- In 2022, a total of 115 persons were notified with newly diagnosed HIV, along with 144 persons who had already been diagnosed abroad. These unusually high numbers are mainly due to refugees from the Ukraine. A total of 84 HIV-positive Ukrainians were notified, among whom 73 were known to have HIV and be receiving treatment in their home country. The remaining 11 were newly diagnosed in Denmark.
- Among the newly diagnosed persons, 79 were either Danes who had become infected in Denmark or abroad, or immigrants infected after their arrival to Denmark. The remaining 36 were immigrants who had become infected before their arrival to Denmark. These 36 persons could not have been reached with Danish HIV-preventive measures.
- Among the newly diagnosed persons, 47 were men who have sex with men (MSM), 52 were infected heterosexually (HTX), among whom 23 were men and 29 women. Five of the diagnosed persons were notified as being drug users; and in 11 cases, the mode of transmission was not stated.
- In 70% of the MSM for whom country of infection was stated and in 46% of the HTX for whom coun-try of infection was stated, the infection had been acquired in Denmark.
- Among the newly diagnosed MSM, 40% were immigrants. The corresponding share for HTX was 51%.
- Among MSM, 45% were tested late. The same applied to 68% of the HTX.
- Immigrants and asylum seekers, etc., should undergo HIV testing as quickly as possible after their ar-rival to Denmark. This facilitates rapid treatment of HIV positives and reduces the risk of transmission of the infection.
- 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. In some cases, this group may be offered pre-exposure prophylaxis (PrEP), i.e. HIV medication taken before exposure.
- Initiation of treatment immediately after the diagnosis means that people who are known HIV positives pose no risk for further HIV transmission as well-treated HIV positives are not infectious.
- Prevention of HIV infection includes:
- Using condoms
- TasP (treatment as prevention, i.e. only having unprotected sex with HIV-positive people who are known to be in effective treatment).
- PrEP (pre-exposure prophylaxis, HIV medication taken before exposure).
- PEP (post-exposure prophylaxis, HIV medication taken immediately after exposure).
2022 saw a total of 259 notified cases of HIV, including 150 men and 109 women, Table 1.
The median age of patients notified in 2022 was 41 years for men (range 19-74 years) and 38 years for women (range 2-75 years).
Among the 259 notified cases, 144 persons (56%) had previously been diagnosed with HIV abroad, including four Danish-born persons and 73 Ukrainians. Seven of the 144 persons who were known to have HIV were children (2-12 years). No children were notified as having become infected in Denmark.
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 2022
The figures have not been updated since 2021 as Statens Serum Institut (SSI) is currently working to adjust down-ward the estimated number of HIV-positives. The below estimate was prepared using the ECDC model for incidence calculations, which applies a large confidence interval. The downward adjustment of the figure will fall within the model range, but will, to a greater degree, be aligned with updated data.
Newly diagnosed HIV positives in 2022: 115
Hereof MSM: 47
Estimated number of persons who are living with HIV in Denmark: 6,800
Hereof MSM: 3,750
The number of persons who are living with HIV in Denmark and have been diagnosed with HIV: 6,300
Hereof MSM: 3,500
The undiagnosed share (the dark figure): 500
Hereof MSM: 250
Share tested late (with a CD4 count below 350 and/or AIDS at the time of their diagnosis) in 2022: 60% (61 out of the 102 for whom a CD4-count was provided). Among MSM, the share was 45% (19 out of 42)
Origin, country of infection and mode of infection among newly diagnosed patients
Among the 115 who were newly diagnosed with HIV, 62 (54%) were born in Denmark, whereas 53 (46%) were born abroad, including nine persons who had not (yet) received a Danish CPR number when they were diagnosed.
A total of 47 men who have sex with men (MSM) were notified, as were 23 men who have sex with women (MSW), 29 women who have sex with men (WSM) and five drug users; and in 11 cases, the route of infection was unknown.
Among 47 MSM, a total of 21 (45%) were born in Denmark and had become infected in Denmark, 10 (21%) were born abroad and had become infected after arriving to Denmark (one during tourist travel abroad), whereas three (6%) were born in Denmark and had become infected abroad. Finally, four (9%) were born in Denmark and had not stated the country of infection on the notification. These 38 persons constitute the number of MSM for whom the preventive measures in Denmark were insufficient (81%). The final nine (19%) were born abroad and had become infected before their arrival to Denmark.
Among 52 HTX, 18 (35%) were born in Denmark and had become infected in Denmark, seven (13%) were born abroad and had become infected after their arrival to Denmark (two had become infected while visiting their coun-tries of origin), whereas seven (13%) were born in Denmark and had become infected abroad. For one person who was born in Denmark, the country of infection was unknown. These 33 (63%) together constitute the number of HTX for whom the preventive measures in Denmark have been insufficient. For one person born abroad, the country of infection was unknown. The final 18 (36%) were born abroad and had become infected before their arrival to Denmark.
