HIV 2017

In 2017, a total of 182 persons were notified with newly diagnosed HIV, along with 71 persons who had already been diagnosed abroad.

Among the newly diagnosed persons, 97 were men who have sex with men (MSM), 73 were infected heterosexually (HTX), four cases were mother-to-child transmission (MTCT) and another four were people who inject drugs (PWID). In four cases, the mode of infection was unknown.

One of the four children was born in Denmark. The mother had become infected after having tested negative in the pregnancy screening.

81% of the MSM and 39% of the HTX had become infected in Denmark.

Among the newly-diagnosed MSM, 35% were immigrants. The corresponding share for HTX was 47%.

Among MSM, 31% were tested late. The same applied to 47% of the HTX.

All MSM who have not been diagnosed with HIV should be HIV tested annually. Furthermore, MSM who lead an active sex life and who do not consistently use a condom should be tested for HIV and other sexually transmitted diseases more frequently, e.g. every 3 months.

Initiation of treatment immediately after the diagnosis means that people who are known HIV positives do not pose a risk for further HIV transmission, as well-treated HIV positives are not infectious.

Prevention of HIV infection includes use of condoms, TasP (Treatment As Prevention, i.e. that you only have unprotected sex with people who are known to be HIV positives and who are in effective treatment), PrEP (Pre Exposure Prophylaxis, HIV medication taken before exposure) and PEP (Post Exposure Prophylaxis, HIV medication taken shortly after exposure).

Ignorance and stigma lead to unfounded fear and rejection of HIV positives, even in MSM communities, why dissemination of more knowledge about the topic is essential.

2017 saw a total of 253 notified cases of HIV, including 201 men and 52 women, Table 1.

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Among these cases, 71 (28%) had previously been diagnosed with HIV abroad, including seven Danish-born persons.

A total of 51 were men and 20 were women; 34 were homosexually infected (MSM), 21 heterosexually infected (HTX), three had become infected by intravenous drug use (PWID), two were mother-to-child transmissions, one was infected via unclean syringes in healthcare services abroad, and in 10 cases the route of infection was not stated. Of the 34 MSM with known HIV, 16 (47%) were from a Western country and 18 (53%) were from Southeast Asia, South America, the Middle East or Africa. Among the HTX, 14 of 21 (67%) were from Sub-Saharan Africa, the Middle East or Thailand, whereas seven (33%) were from Western countries.

Among all persons notified, 2017 recorded a continued increase in the share of those who had previously been diagnosed, Figure 1.

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Box 1. The estimated number of HIV positives in Denmark, the undiagnosed share and the number of cases who were tested late as per 31 December 2017

Newly diagnosed HIV positives in 2017: 182

Hereof MSM: 97

Estimated number of persons who live with HIV in Denmark: 6,400

Hereof MSM: 4,200

The number of persons who live with HIV in Denmark and have been diagnosed with HIV: 5,800

Hereof MSM: 3,700

The undiagnosed share (the dark figure): 600

Hereof MSM: 500

Share with a CD4 count below 350/AIDS at the time of their diagnosis in 2017: 39% (68/175)

Among MSM, the share was 31% (30/96)

Among the 182 persons (149 men and 33 women) who were diagnosed with HIV for the first time, a total of 105 (58%) were Danish-born (including four second-generation immigrants), and 77 (42%) were immigrants, including two tourists.

Among the 33 women with newly diagnosed HIV, nine were detected as part of the general screening of pregnant women. Five were from Africa, two from Southeast Asia and two were from Denmark.

No children were notified as having been infected at birth in Denmark in 2017, but the 2017 pregnancy screening detected two women of African origin who had previously tested negative in the pregnancy screening. One of the women tested negative during a pregnancy in 2015, but subsequently tested positive in the 2017 pregnancy screening. The child from the first pregnancy (who was born in Denmark) subsequently tested positive for HIV, which means that the mother had become infected with HIV during her first pregnancy.

The other woman was tested in her 39th week for HIV due to symptoms. She tested HIV positive at this time after having tested HIV negative in the beginning of the pregnancy screening.

Among the 105 Danish-born persons who had HIV diagnosed for the first time in 2017, 62 were MSM, 39 HTX, one PWID, one MTCT and in two cases the mode of infection was not stated.

