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 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 226 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
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