In addition to the sexually infected persons, a total of five persons had become infected via IV drug use (two of whom were born in Denmark and three who were born in the Ukraine and had become infected before arriving to Denmark). Finally, 11 persons were notified with an unknown mode of infection. Six of these persons were born in Denmark (including three who were notified as having become infected in Denmark) and five were born abroad (none of whom were notified as having become infected in Denmark).
Figure 1 presents the distribution by mode of infection and origin for all of the 79 persons who were born in Den-mark and/or had become infected in Denmark/after arriving to Denmark.
In 2022, a total of 24 women were diagnosed with HIV. Six of these persons - all of whom were born abroad - were diagnosed with HIV via the pregnancy screening programme, whereas the remaining patients were known to have HIV and were receiving treatment.
Increase in the number of notified HIV cases
As from 2017, a strong decline has been observed in the number of notified HIV cases. However, this decline was replaced by a considerable increase in 2022, Figure 2. The decline was particularly pronounced among persons who had become infected in Denmark and coincided with the introduction of PrEP (pre-exposure prophylaxis, HIV medication that is given prophylactically against HIV infection). Additionally, 2020-2021 probably saw fewer HIV tests due to the COVID-19 lock-down (for example, the Checkpoints of the Danish Aids Foundation were closed in several periods in 2020-2021). The increase recorded in 2022 is more pronounced among the group of people who are known to have HIV and are receiving treatment for the condition. This is due, in part, to the large group of Ukrainian refugees who have come to Denmark, some of whom are patients with HIV. Furthermore, a limited number of HIV-positive Ukrainians were notified in Denmark in 2022, who had not previously been tested in their country of origin, and who therefore belong to the newly diagnosed group. When the newly diagnosed patients are divided further, a parallel increase is seen among newly diagnosed patients who were diagnosed as having become infected in Denmark and abroad. The increase seen in each of these groups is not very large and may probably be explained by the fact that the persons who were not tested during the COVID lockdown have now seen their doctor and have therefore received their diagnoses in 2022.
The increase observed from 2021 to 2022 in the number of notifications is largely equally distributed on geographical areas and infectious groups, Table 2.
CD4 counts at diagnosis - tested late
Among the 115 persons who were diagnosed with HIV for the first time in 2022, information was available for 102 (89%) 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. For the remaining 13 persons, this information could not be obtained.
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. Conversely, the CD4 count at diagnosis may be very low if the patient is tested shortly after having become infected, and this may erroneously be recorded as late testing based on the CD4 count. When a person is notified with HIV to the national monitoring scheme at the SSI, we therefore enquire specifically about information that may show if the person in question is, in fact, a newly infected person with a low CD4 count (symptoms of acute HICV, recent negative test, etc.).
Among the 102 persons for whom the CD4 count was stated at the time of diagnosis, 61 (60%) had a CD4 count below 350 cells per µl and/or had been diagnosed with AIDS, whereas 41 (40%) had a CD4 count of 350 or above or had been diagnosed with acute HIV.
This is the largest share of late-tested persons recorded among the notified patients in the past five-year period (the corresponding share ranged from 47% to 55% in the 2018-2021 period).
For a total of 94 persons, the notification included CD4 count, origin and mode of infection. The share of late tested persons varies considerably, by mode of infection and origin. Among all MSM, the share was 45% (19 out of 42). Among MSM who were born in Denmark, the share of late tested persons was 35% in 2022, whereas the corresponding share for HTX who were born abroad was 74%.
Figure 3 shows the distribution of late-tested persons and timely tested persons by origin and infection group.
For various years, the number of HIV diagnoses has followed a declining trend in Denmark. Causes contributing to this trend include frequent testing, mainly of MSM; early treatment initiation (TasP, Treatment as prevention), which stops treated HIV-positives from transmitting the condition; and - in particular - PrEP (Pre Exposure Prophylaxis, HIV medication taken before exposure, which is offered to MSM).
To additionally limit transmission of HIV infection among MSM, it is important that any doctor who establishes that an MSM is positive to gonorrhoea, syphilis or chlamydia/LGV tests the person for HIV - and if he is HIV negative - offers the patient PrEP (by referring to a department of infectious medicine). Among some of the MSM who were born abroad, a barrier may exist, keeping these patients from taking initiative to initiate PrEP treatment, why doc-tors may consider suggesting this.