Among the MSM, 54 (87%) had become infected in Denmark and five in the US, Turkey, Indonesia, Peru and Israel, respectively. In three cases, the country of infection was unknown.

Among the HTX, all 10 women had become infected in Denmark. Among the Danish-born men, eight had become infected in Denmark, 13 in Thailand, two in the Philippines and three in Indonesia, France and South Africa, respectively. For three men, the country of infection was not stated.

Among the 75 immigrants living in Denmark, 22 (29%) were from sub-Saharan Africa, 17 (23%) from Central and Eastern Europe, 14 (19%) from Southeast Asia, four (5%) from Western Europe, six (8%) from the Middle-East and North Africa (including Turkey), seven (9%) from South America, two (3%) from North America and three (4%) from Greenland.

Among the 75 immigrants residing in Denmark, 32 (43%) stated that they had become infected in Denmark, 22 MSM and 9 HTX, and in one case the mode of infection was not stated. These 32 people were from 24 different countries of origin across large parts of the globe.

Among the remaining 43 immigrants, the country of infection was not provided in two cases, and the remaining 41 persons were from a total of 23 different countries of infection, mainly in Sub-Saharan Africa, Southeast Asia and Eastern Europe. A total of 24 (56%) were HTX, 12 (28%) MSM, three PWID and three MTCT. For one person, the mode of infection was not stated.

Six of the 97 MSM (6%) were diagnosed at the initial tests made as they were applying for inclusion in PrEP projects (PrEP, pre- exposure prophylaxis, a preventive antiretroviral treatment for HIV-negative people).

The 2013-2015 period has seen a decline in the number of Danish MSM with newly-diagnosed HIV and a concurrent increase in the number of immigrant MSM with newly-diagnosed HIV. Since 2015, the number of cases in the two groups has remained stable, Figure 2, and immigrant MSM have thus comprised 35% of all newly-diagnosed MSM. This share was 46% for all MSM notified with HIV in Denmark in the same period (newly-diagnosed as well as known HIV diagnosed abroad).

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Table 2 shows the distribution by area and region. A total of 99 (54%) persons resided in the Capital Region of Denmark.

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The median age was 37 years for men (range 1-73 years) and 35 years for women (range 5-70 years). Even though the age distribution among newly-diagnosed MSM has fluctuated somewhat in the past six years, Figure 3, the entire period has seen a considerable share of notified people who were older than 40 years of age, and very few were younger than 20 years of age at the time of their diagnosis.

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CD4 counts at the diagnosis

Among the 182 persons who were diagnosed with HIV for the first time in 2017, information was available for 174 (96%) about their CD4 count when they were diagnosed and/or about recent infection (negative test and/or acute HIV disease) or about AIDS at their diagnosis. In the remaining eight cases, CD4 counts were unavailable.

The CD4 count is a marker that indicates how the HIV virus affects the cellular immune response. For a long period of time, a CD4 count below 350 cells per µl blood has been indication for initiation of highly active antiretroviral therapy (HAART) in Denmark if the patient had not wanted to initiate such treatment earlier. In August 2015, the guidelines were changed so that everyone who is diagnosed with HIV is offered to start treatment immediately, regardless of the CD4 count at the time of diagnosis. CD4 counts below 350 and/or AIDS at the time of diagnosis are still used in this report as a marker for late testing.

Among the 174 persons for whom the CD4 count was stated, there were 78 (45%) whose CD4 count was below 350 cells per µl at their diagnosis, including 14 persons assessed as newly-infected based on primary HIV disease and/or a recent negative HIV test, whereas 96 (55%) had CD4 counts of 350 or above.

The time from infection to diagnosis was estimated on the basis of the information about CD4 counts at the time of diagnosis, previous negative tests and acute HIV disease or AIDS. If information was available about acute HIV disease and/or a negative test within one year, the patient was assessed as having become “infected within 1 year”.

Among 96 MSM for whom the CD4 counts were stated, a total of 66 (69%) had a CD4 count > 349 or signs of new infection at the time of their diagnosis, whereas 30 (31%) had been tested late (CD4 counts below 350). Among 70 HTX for whom the CD4 counts were stated, a total of 37 (53%) had a CD4 count > 349 or signs of new infection at the time of their diagnosis, whereas 33 (47%) had been tested late.

