                                            if left untreated
                                                                                                                                                      also   subside if left un
	
                       	
                                                       and the infections even     andheal the themselves
                                                                                                                           infections evenin some
                                                                                                                                                heal cases,
                                                                                                                                                      themselves in some c
     Sexual transmissibility  Sexual transmissibility
                                            of hepatitis C of hepatitis           they are C too seldom recognised
                                                                                                              they are tooatseldompresent.recognised
                                                                                                                                             Untreatedat present. Untrea
     New study data haveNew    shown study
                                        thatdata
                                             hepatitis
                                                  have C shown
                                                           can be that hepatitis Cinfections
                                                                                      can be can have serious infections  consequences.
                                                                                                                              can have serious
                                                                                                                                             HPV is  consequences.
                                                                                                                                                        a cause       HPV is
     transmitted not only transmitted
                              via blood, but notalso
                                                  onlysexually.
                                                        via blood,This            of     cervical
                                                                     but also sexually. This       cancer,  which
                                                                                                              of    cervical
                                                                                                                       is prevalent
                                                                                                                               cancer, among
                                                                                                                                         which   women.
                                                                                                                                                  is prevalent   among    wom
     mainly affects HIV-positive
                              mainly affects
                                        men who HIV-positive      men who have Among
                                                    have unprotected              unprotected  men, HPV can   Among lead tomen,
                                                                                                                              analHPV
                                                                                                                                    cancercanorlead
                                                                                                                                                 to ato anal cancer or to a
     anal sex, or who engage  analinsex,
                                      high-risk
                                          or whosexual
                                                   engagebehaviour.
                                                             in high-risk         carcinoma
                                                                        Ansexual behaviour. An     of the  penis.
                                                                                                              carcinoma
                                                                                                                     Untreated of syphilis
                                                                                                                                  the  penis. can
                                                                                                                                                Untreated
                                                                                                                                                   cause syphilis can ca
     HIV and hepatitis C virusHIV andco-infection
                                          hepatitis is
                                                    C usually                     serious
                                                        virus co-infection is usually          after-effects which
                                                                                                              serious    can
                                                                                                                           after-effects
                                                                                                                              even   be  life
                                                                                                                                           which
                                                                                                                                               threatening.
                                                                                                                                                    can even be life threat
 
       Integrated Strategy for HIV, Hepatitis B and C and Other Sexually Transmitted Infections                                                            9
	
  
       Other infections such as chlamydia or gonorrhoea can lead
       to infertility if they are untreated, and can cause
                                                                                     4. Gaps in prevention,
       miscarriages or diseases among newborns.                                      testing and care
	
                                                                                   	
  

       3. New challenges caused by                                                   Knowledge and skills
                                                                                     Even though the level of knowledge regarding the
       behavioural changes                                                           transmission of HIV is high, uncertainty remains in
                                                                                     everyday situations and when it comes to personal
       Changing sexual behaviour                                                     contacts with people living with HIV. The level of
       Anyone can contract a sexually transmitted infection. The
                                                                                     knowledge about other sexually transmitted infections
       number of sexual partners, sexual orientation, sexual
                                                                                     such as chlamydia and HPV is generally low. The
       practices, as well as psychosocial factors, influence the
                                                                                     existing HPV vaccination is not taken up to a sufficient
       vulnerability and risk of becoming infected. Furthermore,
                                                                                     degree (Figure 3).
       social networks and Internet dating portals are changing                      	
  
       and facilitating the ways in which people socialise and                       	
  
       form relationships. This is influencing sexual behaviour.                     	
  
                                                                                     	
  
	
                                                                                                                                 Deutschland
                                                                                                                                   Germany   totalgesamt
       New drug consumption patterns                                                                                               Old
                                                                                                                                   Alte Federal Länder
                                                                                                                                        Bundesläner
       Injecting drug users are particularly badly effected by                                                                     New
                                                                                                                                   NeueFederal   Länder
                                                                                                                                         Bundesländer
                                                                                                         60
       HIV, hepatitis B and C transmission via blood contacts.                       	
  
       Besides opioid users, there are new groups of people who                                          50
                                                                                     	
  
                                                                                                    %%

       use drugs, primarily taking Crystal, Speed, GHB and other
                                                                                                         40
                                                                                                 in in

       drugs with a stimulating effect (party drugs) that                            	
  
                                                                                               rate

       influences sexual and protective behaviour. This as well as
                                                                                     Impfquote

                                                                                                         30
                                                                                                         30
                                                                                  Immunisation

       sharing injection and inhalation equipment increases the                      	
  
                                                                                                         20
                                                                                                         20
       risk of infection.
                                                                                     	
  
	
                                                                                                       10
                                                                                                         10
       Mobility                                                                      	
  
