HIV prevention in Hungary

ELSEVIER

Health Policy 40 (1997) 231-236

HIV prevention in Hungary Rede London

Danziger a,*

a Health Services Research Unit, Dept of Public School of Hygiene and Tropical Medicine, Keppel

Health and Policy, St., London WCIE

7HT,

UK

Received 14 February 1997; received in revised form 17 February 1997; accepted 17 February 1997

Abstract Hungary is a country with relatively low HIV prevalence. Since 1989, a wide range of HIV prevention projects hasbeendevelopedboth by governmentagenciesand by an increasingly active voluntary sector. While energy and resources continue to be invested in HIV information and education, some senior public health officials have argued that it is the country’s compulsoryHIV testing and compulsory reporting system which have enabled it to

maintain its low seroprevalencelevels. The testing and reporting systemare soon to be reformed,however, in responseto growing demandsfor better protection of personalprivacy and confidentiality. Whether or not the forthcoming reforms will have an impact on HIV prevention,

and what the nature of this impact will be, remain to be seen. 0 1997 Elsevier

ScienceIreland Ltd. Keywords:

HIV/AIDS; Hungary ; Confidentiality

1. HIV prevention in Hungary 1.1. HIV

and AIDS

in Hungary

Hungary’s AIDS epidemic has so far been relatively contained. As of September 1996 a cumulative total of 234 cases of AIDS had been reported, 504 cases of HIV * Tel.: + 44 171 9272023; fax: + 44 171 5808183; e-mail: [email protected] 0168-8510/97/$17.00 0 1997 Elsevier Science Ireland Ltd. All rights reserved. PIISO168-8510(97)00904-4

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infection had been HIV infection was countries, Hungary AIDS cases (Table

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registered, and the estimated total number of actual cases of placed at 3000-4000. In comparison to many other European can be classified as a country with a relatively low number of 1).

1.2. HIV prevention activities

For much of the 1980s the response to HIV was very much a biomedical one [l], but the 1990s have seen increasing diversity in what has become a markedly multisectoral AIDS programme. HIV prevention in Hungary focuses chiefly on Table 1 Cumulative total number of reported AIDS cases by country (as of September 1996) Country

Cumulative total reported cases of AIDS

Albania Austria Azerbaijan Belarus Belgium Bulgaria Croatia Czech Republic Denmark Estonia Finland France Georgia Germany Hungary Italy Latvia Lithuania Luxembourg Netherlands Norway Poland Portugal Rumania Russian Federation Slovakia Spain Sweden Switzerland Turkey Ukraine United Kingdom

I 1069 4 15 2203 44 101 85 1957 10 248 43 451 11 15 308 234 35 949 16 8 114 4199 533 449 3515 4198 245 13 41598 1445 5397 214 170 13 394

Source: European Centre for the Epidemiological Europe. Quarterly Report No. 51, 30 Sept. 1996.

Monitoring

of AIDS. HIV/AIDS

Surveillance in

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reducing the sexual transmission of the virus: of the 504 registered cases of HIV, 301 are among homosexual or bisexual men and 13 are known to have occurred through heterosexual transmission. (A further 99 cases are registered among ‘foreigners’ without a specified transmission route) [2]. The National Institute of Health Promotion has targeted some of its HIV prevention materials specifically at gay men. Perhaps more significantly, the national AIDS programme has provided funding and/or technical support to gay organisations such as Homeros-Lamda (established in 1988), Budapest Lambda (1991) the Rainbow Association for Gay Rights (1994) and the Hatter Gay and Lesbian Support Society (1995) in order that they may develop HIV/AIDS work. Their combined services now include a telephone hotline, personal counselling, a monthly magazine that includes at least two pages on HIV related issues, and an outreach project in gay bars. In an effort to reach young people, the national AIDS programme has developed a new AIDS education package for army personnel. During their year of compulsory military service all young men receive at least 6 h of sexual health education including a large component on HIV. The National Institute for Health Promotion has also developed a sex education programme for 13- 16 year old school pupils, and a special peer education programme is being run for medical students. Considerable efforts have been made to reach the growing population of female and male prostitutes working in Hungary, particularly those in Budapest. A drop-in centre has been established to provide information, free condoms and referrals, and a special project has been developed to provide services to male prostitutes of Romanian origin. New outreach projects will be needed, however, to establish contact with the rising number of prostitutes who work along highways and border areas. There are at present an estimated 4000-5000 heroin addicts in Hungary, and just 2 of the 504 registered cases of HIV infection have been attributed to transmission via intravenous drug use. Precautions are being taken however to avert an explosion of HIV in the drug using population. A pilot needle exchange programme was recently introduced, but uptake has so far been low. A key feature of HIV prevention in Hungary in the 1980s has been the increased involvement of non-governmental organisations. This has been partly due to external assistance, and in particular the SHAPE (Swiss Hungarian AIDS Prevention Effort) Programme which evolved out of a bilateral agreement between the Swiss and Hungarian governments in 1993. SHAPE funds the Ovegylet Alapitvany, an independent umbrella organisation which in turn finances, supports and coordinates a number of non-governmental HIV projects. These include the needle exchange programme and gay outreach programme mentioned above; community based care for HIV positive children (there are at present just six paediatric HIV cases); peer education among underprivileged youth; HIV prevention in juvenile homes and prisons; and a special project for peer education in State Care Homes for Girls.

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Table 2 Uptake of HIV testing at the Anonymous AIDS Advisory Service in Budapest Year

Persons tested

Persons found positive

1988 1989 1990 1991 1992 1993 1994 1995

75 368 247 337 915 1252 1916 2365

2 3 3 1 13 19 22 11

Source: Anonymous AIDS Advisory Service (MTSZ), Budapest 1996.

