The Swedish response to the Declaration of Commitment on HIV/AIDS

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1 25 March 2006 Ministry of Health and Social Affairs Sweden Public Health Division Ulrika Körnell Status at a glance In an international perspective, HIV infection rates in Sweden are relatively low and levels remain stable. There is a long tradition of preventive measures against infectious diseases and of promoting sexual and reproductive health and rights in Sweden. When the country became aware of the existence of HIV infection, a range of measures was rapidly taken to limit the spread of infection. Since the mid-1980s the Government has allocated special funds to preventive measures against HIV. These funds are at present at the disposal of the National Board of Health and Welfare. The appropriation for 2005 comes to slightly more than SEK 153 million. Appropriations from other political sectors contribute to the struggle against HIV/AIDS, which means that the total sum is considerably higher. Sweden also attaches the highest priority to the international work against HIV and AIDS. As a result, our financial commitment has increased considerably during the past few years and exceeded last year million SEK in multilateral and bilateral development assistance to the work against HIV and AIDS. The Swedish response to the Declaration of Commitment on HIV/AIDS In May 2002, as a response to the Declaration of Commitment on HIV/AIDS, the Government appointed a special commission, whose assignment was to conduct a comprehensive survey of central and local government measures to combat HIV/AIDS. In the commission representatives from agencies and civil society were included. The commission s main task was to present a proposal for a national action plan aimed at restricting the spread of the disease and limiting its consequences. The commission s work was based in part on the Declaration adopted at the special session of the UN General Assembly on HIV/AIDS in Furthermore the commission s work was based on the national public health target: the creation of social conditions to ensure good health, on equal Postal address Telephone registrator@social.ministry.se SE Stockholm SWEDEN Visitors' address Fax Fredsgatan

2 2 terms, for the entire population. The commission submitted a report to the Government in February A National Strategy to Combat HIV/AIDS and Certain Other Communicable Diseases Based on the report of the special commission, the Government put forward the Government Bill National Strategy to Combat HIV/AIDS and Certain Other Communicable Diseases in December During the process resulting in the Bill, hearings with civil society were organised. The Bill gives an account of a comprehensive strategy for measures to be taken by central, regional and local government to prevent the spread and reduce the consequences of HIV infections and other sexually transmitted and bloodborne diseases. The strategy is based on the commitments expressed in the Declaration of Commitment on HIV/AIDS, adopted at the special session of the UN General Assembly on HIV/AIDS in Initiatives taken by central, regional and local government are based on the national public health policy. A special objective for central, regional and local government initiatives to prevent HIV/AIDS and other sexually transmitted and bloodborne diseases should be introduced. The target should be to restrict the spread of HIV infections and other sexually transmitted and blood-borne diseases and to limit the consequences of these infections for society and the individual. The Government also sets up three interim targets for the national efforts: - the number of newly identified cases of HIV infection in which transmission of the disease occurs in Sweden must be halved by 2016, - HIV must be diagnosed within two months for persons who are asylum seekers or applying for residence permit on the grounds of family ties and within six months for persons returning from high endemic areas and - knowledge about HIV/AIDS and what it is like living with the disease must be improved in the public sector, in working life and society as a whole. Long-term preventive work will remain the basis of government initiatives in the area. In addition, it should be possible to take initiatives that mainly involve epidemiology, preventive measures within health and medical care and more acute action. Greater integration of preventive initiatives and treatment should be sought in relation to work being conducted in associated areas or other efforts that are in line with the overall goal of public health policy. With regard to IV drug addicts the main objective is to maintain easy access, including for HIV positive persons, to a comprehensive treatment system. In the Bill the Government presents provisions to introduce needle exchange programmes as complements to the ordinary treatment system. The Government also states in the Bill that the division of responsibilities between government actors in Sweden should be defined and clarified. A special coordinating body should be established at the National Board of Health and Welfare whose tasks would include promoting coordination of

3 3 all national initiatives and ensuring that long-term preventive measures are taken. The Communicable Diseases Act Work on preventing HIV/AIDS, like other serious infectious diseases, is subject to the regulations given in the Communicable Diseases Act. The Communicable Diseases Act states that the primary responsibility for the work against communicable diseases lies with the County Medical Officer. However, responsibility for direct measures to prevent the spread of disease often lies with physicians in charge of treatment and other health and medical care staff. Different types of preventive action include information, counselling and various measures aimed at preventing individuals from catching a communicable disease, such as vaccination. This type of preventive action is undertaken by health and medical care personnel, agencies and NGOs. A prerequisite for enabling infected and infection-free persons to take responsibility is often knowledge about modes of transmission and measures to prevent transmission. Therefore the main focus in the Communicable Diseases Act is on preventive measures. The Act also includes a duty for persons who are or have reason to suspect that they are infected with a communicable disease to inform others. Duty to inform means that a person who knows that he/she is infected with a disease dangerous to public health is required to inform those with whom he/she is in sufficiently close contact for there to be a considerable risk that the infection will be transmitted to the persons in question. The duty to inform others is based on the premise that all individuals are entitled to the possibility to decide whether they wish to expose themselves to the risk of being infected. The Communicable Diseases Act states that the National Board of Health and Welfare is responsible for regulations and supervision in communicable disease control and for coordination of activities at the national level. In its role as expert agency, the Swedish Institute for Infectious Disease Control is responsible for surveillance and analysis of the distribution of communicable diseases nationally and internationally and proposes measures to ensure that national disease control functions efficiently. Ongoing review of non-discrimination regulations Human rights in Sweden are safeguarded above all by three of the four constitutional laws: the Instrument of Government, the Freedom of the Press Act and the Fundamental Law on Freedom of Expression. In addition to the constitutional provisions, provisions at other levels also have a practical bearing on the rights and liberties of the individual, such as nondiscrimination laws and also a system of Ombudspersons safeguarding the human rights for different groups i.e. sex, ethnicity, sexual orientation and physical and psychological disability.