                                                                                                         00
       Mobility is continuing to increase within Germany, in
                                                                                                              2011
                                                                                                              2011             2012
                                                                                                                               2012           2013
                                                                                                                                              2013
       Europe and worldwide. This is influenced by both
       professional and private mobility. Mobility leads to                                                          End of
                                                                                                                     Ende des   calendar year
                                                                                                                            theKalenderjahres
                                                                                     	
  
       vulnerability and risk factors in Germany, as well as for                     	
  
       trips abroad. It promotes the creation of sexual networks                     Figure 3: Immunisation rates for a complete series of vaccinations
                                                                                     against HPV infections among 15-year-old girls from 2011-2013
       within the group of men who have sex with men, the                            according to the vaccination recommendation of the Standing
       utilisation of sexual services or substance use. Tattooing                    Committee on Vaccination (STIKO), which has been in force since
                                                                                     2014
       or piercing shops visited abroad frequently do not come                       Source: Epidemiologisches Bulletin 1/2016, p. 5
       up to the necessary hygiene standards.                                        	
  
                                                                                     	
  
                                                                                     Knowledge is generally scant when it comes to hepatitis B
                                                                                     and C, their modes of transmission, the progression of the
                                                                                     infections, prevention measures, treatment options, as well
                                                                                     as potential cures. Children and adults with a migration
                                                                                     background have so far been insufficiently reached by
                                                                                     hepatitis B vaccination programmes. Hepatitis B
                                                                                     immunisation for people with HIV, men who have sex
                                                                                     with men, people who inject drugs and prison inmates is
                                                                                     being offered and taken up too rarely at present. Adequate
                                                                                     quantities of prevention equipment such as syringes and
                                                                                     needles are not available in all Federal Länder.
                                          	
  
       10                                           8    Integrated Strategy for HIV,
                                                                                  Integrated
                                                                                      Hepatitis
                                                                                             Strategy
                                                                                                B andfor
                                                                                                      C and
                                                                                                         HIV,
                                                                                                            Other
                                                                                                              Hepatitis
                                                                                                                  Sexually
                                                                                                                        B and
                                                                                                                            Transmitted
                                                                                                                              C and Other
                                                                                                                                        Infections
                                                                                                                                          Sexually Transmitted Infections
	
                                           	
  
	
                                           	
  
	
                                           	
  
	
                                           	
  
       Undiagnosed cases                                                         Care services available                       to people         with     a C viral load
                                                    2. Medical
       Gaps in knowledge, a lack of symptoms, as well as in                      heightened riskcontributes
                                                                                                           associated with
                                                                                                                 of infection
                                                                                                                                     a heightened     hepatitis
                                                                                                                                to heightened infectiosity. This explai
                                                    knowledge and
       some cases inadequate access to health services, affect the               Services for the advice,  heightened
                                                                                                                   diagnosis   hepatitis   C co-infection
                                                                                                                                  and treatment     of        rates observed
       large share of non-diagnosed infections. Low-threshold                    sexually transmitted particular
                                                                                                            infections among  (above HIV-infected
                                                                                                                                        all for young men who have sex
                                                    developments
       advice and testing services are not available in all places               women and men, as well    men.as men who have sex with
       where they are needed.  Early
                                  Eveninitiation
                                         where testingof    HIV are
                                                         services    treatment   men) are not sufficiently 	
        well known in some cases, do
       available, the share of   people   who  are unaware     of their
                               On the basis of new study data, the HIV guidelinesnot currently exist inIncreasing
                                                                                                                some regions, and   drug are resistance
                                                                                                                                              not
       HIV infection is increasing     slightly, and  is currently               sufficiently
                               currently recommend treatment to be commenced early, as          expanded   When  for the
                                                                                                                       it  group
                                                                                                                          comes     of
                                                                                                                                    to men    who
                                                                                                                                        gonorrhoea, havethe number of case
       estimated to be around     13 %   (Figure  4). One-third    of            sex
                               soon as possible after the diagnosis. This prevents a  with  men.   In  somerising cases,   services
                                                                                                                      worldwide        for
                                                                                                                                       in   prevention
                                                                                                                                           which  antibiotics    have no eff
       people are diagnosedreduction
                                late wheninthe  disease   has  reached   an      and
                                             the immune status, and serious related    therapy  of  sexually
                                                                                                           because transmitted
                                                                                                                          of        and  blood-born
                                                                                                                               resistance.   This  makes    it more  difficul
       advanced stage. Estimates     suggest   that the  share   of  non-
                               diseases are avoided. Effective antiretroviralinfections
                                                                                   therapy are inadequatelytreat thenetworked
                                                                                                                           gonorrhoea.  andWithout
                                                                                                                                             coordinated
                                                                                                                                                       a successful therapy
       diagnosed hepatitis Bconsiderably
                                 and C cases reduces
                                              in Germany      is much
                                                        the HIV                  with and
                                                                    transmission risk,  the drug
                                                                                            henceand addiction
                                                                                                           infection    carecansystem.
                                                                                                                                  pass toWithin     the
                                                                                                                                            other organs.    Inflammatory
       higher. Available screening     services,  for instance    for            prison
                               also has a preventive effect. Early diagnosis and treatmentsystem,   there  is     room
                                                                                                           processes      forin improvement
                                                                                                                                 the genital     for
                                                                                                                                               area   the
                                                                                                                                                     also  increase  the risk
       chlamydia, are not taken     up  by women    or  offered   by
                               contribute to the reduction of AIDS.   the        large   number   of  incarcerated
                                                                                                           transmission.   drug    users
                                                                                                                                  The     with
                                                                                                                                        failure regard
                                                                                                                                                 of      to
                                                                                                                                                    chlamydia     therapies  d
       medical profession 	
  to an adequate degree. Only 12 % of                the prevention, diagnosis           and   treatment     of  HIV,
                                                                                                           antimicrobial resistance is currently being debated
       women aged under 25 took up the chlamydia screening                       hepatitis  B  and   C  infections.
                                                                                                           	