AIDS

A total of 38 persons were notified with AIDS in 2017.

Among 182 newly HIV-diagnosed persons, a total of 25 (14%) were diagnosed with an AIDS-defining condition concurrently with their HIV diagnosis, including 15 HTX, nine MSM and one PWID.

Additionally, one person was diagnosed with primary HIV disease who also had AIDS-defining disease at the time of the diagnosis. In 2017, four persons who were known to have HIV and who had not previously been notified with HIV were diagnosed with AIDS. Furthermore, eight persons who had previously been diagnosed with HIV were notified with AIDS in 2017 (five HTX and three MSM).

The interval from their HIV diagnosis to the AIDS diagnosis varied from 6 months to 19 years in the 12 AIDS-notified people with previously known HIV. The most frequent AIDS-defining diagnoses were: pneumocystis jirovecii pneumonia (13 cases), tuberculosis (four cases), and three cases of cerebral toxoplasmosis, HIV wasting, Burkitt lymphoma and candida of the oesophagus, respectively.

Checkpoint

Checkpoint is the Danish AIDS Foundation's test sites for MSM and immigrants. Here, you can be tested for HIV and syphilis without scheduling an appointment and you will receive the results immediately. A total of 13 persons tested HIV positive; seven Danes and six immigrants, 12 were MSM, one man was HTX. Additionally, one man tested positive, but was later identified as a known HIV positive.

A total of 13 (7%) of the 182 newly-diagnosed people were tested at a Checkpoint, meaning that 13% of the 96 newly-diagnosed MDM were established at checkpoints.

Transmitted resistance in persons with newly diagnosed HIV

This report comprises all HIV patients who were included in the SERO project, where newly-diagnosed people’s HIV virus is typed and tested for resistance, in the 2015-2017 period, for whom it was possible to sequence the POL gene in HIV 1. A total of 349 patients were included, whereof 207 had become infected in Denmark, 121 had become infected abroad, and in 21 cases the country of infection was not known.

A total of 18 patients with transmitted resistance were found, among whom 11 from a total of 61 tested persons had become infected in Denmark and seven from a total of 37 tested patients had become infected abroad. This corresponds to resistance being present at the time of diagnosis in 18% of the HIV-1 infectees who had become infected in Denmark and 19% of the HIV-1 infectees who had become infected abroad.

In 2017, the resistance mutations were found in all of the three primary antiretroviral (ARV) treatment groups that are used for highly active antiretroviral therapy (HAART): non-nucleoside inhibitors (NNRTI), nucleoside inhibitors (NRTI) and protease inhibitors (PI). Figure 4 presents the distribution of these resistance mutations by treatment groups for the past three years, detailing the shares of patients infected in Denmark and abroad. As numbers are small, fluctuations cannot be attributed statistical significance.

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Pre-exposure prophylaxis (PrEP) is approved by the Danish Health Authority for use in persons who are at risk of becoming infected with HIV. PrEP (Truvada®) consists of the two nucleoside inhibitors emtricitabine (FTC) and tenofovir (TDF). Among the newly diagnosed patients tested in the Sero project, four had a potentially low to intermediary level of resistance against TDF, and one patient had a high level of resistance against FTC. Even so, none of the HIV 1 patients were resistant to both drugs. The low occurrence of resistance mutations, of which none will fully inhibit PrEP, is therefore not expected to affect PrEP efficacy.

HIV subtypes among newly-diagnosed patients

Among newly diagnosed HIV 1 patients who were infected in Denmark, subtype B comprised 57% (37 persons) in 2017, Figure 5. In addition to subtype B, the most frequently occurring subtypes among people who had become infected in Denmark in 2017 were: CRF01 (10 persons), A (five persons) and CRF02 (four persons). Additionally, a limited number of people had become infected in Denmark (nine persons) with the subtypes C, D, F and G or with various recombinant forms of virus.

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Among persons infected abroad, in 2017 subtype B comprised 51% of cases (21 persons), whereas CRF01, A and C occurred less frequently, even though four persons or more were affected by each of these subtypes. Thus, no marked difference was observed in 2017 between the subtype distribution of persons who had become infected in Denmark and abroad, respectively.

This annual report is described in EPI-NEWS 44/18.