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The precise nature of political-economic changes in Europe cannot be foreseen, but anticipating the likelihood of reduced resources and requests for re-structuring can be anticipated. Pro-active measures are more effective than compliance with imposed decisions (see Restructuring the Welfare State).

Epidemiological developments maybe rapid and require flexible responses based on a careful balancing of the Dissonances described in this report. In particular, medical technology has to operate within a framework of psycho-social resources (see Increased Life Expectancy). Innovation has to be encouraged by appropriate institutional leadership balancing semi-autonomy with networking (see Innovation versus Tradition and Networking versus Autonomy).

In general, the results from the four-phase action project lead to the conclusion that Dissonances that is to say, critical differences between alternative strategies cannot be satisfactorily resolved by saying that "both are necessary". For instance: Integration versus Specialization, Prevention versus Treatment, Networking versus Autonomy, Innovation versus Tradition, Well-represented versus Under-represented Need Groups. Reducing these Dissonances or learning from their analysis requires a careful functional examination of the issues.

We believe that in each case the outcome was a significant improvement on the position from which we started the project.

Since our findings are not country-specific and have evolved over two years, they may provide a useful starting point for dialogues with other European centres engaged with HIV/Aids patients or with preventing the spread of the disease.

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The Dissonances	Organizational Learning
Restructuring the Welfare State (Reduction in State Funding) See Innovation v. Tradition	There is an urgent need to anticipate the problem and find new or additional sources of finance and/or to seek expansion of quality assured voluntary work (i.e the Buddy system etc.)
Increased Life Expectancy due to HAART	Exclusive reliance on the 'triple cocktail' (HAART) is dysfunctional. Professional social work should be integrated with the technology of drug administration in a financial package.
Under-represented Need Groups Socially and economically disadvantaged groups	Solutions are not available, but more knowledge (through research) on specific needs is a priority. Empowering under-represented groups through dialogue and self help resources and facilitators is recommended.
Networking versus Autonomy, Leadership, Power & Evaluation	Inappropriate power concentration is the common obstacle for this multifaceted dissonance; hence more participation and/or delegation is necessary. For instance, Evaluation should be grass root designed, not imposed. Hence need to anticipate events.
Integration versus Specialization Inclusive versus Exclusive	Complete integration is dysfunctional, but useful in some contingencies: i.e. Sex education in schools and work with some cultural groups. Explore ‘Specialized Integration’ Solution.
Prevention versus Treatment Primary v. Secondary Prevention Historically, treatment received priority.	Existing financial etc structures and Tradition prevents a solution, but some learning on how to fight the barriers and support Human Rights argument.
Ethics Dissonances	Several old established issues with deep emotional involvement. Progress rather than solutions were established. Main issue is the conflict between the rights of the individual against rights of others (who are also individuals!). Agreement on preventing discrimination.

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The recent epidemiological figures suggest that the Aids-epidemic is at a turning point. Since 1996 there has been a decline in Aids-incidence, which continued in 1999, although at a slower rate.

This development results from both the increasing use of effective antiretroviral treatment (HAART), which has been available in many European countries since 1996, and the patterns of past HIV-incidence, which peaked in the mid-eighties. The current decline in the incidence of Aids, however, does not mean that there is also a decline in HIV-incidence. Unfortunately, it is hard to obtain sound figures for HIV incidence and prevalence.

However, persons who were not aware of their HIV infection at the time of Aids-onset account for an increasing number of the newly diagnosed Aids-cases: while this group accounted for 28% of all Aids-cases in 1996, the proportions were 39% in 1997 and 44% on 1998. This can be seen as an important development with respect to policy considerations, since this group cannot benefit from early HIV-treatment for obvious reasons.

There are also some considerable changes in the distribution of transmission groups among Aids cases, which reflect underlying HIV transmission patterns, although they might also be influenced by differential access to counseling and treatment. Overall, there is a decline in all transmission groups, in particular when it comes to homo- and bi-sexual transmission (a decline of 24%) and transmission through injecting drugs (28% decline). While transmission through heterosexual contact also declined (-10%), it has become the predominant transmission route among new Aids cases in many European countries, including France, Sweden, and Norway. Mother-to-child transmission has also been reduced substantially in Europe, which is seen as an effect of successful prevention intervention (counselling, testing and treatment).

In parallel with the trend in Aids incidence, Aids deaths have also been declining since 1996 (e.g. -32% in 1998), which is also due to more effective treatment options. These figures suggest, however, that the number of people living with HIV is expected to increase in the medium term.

Although in this report we are concerned only with countries from the European Union, where 90% of all Aids cases from the WHO European region were reported, it is worth mentioning that the Aids incidence actually has increased in the Central and Eastern part of that region. Strongly increasing trends have been observed in countries such as Ukraine, Romania, Yugoslavia, and Slovenia. Overall, the increase in Central and Eastern Europe was about 18% between 1997 an 1998. It is anticipated that Aids incidence will greatly increase in several Eastern European countries, including the Russian Federation.

The following table presents Aids cases and Aids incidence rates for the four participating countries (Source: European Centre for the Monitoring of Aids. HIV/Aids Surveillance in Europe. Data reported by June 1999 and adjusted for reporting delays.)

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