Catching up with the rest of Europe: Albania and Hungary seek better HIV services

by Gus Cairns

The European AIDS Clinical Society (EACS) held its seventh Standard of Care for HIV and Co-infections in Europe meeting in Budapest, Hungary earlier this month. This largely biennial meeting, which alternates with the European AIDS Conference, seeks to redress the huge inequalities of HIV treatment and prevention that prevail across the World Health Organization’s European Region.

EACS President Professor Miłosz Parczewski of Poland told the meeting that EACS is perhaps best known for its guidelines. “Guidelines tell us what the best care looks like, based on the scientific evidence,” he said. “But the Standard of Care is different, a consensus on the minimum level of care every person with HIV in Europe should be able to expect, taking into account the real constraints health systems face.

“And crucially, it is designed to be measured, so that we can see where we stand and whether we are improving.”

A majority of the Standard of Care meetings have now been held outside of Western Europe: the 2019 meeting was in Bucharest; the 2020 was originally scheduled for Tbilisi in Georgia, though it was mainly conducted online due to COVID; and the 2024 in Athens.

Progress since 2024

An innovation of 2024’s Athens meeting was to have local co-chairs from two countries that are very different but share some common problems – in that case, Greece and Türkiye.

Dr Konstantinos Protopapas, local co-chair at Athens, told the meeting that “the location of a Standard of Care meeting is part of its intervention.” He drew attention to the 2024 meeting’s part in unlocking access to HIV pre-exposure prophylaxis (PrEP) in Greece. Provision had been approved by the Greek National Public Health Office in 2022 and a legal framework for its dispensation was created in 2023, but it was still stubbornly unavailable by the time of the Athens meeting in November 2024.

One outcome of the Athens meeting was a letter from EACS to the Greek Ministry of Health urging the provision of PrEP. Protopapas, a co-signatory, said: “The EACS letter was catalytic: it did not create PrEP from zero, but it turned a known, unresolved gap into a focused and time-sensitive policy ask.” As a result, the national prescribing and dispensation of PrEP began in May 2025, and it is now available without payment from 24 hospital pharmacies throughout Greece.

A related outcome of that meeting came from the testimony of both doctors and patients that people with HIV in the remoter areas of Greece faced a day’s journey to the nearest HIV clinic. As a result, two additional clinics in Ioannina and Larisa in central Greece have now opened.

But for larger changes such as PrEP it was essential to get political buy-in. “Change becomes more sustainable when it has a home inside the national system,” Protopapas said. And while examining the Standard of Care might result in a long list of gaps that needed filling, prioritising a specific, feasible measure at the right time and with high impact is “more likely to move policy than a catalogue of problems.”

This is illustrated by the case of Türkiye, which has been in the news recently, owing to President Recep Tayyip Erdoğan’s crackdown on LGBTQ+ organisations. Professor Deniz Gökengin, local co-chair of the Athens meeting, said that because of this she did not expect PrEP via Türkiye’s public health system any time soon.

However, the 2024 Athens meeting also exposed several issues that could be progressed in Türkiye. One was surveillance: the last surveillance study of the HIV-positive population in Türkiye was in 2016. A national digital HIV database pilot has now been initiated and an HIV surveillance team has received training from CHIP in Denmark for modelling the Turkish epidemic.

The other issue in Türkiye was that 2016 data suggested that once people were diagnosed with HIV, 88% started antiretroviral therapy (step two of the treatment cascade) and of those, 87% had an indetectable viral load a year later (step three). But the figure for the first step of the cascade was very low: only 41% of people with HIV knew their status.

While the situation had probably improved by 2024, there were still only seven voluntary counselling and testing centres in six cities in this large country, and although 51% of patients at general healthcare centres had conditions that might indicate HIV, only 22% of those were offered an HIV test.

Since 2024, indicator condition-guided testing has been recommended, HIV and hepatitis screening has started in prisons, and there are now 20 voluntary counselling and testing centres in 11 geographically spaced cities.

Hungary and Albania

This ‘Athens formula’ was repeated at this year’s Budapest meeting, which was co-chaired by physicians from Hungary and Albania.

The situation in these two countries may seem very different. Hungary is an EU country emerging from 16 years of right-wing populist rule under Viktor Orban. It has HIV clinics in four cities and access to most current antiretroviral regimens. However, PrEP is not available (despite 25% of Hungarians at risk of HIV saying they want it) and hard to get unofficially. Stigma in the general population and the healthcare system remains a problem.

One issue that came to light during the meeting, highlighted by the meeting’s community co-chair Christian Cziria, was that reproductive health practice still lags behind other European countries. In particular, women are not being tested for HIV in the first trimester of pregnancy to prevent vertical transmission, and this is the kind of issue that the Standard of Care process could audit and seek to improve.

