HIV 2023

HIV 2023

  • In 2023, 110 people were reported with newly diagnosed HIV, as well as 117 people who were already diagnosed abroad. As in 2022, a high number of refugees from Ukraine were reported with HIV in 2023. 56 HIV-positive Ukrainians were reported, of which 45 were known and in treatment from their home country. The remaining 11 were diagnosed with HIV for the first time in Denmark.
  • Among the newly diagnosed, 60 were either Danes infected in Denmark or abroad, or immigrants in-fected after arriving in Denmark. The remaining 50 were immigrants infected before arriving in Den-mark. These 50 could not have been reached by Danish HIV prevention measures.
  • Among the newly diagnosed, there were 39 men who have sex with men (MSM) and 56 heterosexu-ally infected (HTX), of which 28 were men and 28 were women (including two trans women). The re-maining 15 were reported with another (6) or unknown mode of transmission (9).
  • 46% of MSM and 33% of HTX were infected in Denmark.
  • Among newly diagnosed MSM, 64% were immigrants. The proportion was 63% for HTX.
  • Among MSM, 41% were late testers. The same applied to 66% of HTX.
  • Immigrants, asylum seekers, etc., should be tested for HIV as soon as possible after arriving in Den-mark. This allows for rapid treatment of HIV-positive individuals and reduces the risk of further trans-mission.
  • All MSM who do not have known HIV should be tested for HIV once a year. Additionally, MSM who have an active sex life and do not consistently use condoms should be tested for HIV and other sex-ually transmitted infections more frequently, e.g., every 3 months, and possibly offered PrEP (Pre-Exposure Prophylaxis, HIV medication taken before exposure). PrEP has been proven to provide the best prevention against HIV and can be credited for the significantly declining incidence of HIV among MSM in Denmark.
  • Immediate treatment after diagnosis ensures that people who are known to be HIV-positive do not pose any risk of further transmission of HIV, as well-treated HIV-positive individuals cannot transmit the virus.
  • HIV prevention includes:
    o Condom use
    o TasP (Treatment as Prevention, i.e., only unprotected sex with HIV-positive individuals known to be in effective treatment).
    o PrEP (Pre-Exposure Prophylaxis, HIV medication taken before exposure).
    o PEP (Post-Exposure Prophylaxis, HIV medication taken immediately after exposure).
  • The prevalence of HIV resistance has not changed significantly in recent years. Resistance to non-nucleoside inhibitors (NNRTI resistance) is by far the most common.
  • None of the 130 patients who were tested for resistance had a resistance score ≥15 against both emtricitabine (FTC) and tenofovir (TDF), the two nucleoside inhibitors (NRTI) that make up PrEP (Truvada®).

In 2023, 227 cases of HIV were reported, including 154 men and 73 women, as shown in Table 1.

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In 2023, the median age for men was 39 years (range 2-72 years) and 41 years (range 20-75 years) for women.

Among the 227 reported cases, 117 individuals (52%) were previously diagnosed with HIV abroad, including four Danish-born and 45 from Ukraine.

Two adopted children from African countries were reported, one of whom was diagnosed for the first time in Denmark. No children infected in Denmark were reported.

Box 1. The estimated number of HIV-positive individuals in Denmark, the undiagnosed proportion, and the num-ber of late testers as of December 31, 2023

The figures have been adjusted down compared to previous estimates, and the following is partly made using the ECDC’s model for incidence calculations, which has a large confidence interval, and partly using data from the Dan-ish HIV Cohort Study (DHCS). The adjustment is within the framework of the ECDC model but now aligns more closely with the actual figures from DHCS.

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Origin, Country of Infection, and Mode of Transmission among Newly Diagnosed

Among the 110 individuals diagnosed with HIV for the first time, 38 (54%) were born in Denmark and 72 (46%) were born abroad, including four tourists and two undocumented migrants.

There were 39 men who have sex with men (MSM), 28 men who have sex with women (MSW), 30 women who have sex with men, including two trans women (WSM), four people reported with other modes of transmission, and nine reported with unknown transmission routes.