  
                               HIV as a chronic disease
       service in 2014.        Progress in the therapy has enabled people with HIV in                      Mutual influences of co-infections
	
  
	
                                              Germany to have a similar life expectancy as those who                       Data and studies show that some sexually transm
	
                                              are not infected. An HIV infection can therefore be                          infections occur prominently in specific groups b
                                   Anzahl  Therapierte
                                   No. of persons    in therapy
                                                regarded    as a chronic disease today. However, this                        the transmission routes are the same or similar. T
                                   Diagnosed,requires
                                                 but aber
                                   Diagnostiziert,    not treated
                                                           nicht behandelt
                                                           life-long  therapy and needs to be closely                        of infection depends on sexual behaviour. Some s
                                   Non-diagnosed
                                   Nicht              infections
                                                monitored
                                          diagnostizierte     by medical staff since people with HIV have
                                                             Infektionen                                                     practices, such as anal sex, entail higher transmiss
                                   Share of     a considerably
                                                        diagnosedheightened     risk of cancer, as well as of                risks. At the same time, other sexually transmitted
                                   Anteil derpersons
                                               Diagnostizierten     receiving
                                                                    unter     therapy
                                                                          Therapie
                                                                                                                             infections such as gonorrhoea or syphilis increase
                                   Share of
                                   Anteil       heart and
                                          derinfected        vascular
                                                        persons
                                               Infizierten             diseases.
                                                             unterreceiving
                                                                    Therapietherapy
                                                                                                                             of HIV transmission because of infections, irritati
	
                                           	
                                                                              injuries to the oral, intestinal or genital mucosa. S
                         100,000
                         100.000                    Hepatitis B immunisation and new                                                                            100
                                                                                                                                                               100
                                                                                                                             syringes and other equipment entails a high level
	
  
                                                    treatments available for hepatitis C                                     of hepatitis B and C transmission in the group of
                               90,000
                               90.000                                                                                                                          90
                                                                                                                                                               90
	
                                                  Increasing hepatitis B immunisation rates among children,                users. Co-infections with HIV and hepatitis virus
                               80,000
                               80.000               as well as among people with a heightened risk of                        accelerate the respective progression
                                                                                                                                                               80
                                                                                                                                                               80     of the diseas
	
                                                  infection, can prevent the spread and the occurrence of                  more frequently and more quickly lead to serious
                               70,000
                               70.000               chronic hepatitis B in future. The treatments available for              consequences of the disease. 70   70
                der Menschen

	
                                                  hepatitis B are highly laborious so far. They only alleviate             	
  
                               60,000
                               60.000               the symptoms and reduce the incidence of related diseases.               Long-term effects of 60
                                                                                                                                                  sexually
                                                                                                                                                  60       trans
	
  
                                                                                                                             infections underestimated
            of people

                                                    New therapy options for hepatitis B are expected to
                               50,000
                               50.000                                                                                                             50
                                                                                                                                                  50
                                                    emerge in the coming years. Thanks to new therapies with                Sexually transmitted infections can generally be t%
                                                                                                                                                                           in %
	
                                                                                                                                                                 Anteil in
        Anzahl

                                                                                                                            and cured very successfully. As40they frequently h
                                                                                                                                                                   Share
                               40.000
                               40,000               fewer side-effects, more effective, rapid treatments are                                               40
        No.