Albania in transition

Albania is an EU candidate country, with about a quarter of Hungary’s population and less than half of its per-capita GDP. As an upper-middle-income country, it was supported by grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria from 2007, but its last HIV grant closed in December 2024. Since 2004, Albania has financed antiretroviral therapy (ART) through the state budget.

In common with other middle-income countries, Albania has been following the recommendations of the World Health Organization (WHO) regarding ART. This means there is only one first-line regimen: a tenofovir disoproxil, lamivudine and dolutegravir fixed-dose combination pill (TLD). No other regimens, such as ones based on bictegravir, darunavir, or tenofovir alafenamide (TAF), are yet available.

“It’s a public health approach,” said Arjan Harxhi, local co-chair of the meeting and Professor of Infectious Diseases at the University of Tirana. He added that more efforts should be done to improve access to viral load and resistance testing but also to diagnostics and treatment tools for opportunistic infections and co-morbidities.

Albania still has a low-level epidemic. There are only about 1500 people known to be living with HIV in Albania and just 431 people were diagnosed in the last four years. In 2025 it recorded 132 new adult diagnoses, or 4.8 per 100,000, below the EU/EEA average of 5.3.

UNAIDS estimates that 88% of the 1650 people living with HIV in Albania know their status, yet this indicator does not reflect the timeliness of diagnosis or the proportion who are diagnosed at an advanced stage of HIV infection. In the WHO European Region as a whole, 54% of people are diagnosed late – i.e. with a CD4 count below 350. In Albania last year it was 62%, a decrease from 73% in 2022. Forty-one per cent were diagnosed with ‘advanced’ HIV, with a CD4 count below 200, compared to a European average of 34%. Nearly half of those diagnosed are aged over 50.

The odds of late diagnosis rise by 73% with every ten additional years of age: almost nine in ten people diagnosed at 50 or over are diagnosed late. Advanced HIV disease at diagnosis was associated with substantially higher mortality during follow-up: 18.6%, compared with 2.0% among those diagnosed at an earlier stage.

Voluntary testing accounted for only 2% of nearly 75,000 HIV tests performed in 2025, indicating limited uptake of testing on individuals’ own initiative. Most diagnoses were made following physician referral, often prompted by symptoms. Among those diagnosed, 61% had attended a healthcare service on at least one previous occasion without being offered an HIV test, highlighting missed opportunities for earlier diagnosis.

One reason for delayed diagnosis may be stigma. Diagnoses have risen since 2023, and the increase is among men. Men outnumber women 3.5 to 1. Yet 73% of cases are still reported as due to heterosexual transmission, suggesting that sex between men is under-reported. HIV prevalence among men who have sex with men rose from 2.0% in 2019 to 3.3% in 2024. Only 31% of those had been tested in the past year, and PrEP is still not available. Sex work is criminalised, and fear of the police discourages sex workers from carrying condoms.

Dr Roland Bani of Albania’s Institute of Public Health said that data from a national cohort of 431 adults diagnosed with HIV from 2022-2025 found that the median interval from symptom onset to diagnosis was 62 days, meaning that many may have been waiting longer. But, he said, once people are diagnosed with HIV, the health system moves fast. “People enter care within days,” he said. “The inequity is not in the care itself. It is in who finds it, and also from how far away.” Services are concentrated in Tirana, and 68% of people living more than two hours away had advanced HIV at diagnosis, against 41% in the capital – though once diagnosed, they started ART just as quickly as people in Tirana.

Dr Bani said that the main message he’d like to share is that only 73% of diagnosed people are currently on ART. Most of the nearly 400 not on treatment were diagnosed before 2022; among those diagnosed since, 83-88% are on ART. This points to a problem of retention in care rather than linkage, said Dr Bani, and that may point to a lack of community support.

Arjan Harxhi added that although viral load testing should be carried out annually, the proportion of people who have had a viral load test in the previous year has been decreasing, from 80% in 2022 to 57% in 2025. This lack of testing means that the true proportion of people with viral loads below 1000 could be anything between 95% (if all people who have not received a viral load test are virally suppressed) and 69% (if none are). He hoped this situation was transitional, he added, pending the consolidation of domestic funding.

But Dr Bani said that community services had been the hardest hit by the end of Global Fund support. While treatment, laboratory monitoring and opioid agonist therapy are now funded domestically, there is no mechanism for the state to contract NGOs for prevention programmes. NGO-led testing in key populations halved in 2025, needle and syringe programmes stopped, and prevention commodities ran out. “Transition worked for treatment, but not for prevention,” he commented.

Three priorities are key to closing the gap, he added: diagnosing HIV earlier through routine testing and expanded community testing outside Tirana; bringing care closer through regional ART dispensing and follow-up; and ensuring domestic funding for community services.

Editing by Roger Pebody | Proofreading by Amelia Jones