Of the 39 MSM, 13 (33%) were born in Denmark and infected in Denmark, 12 (31%) were born abroad and infected after arriving in Denmark, while one (2%) was born in Denmark and infected abroad. These 26 represent the num-ber of MSM for whom prevention efforts in Denmark have not been effective (67%). The remaining 13 (33%) were born abroad and infected before arriving in Denmark. The 39 newly diagnosed MSM, as well as the 14 Danish-born MSM, are the lowest numbers of MSM recorded since HIV surveillance began in 1990.

Among the 56 HTX (heterosexually infected), 13 (23%) were born in Denmark and infected in Denmark, eight (14%) were born abroad and infected after arriving in Denmark, while eight (14%) were born in Denmark and infected abroad. These 29 (52%) represent the number of HTX for whom prevention efforts in Denmark have not been ef-fective. The remaining 27 (48%) were born abroad and infected before arriving in Denmark.

In addition to those infected homosexually and heterosexually, five people were reported with transmission routes listed as intravenous drug use, blood transfusion abroad, mother-to-child transmission, and “sexually transmitted” without information on homosexual or heterosexual transmission. Finally, nine people were report-ed with unknown transmission routes, two born in Denmark and seven born abroad.

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Pregnancy

In 2023, eight pregnant women with HIV were identified, all born abroad. Two were found HIV-positive through pregnancy screening, while the others had known and treated HIV.

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CD4 Count at Diagnosis – Late Testers

Among the 110 people diagnosed with HIV for the first time in 2023, 109 (99%) had information on CD4 count at di-agnosis and/or information on recent infection (negative test and/or acute HIV illness) or information on AIDS at diagnosis. For the last person, this information could not be obtained.

The CD4 count is a marker of the HIV virus’s impact on the cellular immune system. A CD4 count below 350 cells per µl of blood has long been an indication to start highly active antiretroviral therapy (HAART) in Denmark, unless the patient wished to start earlier. Since August 2015, guidelines have changed so that everyone diagnosed with HIV is offered treatment immediately, regardless of CD4 count at diagnosis. A CD4 count below 350 and/or AIDS at the time of diagnosis is still used in this report as a marker for late testers. Conversely, the CD4 count at diagnosis can be very low if the person is tested shortly after infection, and can therefore be mistakenly perceived as a “late tester” based on the CD4 count. When a person is reported with HIV to the national surveillance at SSI, specific in-formation is requested to show whether it is a newly infected person with a low CD4 count (symptoms of acute HIV, recent negative HIV test, etc.).

Among the 109 people with reported CD4 count at diagnosis, 61 (56%) had a CD4 count below 350 cells per µl and/or were diagnosed with AIDS, while 48 (44%) had a CD4 count of 350 or higher or were diagnosed with acute HIV.

The proportion of late testers has thus fallen slightly since 2022, when it was 60% (the proportion was between 47% and 55% in 2018-2021).

A total of 101 were reported with both CD4 count and origin and mode of transmission. There is a significant differ-ence in the proportion of late testers depending on mode of transmission and origin. Among all MSM, the propor-tion of late testers was 41% (16 out of 39). Among MSM born abroad, the proportion of late testers was 35% in 2023, while it was 54% for MSM born in Denmark.

This is the first time that MSM born in Denmark have a higher proportion of late testers than MSM born abroad. This can be explained by the fact that MSM who are not on PrEP treatment in Denmark belong to a less resourceful and/or less self-aware group that, in addition to not receiving PrEP, does not follow the advice to get tested for HIV every year. Thus, fewer and fewer Danish MSM are being diagnosed with HIV, but they are being diagnosed later.

Among seven late-tested Danish-born MSM, five (71%) were reported as bisexual. For non-late-tested Danish-born MSM, the proportion was one out of six (17%). Among MSM born abroad, the proportion reported as bisex-ual was three out of nine late testers (33%) and two out of 17 non-late testers (12%).

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Preventative measures

Over the years, the number of new HIV diagnoses in Denmark has decreased. Contributing factors include frequent testing, especially among MSM, early treatment initiation (TasP, Treatment as Prevention), which prevents treated HIV-positive individuals from transmitting the virus, and especially PrEP (Pre-Exposure Prophylaxis, HIV medication taken before exposure, offered to MSM).