	
                                                  available to cure hepatitis C.                                          symptoms, or the symptoms also subside if left un
                               30.000
                               30,000        	
                                                                             and the infections even heal themselves
                                                                                                                                                           30
                                                                                                                                                           30        in some c
	
                                                  Sexual transmissibility of hepatitis C                                  they are too seldom recognised at present. Untrea
                               20.000
                               20,000                                                                                                                      20
                                                                                                                                                           20
                                                                                                                            infections can have serious consequences.   HPV is
	
                                              New study data have shown that hepatitis C can be
                                                transmitted not only via blood, but also sexually. This                     of cervical cancer, which is prevalent among wom
                               10,000
                               10.000                                                                                                                       10
                                                                                                                                                           10
                                                                                                                            Among men, HPV can lead to anal cancer or to a
	
                                         	
   mainly affects HIV-positive men who have unprotected
                                   00           anal sex, or who engage in high-risk sexual behaviour. An                   carcinoma of the penis. Untreated
                                                                                                                                                           00 syphilis can ca
                                           2006
                                              2006      2007
                                                          2007      2008
                                                                    2008       2009
                                                                                2009       2010
                                                                                            2010      2011
                                                                                                       2011                 2012
                                                                                                                            serious    2013
                                                                                                                             2012 after-effects
                                                                                                                                        2013      2014
                                                                                                                                                   2014can even be life threat
                                                                                                                                                 which
	
                                              HIV and hepatitis C virus co-infection is usually
       Figure 4: Number and shares of people living in Germany with HIV infections by diagnosis and therapy status
       Source: Epidemiologisches Bulletin 45/2015, p. 481
 
       Integrated Strategy for HIV, Hepatitis B and C and Other Sexually Transmitted Infections                                                11
	
  
       5. Stigmatisation and                                                       in everyday life, at work, in healthcare, in long-term care,
                                                                                  in prisons and in other areas (Figure 5). It is particularly
       discrimination                                                             important to reduce the existing knowledge gaps and the
	
                                                                                discrimination that is experienced in the healthcare system
       Taboos, a sense of shame, as well as prejudices, prevent                   since restricted access to the treatment system can have
                                                                                  major health consequences.
       open communication on sexually transmitted and blood
       borne infections in relationships, as well as between
       physicians and patients. In particular people with HIV,
       hepatitis B and C continue to be discriminated against
	
  
	
                                                                                                More employees lost their
                 One person in five has                                                           jobs due to discrimination
                 been refused medical                                                                than to poor health!
                      treatment.
	
  
              10 % did not                                	
                                                 26 % of employees
              consult a doctor                            	
                                                 who are open about
                                                          	
                                                 their HIV infection
              when they should                            	
  
              have.                                       	
                                                 report of discrimina-
	
                                                        	
                                                 tory reactions on the
	
                                                        	
                                                 part of their employ-
                       13 % do not regard                 	
                                                 ers.
                       their medical                      	
  
                       records as                         	
  

                                                                 1,148
                       confidential.

                                                                 people with HIV
                                                                     report
	
  
       Figure 5: Discrimination against people with HIV
       Source: Positive Stimmen verschaffen sich Gehör – Die Umsetzung des PLHIV Stigma Index in Deutschland; Deutsche AIDS Hilfe e.V., 2012
                         	
  
       12                          8    Integrated Strategy for HIV,
                                                                 Integrated
                                                                     Hepatitis
                                                                            Strategy
                                                                               B andfor
                                                                                     C and
                                                                                        HIV,
                                                                                           Other
                                                                                             Hepatitis
                                                                                                 Sexually
                                                                                                       B and
                                                                                                           Transmitted
                                                                                                             C and Other
                                                                                                                       Infections
                                                                                                                         Sexually Transmitted Infections
	
  
	
                          	
  
	
                          	
  
	
  
       II. The goal  of the Strategy
               2. Medical                                                                               associated with a heightened hepatitis C viral load
                                                                                                        contributes to heightened infectiosity. This explai
	
  
	
