- In 2018, a total of 159 persons were notified with newly diagnosed HIV, along with 59 persons who had already been diagnosed abroad.
- Among the newly diagnosed, 110 were either Danes who had become infected in Denmark or abroad, or immigrants infected after their arrival to Denmark. The remaining 49 were immigrants who had become infected before their arrival to Denmark. These 49 persons could not have been reached with Danish HIV-preventive measures.
- Among the newly diagnosed persons, 84 were men who have sex with men (MSM), 67 were infect-ed heterosexually (HTX), one was a child who had become infected at birth in Africa and four were drug users. In three cases, the mode of infection was unknown.
- 76% of the MSM and 25% of the HTX had become infected in Denmark.
- Among the newly diagnosed MSM, 33% were immigrants. The corresponding share for HTX was 57%.
- Among MSM, 40% were tested late. The same applied to 66% 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 posi-tives pose no 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 provided they are in ef-fective 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 commu-nities, why dissemination of more knowledge about the topic is essential.
2018 saw a total of 218 notified cases of HIV, including 169 men and 49 women, Table 1. One person was notified with HIV 2 the remaining with HIV 1. The corresponding number was 244 in 2016 and 253 in 2017.
The median age was 39 years for men (range 16-80 years) and 38 years for women (range 13-59 years).
Among these 218 notified cases, 59 persons (27%) had previously been diagnosed with HIV abroad, including five Danish-born persons, Figure 1.
A total of 41 were men and 18 were women; 26 were homosexually infected (MSM), 23 heterosexually infected (HTX), two had become infected by intravenous drug use (people who inject drugs, PWID), one was infected via mother-to-child transmission, and in seven cases the route of infection was not stated. Of the 26 MSM with known HIV, 12 (46%) were from a Western country and 14 (54%) were from Southeast Asia, South America, Eastern Europe or Africa. Among the HTX, 20 of 23 (87%) were from Sub-Saharan Africa, the Middle East or Eastern Europe, Southeast Asia or Greenland, whereas three (13%) were from Western countries.
The estimated number of HIV positives in Denmark, and the number of people who have been diagnosed with HIV are the two first steps in the so-called HIV cascade. The next steps estimate the share who have been referred to an infectious medicine clinic, have initiated treatment and have a low (“non-measurable”) virus count, meaning that they are not infectious. These three steps are estimated on the basis of the Danish HIV Cohort, which counts all patients attending controls and treatment at an infectious medicine clinic in Denmark, Box 1.
Origin, country of infection and mode of infection
Among the 159 persons who were diagnosed with HIV for the first time, a total of 87 (55%) were born in Denmark (including five second-generation immigrants), and 72 (45%) were immigrants, including five tourists and two per-sons staying illegally in Denmark.
Among the 159 persons who were diagnosed with HIV for the first time, 49 were immigrants/tourists who had be-come infected before arriving to Denmark. A total of 66 persons were born in Denmark and notified as having be-come infected in Denmark, whereas 21 were born in Denmark, but had become infected abroad. Furthermore, 20 immigrants/tourists had become infected in Denmark, and three immigrants had become infected abroad after moving to Denmark.
Among 84 MSM, a total of 49 (58%) were born in Denmark and had become infected in Denmark, 15 (18%) were born abroad and had become infected in Denmark, whereas seven (8%) were born in Denmark and had become infected abroad. These 71 (85%) together constitute the number of MSM for whom the preventive measures in Denmark have been insufficient. The remaining 13 (15%) were born abroad and had become infected before their arrival to Denmark, Figure 2.
Among 67 HTX, 15 (22%) were born in Denmark and had become infected in Denmark, five (7%) were born abroad and had become infected after their arrival to Denmark (two had become infected in Denmark and three during travels abroad), whereas 14 (21%) were born in Denmark and had become infected abroad. These 34 (51%) together constitute the number of HTX for whom the preventive measures in Denmark have been insufficient. The final 33 (49%) were born abroad and had become infected before their arrival to Denmark, Figure 3.
Among the seven Danish-born MSM who were notified as having become infected abroad, two had become infected in Thailand, two in South America, one in The Middle East and one in Western Europe. In one case, the country of infection was not stated.
Among the 13 immigrant MSM who were notified as having become infected abroad, five had become infected in Southeast Asia, four in South America, one in Sub-Saharan Africa, one in Central Europe and one in Eastern Eu-rope. In one case, the country of infection was not stated.
Among the 14 Danish-born HTX who were notified as having become infected abroad, seven had become infected in Southeast Asia (six in Thailand and one in Indonesia), five in Sub-Saharan Africa, one in South America and one in Western Europe.
Among the 36 immigrant HTX who were notified as having become infected abroad, 28 (78%) had become infected in Sub-Saharan Africa, three in Southeast Asia one in Eastern Europe and one in The Middle East. For three per-sons, the country of infection was not stated.
Other mode of infection
In addition to the sexually infected persons, a child was notified as having become infected at birth in Africa, four persons as having become infected by IV drug use (all born abroad, three infected in Denmark and one in Rumania), and in three cases the mode of infection was unknown.
Nine women were found owing to the general screening of pregnant women. Eight were from Africa, including four women who had been diagnosed abroad previously. The final person was Danish, and newly infected with HIV.
Trend in the number of notified persons
The number of MSM notified as having become infected in Denmark has declined in the past five years. For HTX infected in Denmark, a corresponding decline has not been observed from 2014 to 2018, Figure 4.
Table 2 shows the distribution by area and region. A total of 81 (51%) persons resided in the Capital Region of Denmark.