2. HIV testing While many support the HIV prevention initiatives outlined above, some of Hungary’s most eminent public health experts argue that it is the HIV testing programme which has been crucial for maintaining the country’s low HIV prevalence levels (personal communication with Istvan Domok, Deputy Director, National Institute of Hygiene, Budapest and personal communication with Viktoria Varkonyi, Deputy Director, National Institute of Dermato-Venereology). They oppose any reform of this programme on the grounds that to tamper with the programme would be tantamount to tampering with its success. A Ministerial Decree passed in 1988 provides the foundations of the present HIV testing programme. The Decree requires compulsory HIV testing for: blood, tissue, organ and sperm donors; all sexually transmitted disease (STD) patients; prostitutes; prisoners; juvenile criminals; drug users; and the sexual contacts of infected people [3]. Voluntary testing is also available free-of-charge through the 124 dispensaries which are run by the National Institute of Dermato-Venereology. The 1988 Decree does not distinguish between compulsory and voluntary tests in its requirement that all HIV positive test results must be reported, together with detailed personal and medical data. Although this reporting requirement effectively renders anonymous testing illegal, two anonymous testing sites have nevertheless been established in the cities of Budapest and Pets, and a third is shortly to open in Sopron. The first of these sites was opened in 1988 in Budapest by an uncommon alliance which brought together clinicians and members of Homeros-Lambda, and later Budapest Lambda. Even more surprising perhaps-given that the project was technically illegal-is the fact that the service was funded and continues to be part-financed by the National Institute for Health Promotion which is itself dependent on the National AIDS Committee for its budget. Anonymous testing has increased in popularity, rising from just 75 tests being carried out in Budapest in 1988 to over 2300 in 1995 (Table 2). According to the providers of the anonymous testing service, the rate of HIV detection is consider-

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ably higher through anonymous, as opposed to compulsory, testing. In 1994, 22 of the 1916 patients who were tested anonymously tested positive, as compared to an estimated rate of 1 in 10000 among those who are tested compulsorily [4].

3. Reform of the HIV testing programme Compulsory testing per se has not at any time provoked protest in Hungary [5], but there is mounting opposition to compulsory reporting of medical and personal data of HIV positive people, and the poor protection of confidentiality which is associated with data registration in Hungary (personal communication with Zoltan Laczo, President of PLUSS, the Hungarian HIV Positive Self-Help Association). Some argue that health authorities currently collect and register far more data than is strictly necessary and that tighter controls are required on the amount, nature and protection of data to be collected. Others go further than this and argue that the law should allow for anonymous testing. Faced with compelling demands for reform, the Parliamentary Secretary of State with responsibility for AIDS, who also acts as President of the National AIDS Committee and Head of the National AIDS Programme, Dr Mihaly Kokeny, has thrown his support behind the drafting of a bill which, when enacted, will supersede the 1988 Decree. The ‘Handling of Health and Personal Data in Health Care Bill’ does not aim to end the compulsory testing of the groups specified in the 1988 Decree, nor does it guarantee confidentiality to those who are tested compulsorily. Rather, it seeks to protect the privacy of people who are tested voluntarily. The final shape of the Act is still under discussion, but of the three options are being discussed, only one would affect people who are tested compulsorily. The first option requires the National Institute of Public Health to provide blanket permission for all people who go for voluntary testing to be tested anonymously. In this case, nobody who goes for voluntary testing would be asked for personal or medical data. The second option would devolve the decision to the individual. In other words, when going for a voluntary test, an individual would be asked for personal and medical details, but they would be free to withhold this information. Data would only be collected on the basis of voluntary and informed consent. The third option currently under discussion could benefit all people, whether they are tested voluntarily or compulsorily. In this scenario, registration of some data would still be required of all HIV positive people. However, medical and political authorities who have access to the data would be held more accountable than they currently are, and anyone found to have breached confidentiality could be disciplined. Each of these options reduces to varying degrees the ability of health authorities to identify and keep track of infected individuals. At present, a key feature of the HIV prevention and control programme includes compulsory three-monthly checkups of all infected people, in which blood is taken for monitoring, counselling is

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provided, and information is requested regarding sexual contacts, past and present. The National Institute of Public Health regards these check-ups as vital to HIV prevention and for this reason favours the third option as being least likely to interfere with its prevention work.

4. The future of HIV prevention in Hungary While there is still some debate over the shape of the reform of the 1988 Decree, there is no doubt that some sort of changes will be introduced within the next 12 months. It is widely expected that the reform will result in increased availability and uptake of voluntary and anonymous HIV testing. By the same token, it will reduce the power of public health authorities to monitor the health and the actions of HIV infected people. The nature of HIV is such that it will take many years before the consequences of these reforms unfold.

Acknowledgements I am very grateful to Dr Denes Banhegyi of the St Laszlo Hospital, Budapest, and to Mr Jozsef Schlammadinger at the Hungarian Ministry of Welfare for helpful comments on an earlier draft of this paper. Funding for this research was provided by an E.S.R.C. research fellowship (H53627503795).

References [l] World Health Organization Global Programme on AIDS, Hungary National AIDS Programme: Report of the External Review 22 June-3 July 1995. [2] National institute of Hygiene, Budapest, 30 September 1996. [3] Mellekiet az 5/1988. 01.31) SZFM rendelethez (Ministerial Decree Annex No. 5/1988. [4] Project for 1996 ofthe Anonymous AIDS Advisory Service Budapest Anonymous AIDS Advisory Service AATSZ, 1 Budapest, 12 February 1996. [5] Danziger R. Compulsory testing for HIV in Hungary. Sot. Sci. Med. 43(8) 1996 1199-1204.