                                 knowledge and                                                        heightened hepatitis C co-infection rates observed
                                                                                                        particular among HIV-infected   men who have sex
                                   developments
       The Strategy aims to sustainably contain HIV, hepatitis B
       and C, syphilis, gonorrhoea, chlamydia, HPV and other
                                                                                    → further expanding    needs-orientated
                                                                                                        men.
                                                                                                                              services for
                                                                                      populations at risk and affected, taking various
       sexually transmitted Early       initiation
                                infections.            of HIVthetreatment factors and conditions
                                             This can improve                                        	
       into account that affect
       overall health of the On population   by preventing  serious               vulnerabilities
                                    the basis of new study data, the HIV guidelines               andIncreasing
                                                                                                          risk exposure,drug      resistance
                                                                                                                           and considering  the
       related diseases suchcurrently
                                 as AIDS,recommend
                                            cancer or cirrhosis of the
                                                        treatment to be commenced wideearly, as
                                                                                        variances    When      it comes
                                                                                                   in regional prevalence;to  gonorrhoea, the number of case
       liver. Undesired childlessness     and   miscarriages are averted
                                soon as possible after the diagnosis. This prevents   a              rising    worldwide     in which antibiotics have no eff
                                                                              → developing      integrated services which address the
       and diseases among newborns         prevented.  In addition  to
                                reduction in the immune status, and serious related                  because      of resistance. This  makes  it more difficul
                                                                                  different infections and make available coordinated
       positive individual and     societal
                                diseases areeffects, preventing
                                              avoided. Effective antiretroviral therapy              treat the gonorrhoea. Without a successful therapy
                                                                                  prevention, testing and care services in order to
       infections, as well asconsiderably
                                 early diagnoses,  might
                                               reduces thecontribute   to a
                                                            HIV transmission  risk,prevent
                                                                                    and hence        infection can pass to other organs. Inflammatory
                                                                                           transmission and co-infections and to
       reduction in healthcare     expenditure.
                                also has a preventive effect. Early diagnosis and treatment          processes in the genital area also increase the risk
                                                                                  recognise and treat infections early. Vital importance
                                contribute to the reduction of AIDS.                                 transmission.      The failure of chlamydia therapies d
                                                                                  attaches to testing,antimicrobial
                                                                                                          which closesresistance
                                                                                                                         the gap between
                                                                                                                                   is currently being debated
       The Strategy aims to	
  
                                                                                  prevention and care;
                                                                                                     	
  
                                   HIV as a chronic disease
                                                                               → promoting networking Mutual   andinfluences
                                                                                                                    cross-sectoralof co-infections
       → create an enabling       environment
                               Progress           whichhas
                                         in the therapy   promotes
                                                              enabledthepeople with HIV in
                                                                                   cooperation in order
                                                                                                      Datatoand
                                                                                                              reach  people
                                                                                                                 studies show in their
                                                                                                                                 that some sexually transm
         acceptance of sexual      orientations
                               Germany    to haveand  different
                                                   a similar life expectancy as those who
                                                                                   respective circumstances    and  to facilitate
                                                                                                      infections occur prominently coordinated,
                                                                                                                                         in specific groups b
         lifestyles, which doesare not
                                    notinfected. An HIVsexual
                                        make different     infection can therefore be
                               regarded  as a chronic  disease today.              high-quality, integrated
                                                                                                      the    prevention,
                                                                                                          transmission     testing
                                                                                                                         routes   areand
                                                                                                                                      the care
                                                                                                                                           same or similar. T
         practices taboo, which      promotes   communication      aboutHowever, this
                               requires life-long infections,
                                                   therapy andand                  services;
                                                                 needs to be closely                  of infection  depends    on  sexual  behaviour. Some s
         sexuality and sexually      transmitted
                               monitored the
                                           by medical   staff since people with→HIV                   practices,  such as anal   sex,
                                                                                       have and expanding strategic information and
                                                                                   generating                                          entail higher transmiss
         which does not marginalise            people concerned;
                               a considerably heightened risk of cancer, as well   data  as the basis for the planning and implementation transmitted
                                                                                     as of            risks. At the  same  time,   other  sexually
                                                                                                      infections
                                                                                   of prevention, testing         such as gonorrhoea
                                                                                                           and treatment    interventions.or syphilis increase
                               heart and vascular diseases.
                                                                                                      of HIV transmission because of infections, irritati
                          	
                                                                          injuries to the oral, intestinal or genital mucosa. S
                               Hepatitis B immunisation and new                                       syringes and other equipment entails a high level
                               treatments available for hepatitis C                                   of hepatitis B and C transmission in the group of
                               Increasing hepatitis B immunisation rates among children,              users. Co-infections with HIV and hepatitis virus
                               as well as among people with a heightened risk of                      accelerate the respective progression of the diseas
                               infection, can prevent the spread and the occurrence of                more frequently and more quickly lead to serious
                               chronic hepatitis B in future. The treatments available for            consequences of the disease.
                                   hepatitis B are highly laborious so far. They only alleviate             	
  
                                   the symptoms and reduce the incidence of related diseases.               Long-term effects of sexually trans
                                   New therapy options for hepatitis B are expected to                      infections underestimated
                                   emerge in the coming years. Thanks to new therapies with                 Sexually transmitted infections can generally be t
                                   fewer side-effects, more effective, rapid treatments are                 and cured very successfully. As they frequently h
                                   available to cure hepatitis C.                                           symptoms, or the symptoms also subside if left un
                            	
                                                                              and the infections even heal themselves in some c
                                   Sexual transmissibility of hepatitis C                                   they are too seldom recognised at present. Untrea
                                   New study data have shown that hepatitis C can be                        infections can have serious consequences. HPV is
                                   transmitted not only via blood, but also sexually. This                  of cervical cancer, which is prevalent among wom
                                   mainly affects HIV-positive men who have unprotected                     Among men, HPV can lead to anal cancer or to a
                                   anal sex, or who engage in high-risk sexual behaviour. An                carcinoma of the penis. Untreated syphilis can ca
                                   HIV and hepatitis C virus co-infection is usually                        serious after-effects which can even be life threat
 