CD4 counts at diagnosis - tested late
Among the 159 persons who were diagnosed with HIV for the first time in 2018, information was available for 156 (98%) 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 three 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 156 cases for whom the CD4 count was stated, 82 (53%) had CD4 counts below 350 cells per µl at diagnosis, including four persons assessed as newly infected based on primary HIV disease and/or a recent negative HIV test, whereas 74 (47%) had CD4 counts of 350 or above.
Among 81 MSM for whom the CD4 counts were stated, a total of 49 (60%) had a CD4 count > 349 or signs of new infection at the time of their diagnosis, whereas 32 (40%) had been tested late (CD4 counts below 350). Among 67 HTX for whom the CD4 counts were stated, a total of 23 (34%) had a CD4 count > 349 or signs of new infection at the time of their diagnosis, whereas 44 (66%) had been tested late.
Among immigrants who had become infected heterosexually before their arrival to Denmark, 73% were tested late. Among persons born in Denmark and infected in Denmark, 67% were tested late, whereas 50% of the Danish-born patients who had become infected abroad were tested late. Only two persons who were born abroad had become in-fected in Denmark.
Among immigrants who had become infected homosexually before their arrival to Denmark, a higher share of per-sons with late tests was observed (73%) than among immigrant MSM infected in Denmark (33%). The latter share largely corresponds to the share of late tested persons among Danish-born MSM (35%).
Time from immigration to diagnosis - the public health perspective
Among 25 immigrants who were notified as having become infected heterosexually before arriving to Denmark and who had stated their time of immigration, 15 (60%) had stayed in Denmark for more than one year (a mean four years) before being tested for HIV.
For immigrants who have become infected before arriving to Denmark, the most important measure of secondary prevention is diagnosing the patients as quickly as possible. It is therefore of concern that 60% of the immigrants who were notified as having become infected heterosexually prior to their arrival to Denmark had stayed in Den-mark for more than a year before being tested for HIV despite the Danish Health Authority’s guideline recommending testing as soon as possible after arrival to Denmark if you arrive from a high-endemic country.
Six out of nine immigrants (67%) who were notified as homosexually infected before their arrival to Denmark and who had stated their time of immigration had stayed in Denmark for less than one year. Two had been tested seven years after arriving and one person had been tested two years after arriving to Denmark.
A total of 28 persons were notified with AIDS in 2018.
Among 159 newly HIV-diagnosed persons in 2018, a total of 25 (16%) were diagnosed with an AIDS-defining condition concurrently with their HIV diagnosis, including 15 HTX, nine MSM and one person for whom the mode of infection was missing. Furthermore, three persons who had previously been diagnosed with HIV were notified with AIDS in 2018. The most frequently recorded AIDS-defining diagnosis was Pneumocystis jirovecii-pneumonia.
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 12 persons tested HIV positive for the first time; six Danes and six immigrants, 10 were MSM, two men were HTX. Additional-ly, two men tested positive who had already been diagnosed abroad.
A total of 12 of the 159 newly diagnosed people (8%) were tested at a Checkpoint, and 10% of the 84 newly diag-nosed MSM (12%) were established at Checkpoints.
Transmitted resistance in persons with newly diagnosed HIV
The Unit for Virus Research and Development at the SSI has prepared a report comprising all HIV patients included in the SERO Project (HIV-1 genotypical determination of resistance) in the 2016-2018 period, for whom it was possible to sequence the POL (DNA polymerase) gene in HIV-1. A total of 349 patients were included, whereof 204 had become infected in Denmark, 121 abroad and in 24 cases the country of infection was not known.
In 2018, a total of 14 patients were recorded with transmitted resistance. Hereof, 10 (from a total of 52 tested patients) had become infected in Denmark and three (from a total 37 tested) had become infected abroad. Furthermore, in one case (from a total of five patients tested), the country of infection was not stated. This corresponds to 19.2% of the HIV-1 infectees who had become infected in Denmark and 8.1% of the HIV-1 infectees who had be-come infected abroad being resistant at the time of their diagnosis. Even so, no statistically significant difference between the occurrence of resistance mutations in persons who had become infected in Denmark was found com-pared with persons who had become infected abroad. In 2018, resistance mutations in the persons infected in Den-mark were found in all of the three primary treatment groups that are used for highly active antiretroviral therapy (HAART): non-nucleoside inhibitors (NNRTI), nucleoside inhibitors (NRTI) and protease inhibitors (PI). NNRTi resistance was the most frequently observed type and was also the only treatment group with resistance among per-sons who had become infected abroad or for whom the country of infection was unknown, Figure 5.
The Danish Health Authority recommends use of Pre Exposure Prophylaxis (PrEP) in special risk groups. PrEP (Truvada®) consists of the two nucleoside inhibitors emtricitabine (FTC) and tenofovir (TDF). Among the newly diagnosed patients who had been tested as part of the SERO Project, 2018 recorded one person with a low resistance level against both of these drugs, whereas 2016 and 2017 in total recorded four cases of resistance against one of the two PrEP drugs.
HIV subtypes among newly diagnosed patients
Among newly diagnosed HIV 1 patients who have been infected in Denmark, HIV 1 of subtype B comprised 61.5% (32 persons) in 2018. Among those infected abroad, in 2018 subtype B only constituted 16.2% (six persons), where-as the circulating recombinant form (CRF) CRF01 was the more frequent form (29.7%, 11 persons), Figure 6. In 2018, CRF12, which had not previously been observed in Denmark, was recorded in two persons who both reported having become infected in Denmark.
This annual report is described in EPI-NEWS 44/19.