In relation to heterosexually transmitted HIV, it is particularly important to test immigrants from countries with a high HIV occurrence shortly after their arrival to Denmark. The Danish Health Authority’s guideline published in 2013 states that HIV testing should be considered for persons from Africa, Asia, South America and Eastern Europe when they first come into contact with Danish healthcare, regardless of the reason for such contact.
It can be difficult to identify persons who are at risk of HIV infection among heterosexual people born in Denmark.
However, some options exist that may help to prevent infection in this group. They may be single people who engage in “sex vacations” in the Far East or Africa, or persons who visit swinger clubs.
To prevent transmission of infection from persons with unacknowledged HIV, doctors must remain aware of patients with so-called signal diseases/indicator diseases, e.g., hepatitis (A, B, C), anal cancer, etc.
In 2022, 22 of the 115 newly HIV-diagnosed persons (19%) were notified with AIDS as they were diagnosed with an AIDS-defining condition concurrently with their HIV diagnosis. Among these, 13 were HTX, six were MSM and one was an IV drug user. The most frequently recorded AIDS-defining diagnosis was pneumocystis jirovecii-pneumonia.
A total of 41 HIV-notified persons died in 2022. Hereof, four who had been diagnosed with both AIDS and HIV in 2022. The remaining 37 persons had been diagnosed between 1987 and 2022 and were 33-83 years old at their time of death. As information from the Causes of Death Registry are published with a minimum one-year delay, it is not possible within the current death year to assess which share of the deceased persons died from a HIV-related condition and who died due to other causes. Retrospectively, though, the experience is that approx. one in every four deaths among HIV-positives is HIV related.
Checkpoint is the Danish AIDS Foundation's test sites for MSM and immigrants in Copenhagen, Frederiksberg, Aalborg, Aarhus and Odense for LGBT+ persons and others who are at a high risk for HIV. Here, you can be tested for HIV and syphilis, among others, with or without scheduling an appointment, and you will receive the results immediately. A total of six men tested HIV positive for the first time, four were born in Denmark and two abroad, all were MSM.
Resistance among treatment-naive 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 2019-2022 period, for whom it was possible to sequence the POL (DNA polymerase) gene in HIV-1. A total of 224 patients were included, whereof 123 had become infected in Denmark, 88 abroad and in 13 cases the country of infection was not known.
The ECDC’s definition of treatment-relevant resistance, pre-treatment drug resistance (PDR), was used in this report to assess the occurrence of resistance. The definition includes all cases of treatment-relevant resistance, scoring 15 or more on the Stanford HIVdb algorithm. Resistance is tested for the three primary antiretroviral (ARV) treatment groups used for highly active antiretroviral therapy (HAART): non-nucleoside inhibitors (NNRTI), nucleoside inhibitors (NRTI) and protease inhibitors (PI). In this report, genotypes were determined using COMET.
Overall, the period recorded 28 persons with PDR, corresponding to 12.5% of all newly diagnosed cases. NNRTI resistance was by far the most frequently occurring type of resistance and was recorded in 26 of the 28 cases, of whom eight had either NRTI and/or PI resistance, whereas three only had NRTI resistance.
The Danish Health Authority recommends pre exposure prophylaxis (PrEP) for persons in special risk groups. PrEP (Truvada®) consists of the two nucleoside inhibitors (NRTI) emtricitabine (FTC) and tenofovir (TDF). Among the newly diagnosed who were tested in the SERO project, one person in the period had a low level of resistance to TDF and a high level of resistance to FTC.
As the period has witnessed a decline in the number of samples submitted to the SERO project from 44.4% of all newly diagnosed patients in 2019 to 15.4% in 2022, it was not possible to identify with any certainty trends in the occurrence of transmitted resistance or to present these trends by country of infection or year. This underlines that a detailed monitoring of HIV-1 resistance among newly diagnosed patients hinges on the submission of samples from the treating departments of infectious medicine.
HIV subtypes among newly diagnosed patients
Among newly diagnosed persons who had become infected in Denmark, the HIV-1 subtype B comprised 63.8% in 2019, but this share declined to 42.3% in 2022. Among persons who had become infected abroad, Subtype B comprised 28.9% in 2019, increasing to 44.4% in 2022. These changes in the distribution seem not to have been caused by the decrease in the number of samples submitted that we described above. We therefore cannot exclude that the changed distribution may reflect a changed risk and travel behaviour during the COVID-19 pandemic. However, fluctuations have previously been recorded in the share of subtype B between years, EPI-NEWS no. 44/2019.
Subtype A6 was previously seen only sporadically in Denmark. However, in 2022, A6 comprised 27.8% of all geno-types in persons who had become infected abroad. A6 is the dominant subtype in the Ukraine and Eastern Europe, and the A6 cases recorded in 2022 also represent persons who have become infected in the Ukraine.
This report is also described in EPI-NEWS no. 40/2023.