4 One of the principal objectives of central, regional and local government efforts to combat HIV/AIDS is to alleviate the personal and social consequences of the disease. HIV infected persons who consider themselves discriminated on basis of their positive HIV status have the right to make a complaint on the grounds of disability. In 2005 the Government gave the Discrimination Commission (originally appointed in 2002) an additional assignment to investigate the possibilities of general legislation against discrimination covering all or most grounds for discrimination and sectors of society and to consider the possibility to merge the various systems of Ombudspersons or to establish an agency with over-all responsibility for all the grounds of discrimination. In this assignment the Discrimination Commission had to take into account the findings made by the special commission on HIV/AIDS (see section on The Swedish response to the Declaration of Commitment on HIV/AIDS) regarding discrimination of HIV positive persons. The commission submitted a report to the Government in January Overview of the Swedish HIV/AIDS epidemic The development of the HIV epidemic in Sweden continues to mirror the global HIV situation. More than half of the reported cases in 2005 were persons who had been infected in Africa or Asia. Most of these persons had been infected before they arrived in Sweden. The number of persons infected in Sweden remains on a low level (no major change since the mid 1990-ties), despite an increase among men who have sex with men (MSM) during At the end of 2005 the total number of persons diagnosed with HIV since the onset of the epidemic was (5065 men, 2034 women). During 2005, 392 new cases of HIV infection were reported. Out of these 228 were men and 164 women. The numbers reported in 2003 and 2004 were 431 and 364 respectively. Of the reported cases during 2003, 193 were by heterosexual transmission (65 men and 128 women). 103 of these persons had been infected before their arrival in Sweden. The average age at the time of diagnosis was 36 years. In 2005, 96 cases of MSM transmission were reported. This is in line with a slight annual increase since 2003 when 78 men were reported and 82 cases of MSM transmission in For 54 of the men the place of transmission was reported to be in Sweden compared to 41 persons in 2003 and 43 in The average age at the time of diagnosis remained unchanged at 39 years. 25 persons (22 men and 3 women) have been reported as infected via intravenous drug use (IVDU) in The number for 2003 and 2004 were 31 and 30 cases respectively. In 17 of the cases transmission was considered to have happened in Sweden.

5 Major challenges faced and actions needed to achieve the UNGASS goals and targets As stated above in an international perspective, domestic HIV infection rates in Sweden are relatively low and levels remain stable. It is, however, the Government s view that, despite this apparently fairly favourable starting point, there are reasons for continued awareness about the situation in Sweden. The first reason regards the developments in the epidemiological situation, such as the growing number of persons infected in Sweden with other sexually transmitted diseases and the increasing number of people living with HIV infection thanks to successful health care and treatment. Furthermore the Swedish epidemiological status mirrors the international development, such as the growing number of HIV-infected people immigrating to Sweden from high endemic areas. The development of the HIV epidemic in the countries in our immediate vicinity is also worrying. The second reason regards issues of stigma and discrimination. Further efforts are needed to ensure better implementation of existing legislation in for instance health care settings. Greater awareness of HIV/AIDS issues within the judicial system, including the police, is needed. Health issues for migrating populations, e.g. refugees, immigrants and their relatives need continued attention. Thirdly, thanks to successful health care and treatment, the sense of crisis and therewith a high awareness level as regards HIV/AIDS has changed into a sense of normalisation of the HIV-epidemic. This call for a new kind of support to HIV infected persons, such as family planning, rehabilitation to enable a return to an active work life and enhanced efforts to combat stigma in the work place. In a not so distant future it also calls for preparedness in the elderly care to manage a new group of patients. The normalisation of the HIV-epidemic is also a challenge for the preventive work in order to keep the issue alive and to influence young peoples sexual risk behaviour in the framework of reproductive and sexual education. The preventive work requires inclusion of various sectors and calls upon a broad range of actors to take their individual responsibility. In line with the national public health policy, the HIV preventive work has to shift from prevention of sickness to promotion of health. All these challenges are addressed in the Government s Strategy to Combat HIV/AIDS and Certain Other Communicable Diseases. 5 Support from country s development partners Not applicable to Sweden. Monitoring and evaluation environment In the Government Bill National Strategy to Combat HIV/AIDS and Certain Other Communicable Diseases, decided by the Government in December 2005 an improved monitoring and evaluation system is presented by which

6 the national Board of Health and Welfare has the major responsibility to assure the long term evaluation and monitoring. 6