AIDS’ so-called quiet pandemic saw its “symbolic eradication” at the First International Conference on AIDS (1985). Important achievements were reviewed at this meeting, such as the discovery of the virus, its transmission routes, the related clinical picture and early diagnostic techniques. Moreover, the magnitude of the problem was considered. This knowledge facilitated the construction of a realistic vision of HIV/AIDS. In addition, scientists and professionals were alerted to the importance of this disease and formed a united front against it, which continues to this day. In 1988, the Autonomous Plan for the prevention and control of AIDS was created for NWS, following the creation of the Commission for control and follow-up. Later, “The Galician Service of Information on HIV” (SIGIVIH) was founded to complement and improve recorded information from previous systems and equate it to present infection data [1].

The first diagnosis of AIDS in NWS occurred in 1984 in an IDU male. Since then, the number of cases has increased, and new transmission routes have been reported. In 1985 appeared the first cases in a patient that had received blood derivates and in homosexual and bisexual males, at the same time the incidence of new cases among IDUs continued to increase. Although the proportion of cases corresponding to each transmission category has varied over the years, until recently, IDUs were the prevailing routes of infection.

However, the AIDS epidemic in NWS has evolved in a favorable way. By the beginning of the twenty-first century, the situation was less grave than in the two previous decades, although, as is reflected in successive plans, HIV infection still constitutes one of the main public health problems in our community.

Since 2005, the annual number of new AIDS cases in NWS has been fewer than 100 cases per year, continuing the trend seen at the end of the twentieth century. The number of cases has since stabilized at fewer than 50 cases per million inhabitants which was one of the objectives outlined in the 2006 to 2010 Galician Health Plan [1, 2].

Recent years have seen an increase in infections caused by unsafe sexual practices associated with heterosexual transmission. Such activities are now the most frequent transmission route. An additional problem in recent years is immigrants, due to their social and economic vulnerability. Notably, the majority of women who practice prostitution in our country are immigrants [3].

We studied the Galician AIDS population from an epidemiological point of view over a period of 25 years (1984 to 2008) with the following aims:

1. Focus the health system toward both the diagnosed and undiagnosed HIV populations.
2. Characterize and quantify the population of patients who are diagnosed late after infection, and then identify consequences that arise from this late diagnosis.
3. Identify the social, medical and structural barriers preventing early HIV diagnosis and control, and propose solutions accordingly.
4. Promote a joint effort from all angles (specialists, patients, NGO, health authorities, the mass media and the general public) to propel the fight against HIV/AIDS at all levels.

Clearly, the profile of HIV infected patients has changed in recent years. In the past, the majority of infections were transmitted IDUs sharing materials. Transmitting HIV through the sexual route of infection is becoming increasingly common. This trend has been observed in Spain and the European Union. Similar to what we report for NWS, transmission through IDUs decreased in the United States from 2004 to 2007 [4-8]. Cases resulting from MSM have increased and have represented the most common transmission route for the last three years of the period, accounting for more cases than heterosexual practices and IDUs [9].

With respect to date of birth, patients born between 1960 and 1969 represented 56% of the accumulated cases. It is also interesting to note that most frequent age at diagnosis continues to rise and is presently 41years-old. This trend has been reported throughout Spain as well as in other countries. Notably, we have recorded 66 cases of AIDS in persons over 65 years old. The majority of these cases were in males (80%) and were mainly transmitted by the heterosexual route. We must therefore begin performing routine diagnostic tests for the early detection of HIV/AIDS in elderly patients requesting health care [10, 11].

The region of NWS has a strong record of HIV testing among childbearing women, although it is lower in private hospitals. Frequently, prenatal HIV testing is not documented in medical records and women are unaware of it. Improving prenatal care and tailoring these programs to specific populations, such as immigrants or marginalized groups, will result in a better understanding of HIV prevention and an increase in HIV testing before delivery [12, 13].

Patients infected with HIV but unaware of their diagnosis are of great concern to public health managers and clinics for various reasons. Because they do not receive highly effective antiretroviral treatment (HAART), their chances of developing and dying from AIDS greatly increase compared to patients treated at an earlier stage of disease [14]. Additionally, these patients can transmit the infection without realizing it. Our studies revealed that 54% of new infections were transmitted by the 25% of patients that were unaware of their infection status. In addition, the treatment and care cost for patients with late diagnoses is much greater than for patients diagnosed at an early stage [15, 16]. For these reasons, detecting people infected with HIV who are unaware of their infection (constituting what is referred to as the “hidden epidemic”) has become a priority in controlling HIV throughout the world.