       Integrated Strategy for HIV, Hepatitis B and C and Other Sexually Transmitted Infections                                              13
	
  
       III. Areas of action
	
  
                                                                                  and taboos, and to promote open communication about
       1. Creating an enabling                                                    sexually transmitted infections.
       environment
                                                                                  	
  
                                                                                  Interventions:
	
  
                                                                                  → Refining mass communication and personal
       Removing the taboo from
                                                                                       communication campaigns and activities for the
       sexually transmitted infections
       Sexuality is part of life, and it is important for physical                     population as a whole and for specific groups,
       and emotional as well as mental well-being. Sexuality,                          involving civil socitey organisations and volunteers
       and sexually transmitted infections in particular,                              who impart knowledge, contribute towards reducing
       however frequently go hand-in-hand with feelings of                             taboos and promote protective behaviour
       shame and taboos. Sexually transmitted infections are                      → Drafting and providing materials for schools in order
       for instance frequently attributed to misbehaviour and                          to deal with the topic within sexuality education in
       considered to have been self-induced. What is more,                             lessons. Independent agencies can support teachers in
       most people do not find it easy to speak about sexuality                        this endeavour.
       and sexually transmitted infections. Open                                  → Expanding the basic and further training available to
       communication is important in order to protect oneself                          the medical profession (including general
       and others against infection, and where necessary to take                       practitioners, gynaecologists, dermatologists,
       up diagnostic and therapeutic services. A major
                                                                                       urologists and paediatricians) as well as medical staff
       precondition for responsible communication about
                                                                                       in order to make it easier to talk about sexuality and
       sexuality and sexually transmitted infections is respect
                                                                                       sexually transmitted infections in the doctor-patient
       for sexual and reproductive rights, and in this context
                                                                                       relationship, as well as to draw up materials enabling
       the acceptance of and freedom from prejudices about
                                                                                       a better sexual medical history to be drawn up.
       different sexual orientations, sexual practices and
       lifestyles.                                                                	
  
	
                                                                                Reducing stigmatisation and
       Imparting knowledge and preventive interventions can                       discrimination
       help people to speak with their sexual partners about                      Fear of infection and stigmatisation in the context of HIV,
       sexuality, and about sexually transmitted infections in                    hepatitis B and C, as well as of other sexually transmitted
       particular. The aspect of communication between                            infections, is frequently heightened by reservations against
       partners is particularly important in order to break the                   different sexual lifestyles and orientations, illegal
       chain of infection. Many sexually transmitted infections                   substance use, people of different origins, or sex work.
       cause virtually no symptoms, so that the infection goes                    Fear of stigmatisation can prevent people from taking up
       undetected for a long time. In addition to communication                   testing and support services and from being open about
       between sexual partners, communication is also key for                     their status. Stigmatisation and discrimination are harmful
       advice, testing, treatment and care providers. Talking                     to the quality of life of those concerned. They lead to
       openly about sexuality in a manner that is free of                         people not confiding in those around them and
       prejudices is a major precondition when it comes to                        withdrawing from friends or family and being less
       taking up the testing and treatment that are available.                    integrated in society. This can cause damage both to
       Establishing a sexual medical history is a suitable means                  mental and physical health, and to the health and
       to first of all learn something about the sexual and risk                  protective behaviour of those concerned.
       behaviour of clients and patients, and then to have                        Ignorance, prejudices and fears continue to lead to people
       corresponding diagnostic tests carried out. There is                       who are infected with HIV and hepatitis being placed at a
       therefore a need to reduce feelings of shame                               disadvantage in the healthcare system, in the long-term
                                                                                  care area, in prisons, at work and in other areas.
                              	
  
       14                               8   Integrated Strategy for HIV,
                                                                     Integrated
                                                                         Hepatitis
                                                                                Strategy
                                                                                   B andfor
                                                                                         C and
                                                                                            HIV,
                                                                                               Other
                                                                                                 Hepatitis
                                                                                                     Sexually
                                                                                                           B and
                                                                                                               Transmitted
                                                                                                                 C and Other
                                                                                                                           Infections
                                                                                                                             Sexually Transmitted Infections
	
                               	
  
	
                               	
  
	
                               	
  
	
                               	
  
                                                                                               Focus on specific populations
                                        2. Medical
       The obligation to observe confidentiality and privacy are
       not respected in all cases. There is a need to accept                             Knowledge about HIV
                                                                                                             associated with a heightened hepatitis C viral load
                                                                                                                       contributes
                                                                                                                              and protective to heightened
                                                                                                                                                      behaviour    infectiosity.
                                                                                                                                                                       is to be This explai
                                        knowledge and
       diversity, to continue to reduce stigma and discrimination,                                                     heightened            hepatitis      C  co-infection
                                                                                         kept at a high level in the overall population. The basic rates observed
       and to safeguard the rights of those concerned.                                   knowledge about other         particular
                                                                                                                              sexuallyamong           HIV-infected
                                                                                                                                             transmitted        infections   men
                                                                                                                                                                               andwho have sex
	