In NWS, in the early years of the epidemic, the time interval between diagnosis with an HIV infection and diagnosis with AIDS was short. It was common for people to discover that they were infected with HIV at the same time that they were diagnosed with AIDS. Through the mid-1990s, the proportion of people who were diagnosed with AIDS after knowing they were HIV+ for several years increased. Despite this improvement, there is still a significant proportion (over one-third) of people diagnosed of AIDS who are either unaware that they were infected with HIV or had only learned of their infection status within the previous six months. Notably, the percentage of people in this situation, in the NWS, reached 50% in 2005 and 2006.

In the United States, it is estimated that around 25% of HIV infected persons are not aware of their status [17-20]. In China, the percentage is even higher [21]. Estimates have been published about the magnitude of this situation within the European Union, although many countries do not have complete information regarding it. Throughout the European Union, it is estimated that the percentage of undiagnosed HIV+ people is 30%, ranging from 15% (Norway) to more than 50% (Poland). In other countries of the European Region belonging to the WHO, the undiagnosed fraction may be as high as 65% [22-29].

With respect to the diseases indicative of AIDS, we must comment on the period between 1994 to 2008. In 1994, the definition of AIDS was added to the epidemiological vigilance register, adding three new entities: pulmonary tuberculosis in people over the age of 12, recurrent bacterial pneumonia (two outbreaks or more in a 12 month period) and invasive cervical cancer associated with HPV [30-32]. We have been working on this disease for many years. Squamous cell carcinoma is the most frequent histological type of HPV representing 90% of all vulvar and cervical primary neoplasias in HIV patients [33].

In Europe, the situation of immigrants varies by their country of origin. Immigrants from developing countries account for the majority of HIV-positive people in a number of developed countries. In the UK, heterosexual activity is now responsible for about half of all new HIV diagnoses with the majority of these with the majority of these newly-identified individuals being of African origin [34]. Compared with people born in Portugal, African immigrants had a higher mortality rate for infectious diseases, including AIDS. There was considerable heterogeneity among Africans, with those from Cape Verde having the highest mortality. Death rates were more than five times higher among those who were unmarried compared to those who were. This result may be explained by a larger proportion of Africans being unmarried compared to non-African patients. Death rates were also higher among men who were manual workers compared to men who were not. Africans in Portugal fare worse than Africans in England and Wales, as death rates due to infectious disease and AIDS in Portugal are much higher [35].

Many male Tajik immigrant workers in Moscow have had unprotected sex with commercial sex workers. Although some of the immigrants have basic knowledge about HIV, their ability to protect themselves from acquiring HIV is compromised by harsh living and working conditions as a consequence of being unprotected by law in Russia [36].

Immigrants living in France represent 32% of new infections and appear to be a target population for prevention [37].

Since 1996, the number of cases of AIDS in Italy has declined in the native Italian population. However, cases of foreign patients, including both recent immigrants and long-term residents, has increased from 3.9% (in 1995 to 1996) to 15.4% (in 2001 to 2002) [38].

AIDS patients born outside of Spain and living in NWS account for 19% of the cases currently registered (29% of women and 15% of men). However, the neighboring country of Portugal accounts for 85% of the HIV (+) patients from the combined group of all of the European immigrants. As a result of this increase in the immigrant population in Spain over recent years, we must diversify prevention programs and adapt them to Portuguese immigrants, a population that is especially vulnerable because it is highly heterogeneous both socially and culturally. This is especially true in the case of women, many of whom practice prostitution [39].

In summary, the prevention and the control of HIV infection among the immigrant community remains an important challenge. We should involve Family Physicians who must investigate risk practices, prevent new cases by educating uninfected persons, and monitor the evolution of the disease in infected patients while offering them support and comfort.

The annual incidence of AIDS cases in NWS has stabilized at fewer than 50 cases per one million inhabitants since the year 2001. Of the 3,766 accumulated cases, 2,085 (55%) have resulted in death. Over recent years, we have observed an increase in incidence but a decrease in mortality.

Reducing the percentage of people that have not been diagnosis with HIV infection (44%) is a priority for people responsible for the control of the epidemic in NWS. We must increase the perception of the risk of infection.

We should promote testing for HIV as a contribution to the individual right of the patient to obtain information on his or her health condition, with particular emphasis on:

• The general population, especially with respect to heterosexual transmission.
• Providing attention to people who are over the age of 40 and particularly over the age of 65.
• European (especially Portuguese), Latin American and sub-Saharan African immigrants.
• Young people that suffer or are at risk of suffering from social exclusion.