                                      developments                                     hepatitis B and C is to       men.  be established. People are to be
       Interventions:            Early initiation of HIV treatment                       motivated to consult 	
  a physician if they suspect an
       → Continuing and refining            activities
                                 On the basis      of newandstudy
                                                              campaigns                  infection. A planned Increasing
                                                                              to HIV guidelines
                                                                      data, the                                           study on adult sexualitydrug resistance will provide
           reduce stigma andcurrently
                                   discrimination
                                               recommend treatment to be commenced       data toearly,furtherasadjustWhen   prevention
                                                                                                                                    it comes interventions.
                                                                                                                                                   to gonorrhoea, the number of case
       → Continuing and creating soon as additional
                                            possible after further                       	
  
                                                                     training forThis prevents
                                                                the diagnosis.                       a                 rising       worldwide         in which antibiotics have no eff
           healthcare professionals
                                 reduction in order
                                                in the to  guarantee
                                                        immune                           Young
                                                                         thatand serious related
                                                                    status,                           girls   can  be  because
                                                                                                                      protected         of  resistance.
                                                                                                                                         against     cervical Thiscancer
                                                                                                                                                                      makes it more difficul
                                 diseasescare
           those concerned receive           are inavoided.    Effective antiretroviralthrough
                                                      a non-discriminatory                    therapyearly immunisation.
                                                                                                                       treat the An          awarenessWithout
                                                                                                                                        gonorrhoea.            is to be a successful therapy
                                 considerably       reduces
           manner, and to achieve better application of the    the  HIV    transmission  created
                                                                                        risk,     and  among
                                                                                                         hence  parents       and
                                                                                                                       infection    in   the
                                                                                                                                          can  medical
                                                                                                                                                pass    to   profession
                                                                                                                                                             other  organs.  in Inflammatory
                                                                                         order     to   increase   the   HPV
                                                                                                                       processes   immunisation
                                                                                                                                           in the   genitalrates.
                                                                                                                                                                areaThe also  increase the risk
           recommendationsalso        hasCommission
                                  of the     a preventivefor  effect.   Early diagnosis and treatment
                                                                   Hospital
                                 contribute      to the reduction      offor
                                                                          AIDS.          expansion         of HPV    immunisation
                                                                                                                       transmission.          to  include
                                                                                                                                                The    failure  boys
                                                                                                                                                                   of   is
                                                                                                                                                                       chlamydia     therapies d
           Hygiene and Infection        Prevention       (KRINKO)             the
                            	
                                                           currently being examined                  by the Standing
                                                                                                                       antimicrobial            resistance    Committee
                                                                                                                                                                 is currently on being debated
           prevention of nosocomial          infections specifically on
                                 HIV      asinfections
                                                a chronic disease                        Vaccination         (STIKO).  	
  
           HIV or other blood       borne
                                 Progress in the therapy has enabled people with         	
   HIV in                   Mutual influences of co-infections
       → Refining interventions which ensure that people with                            Juveniles         form  a  group
                                                                                                                       Data    that
                                                                                                                                  andis studies
                                                                                                                                           central show
                                                                                                                                                      to thethatprevention      of
                                                                                                                                                                      some sexually     transm
                                 Germany to have a similar life expectancy as those who
           HIV receive care that is free of discrimination within                        HIV be   and other sexually           transmitted
                                                                                                                       infections          occurinfections.
                                                                                                                                                     prominently    Thein specific groups b
                                 are not infected. An HIV infection can therefore
           long-term care                                                                younger
                                 regarded as a chronic disease today. However,                  this generations the     must      be repeatedly
                                                                                                                                transmission              reached
                                                                                                                                                     routes     are thewith same or similar. T
       → Continuing and developing               interventions     in  order   to
                                 requires life-long therapy and needs to be closely      topical      information.     of     infection
                                                                                                                       Freely-accessible      depends        on
                                                                                                                                                      educationalsexual     behaviour. Some s
                                                                                                                                                                          media
           counter stigmatisation       and    discrimination      within
                                 monitored by medical staff since people with HIV have   on     HIV    and   other     practices,
                                                                                                                    sexually               such
                                                                                                                                    transmitted   as   anal    sex,
                                                                                                                                                       infections,    entail   higher transmiss
           institutions such as     prisons, the police
                                 a considerably               forcesrisk
                                                       heightened                          well as of services in the field of social media, as well as transmitted
                                                                        or of cancer, as prevention                    risks.      At    the  same      time,    other    sexually
           employment agencies                                                           quality-assured sexuality     infections educationsuch in asschools,
                                                                                                                                                       gonorrhoea   are to or syphilis increase
                                 heart and vascular diseases.
                                                                                                                       of     HIV     transmission
                                                                                         enable young people to deal responsibly with sexuality              because     of  infections,
                                                                                                                                                                                and      irritati
       → Continuing the 	
  activities of civil society organisations
                                                                                         sexually transmitted injuries  infections.    to the
                                                                                                                                            This oral,    intestinal
                                                                                                                                                    includes             or genital mucosa. S
                                                                                                                                                                  information
           and community led     Hepatitis
                                    initiatives, B      immunisation
                                                     including    informing and new
                                                                                                                       syringes         and    other     equipment        entails
                                                                                         about and acceptance of sexual diversity and lifestyles.                               In a high level
           patients.             treatments available for hepatitis                             C                      of     hepatitis
                                                                                         particular, the awareness of the possible long-term B   and   C    transmission       in the group of
	
                               Increasing hepatitis B immunisation rates among children,                             users. Co-infections with HIV and hepatitis virus
                                                                                         consequences of chlamydia infections is to be increased, as
       2. Further expansion of   as well as among people with a heightened risk of
                                 infection, can prevent the spread and the occurrence of
                                                                                                                       accelerate the respective progression of the diseas
                                                                                         is the take-up of screening services.
                                                                                                                       more frequently and more quickly lead to serious
       demand-orientated services                                                        	
  
                                 chronic hepatitis B in future. The treatments available for                           consequences of the disease.
                                                                                         Men who have sex with men constitute the largest
	
                               hepatitis B are highly laborious so far. Theygroup           only alleviate           	
  
                                                                                                    of people living with HIV. The prevalence of
       HIV, hepatitis B andthe    C and   other sexually
                                     symptoms                  transmitted
                                                      and reduce     the incidence of related
                                                                                         HIV, and   diseases.          Long-term effects of sexually trans
                                                                                                          the rates of infection with further sexually
                                                                                                            infectionsinfections                  underestimated
       infections are not spread      equally      within   the  population
                                 New therapy options for hepatitis B are expectedin                to
                                                                                         transmitted                         such as syphilis,          are also
       Germany and over geographic
                                 emerge in regions.         Because
                                                                years.ofThanks to new high.
                                                 the coming                                        Among HIV-positive men who haveinfections
                                                                                           therapies      with         Sexually          transmitted          sex with can generally be t
       different vulnerability     and   risk    factors,  specific    needs
                                 fewer side-effects, more effective, rapid treatments                  are             and       cured     very   successfully.         As they frequently h
                                                                                         men, additionally          co-infections of HIV and
       therefore arise for parts     of  the   population.
                                 available to cure hepatitis C.In  order   to                                          symptoms,             or  the   symptoms         also  subside if left un
                                                                                         hepatitis C need to be taken into account.
       achieve a greater impact,
                            	
         and    to  make    optimum      use  of                                         andand    theother
                                                                                                                                      infections       even heal themselves in some c
                                                                                         Knowledge about HIV                                  sexually
       the available resources,      prevention,
                                 Sexual                testing, treatmentof hepatitis C
                                               transmissibility                                                        they       are   too   seldom       recognised at present. Untrea
                                                                                         transmitted infections, as well as the protective
       and care services should be in line with people’s needs,                                                        infections          can   have      serious    consequences. HPV is
                                 New study data have shown that hepatitis Cbehaviour        can be of men who have sex with men, remains
       and supplemented by activities that promote the                                                                 of     cervical      cancer,      which     is  prevalent among wom
                                 transmitted not only via blood, but also sexually.      at a high Thislevel as a whole. There is a need to
       empowerment of themainly   people affects
                                            affected.    Given    that  people                                         Among men,
                                                      HIV-positive men who have continually
                                                                                         unprotectedprovide education                     and HPV        can lead to anal cancer or to a
                                                                                                                                                information
       cannot as a rule be attributed        to   one  single   group    only,
                                 anal sex, or who engage in high-risk sexual about        behaviour.                   carcinoma            of
                                                                                                            An protection and risk management   the   penis.     Untreated syphilis can ca
                                                                                                    effective
       different characteristics     lead   to   groups   being    formed
                                 HIV and hepatitis C virus co-infection is usually       strategies in order to minimise the possibility ofcan even be life threat
                                                                                                                       serious        after-effects         which
       from the interventions needing to be adjusted, re-worked
                                                                                         risks being wrongly assessed. Due to the heightened
       and re-orientated more in line with the regional
                                                                                         risks posed by individual sexual practices and to
       prevalences. Gender-related aspects need to be taken into
                                                                                         other factors such as the number of
       account in this regard.
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