To further prevent HIV transmission among MSM, it is important that the doctor who finds an MSM positive for gonorrhea, syphilis, or chlamydia/LGV tests them for HIV and, if they are HIV-negative, offers the patient PrEP. The Danish Health Authority updated the specialty plan for infectious disease medicine in 2024, so PrEP can now be dispensed at the main function level . For some MSM, there may be a barrier to taking the initiative to seek PrEP treatment, so doctors are encouraged to suggest this.

Likewise, being bisexual may negatively influence the patient’s initiative to seek both HIV testing and PrEP treat-ment, which staff at testing sites should also be aware of.

Regarding heterosexually transmitted HIV, it is especially important to test immigrants from countries with a high prevalence of HIV quickly after arrival. The Danish Health Authority’s 2013 guidelines state that people from Africa, Asia, South America, and Eastern Europe should be considered for HIV testing at the first contact with the healthcare system, regardless of the reason for the contact.

It can be difficult to identify people at risk of HIV infection among Danish-born heterosexuals. However, there are some possibilities for preventing infection in this group. These may include individuals who go on “sex holidays” to Eastern Asia or Africa, or people who frequent swinger clubs. Additionally, in 2023, there was a relatively large pro-portion of reported HTX-infected individuals with information about homelessness, prostitution, etc. Thus, HIV has increasingly become a disease with a social bias, whereas in Denmark it was previously a disease most often diag-nosed among resourceful, self-aware MSM.

To prevent further transmission from individuals with undiagnosed HIV, doctors should also be aware of patients with so-called signal diseases/indicator diseases, such as hepatitis (A, B, C), anal cancer, etc.

AIDS

In 2023, 24 of the 110 newly diagnosed with HIV (22%) were reported with AIDS, as they were diagnosed with an AIDS-defining illness at the same time as the HIV diagnosis. Among them were 17 HTX, four MSM, and three individuals with an unknown mode of transmission. The most common AIDS-defining diagnosis was pneumocystis jirovecii pneumonia. A total of 38 HIV-reported individuals died in 2023. None of these were diagnosed in 2023, but between 1989 and 2022. Since information in the Cause of Death Register is published with at least a one-year de-lay, it is not possible during the current year of death to assess what proportion of the deceased died from an HIV-related illness and who died from something else. Retrospectively, however, it is estimated that about a quarter of deaths among HIV-positive individuals have an HIV-related cause.

Checkpoint

Checkpoint is the AIDS Foundation’s testing clinics in Copenhagen, Gentofte, Frederiksberg, Aalborg, Aarhus, and Odense for LGBT+ individuals and others at high risk for HIV, where one can be tested for HIV and syphilis, among other things, with or without a prior appointment and receive immediate results. A total of three men tested posi-tive for HIV for the first time, all born abroad, all MSM.

Resistance among treatment-naive individuals with newly diagnosed HIV

The Section for Virus Research & Development at SSI has compiled a report that includes all HIV-infected individu-als who have been included in the SERO project (HIV-1 genotypic resistance determination of treatment-naive and newly diagnosed patients) from 2022 to October 2024, where it has been possible to sequence the POL (DNA pol-ymerase) gene in HIV-1. This period was chosen as it includes the latest data from the submission of HIV-1 samples for resistance determination, which became mandatory in November 2023 (Regulation on the notification of infectious diseases). This involves a total of 130 patients, of whom 65 were infected in Denmark, 63 were infected abroad, and for two, the country of infection is unknown.

ECDC’s definition of treatment-relevant resistance, pre-treatment drug resistance (PDR), is used in this report to assess the prevalence of resistance. According to this definition, all cases of treatment-relevant resistance with a score of at least 15 according to the Stanford HIVdb algorithm are included. Resistance is examined 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). Genotypes in this report are determined using COMET.

Overall, there were 16 individuals with PDR during the period, which is 12.3% of all newly diagnosed. Among those infected in Denmark, there was resistance in seven (11%), and among those infected abroad, nine (14%) had re-sistance. NNRTI resistance was by far the most common and was seen in 15 of the 16 cases, of which nine had NNRTI resistance alone, four had NRTI+NNRTI resistance, one had NRTI resistance alone, and two had PI+NNRTI resistance. There is no significant difference in infection in Denmark or abroad, nor is there any difference in the prevalence of resistance compared to last year’s HIV report (HIV 2022). From September 2024, resistance to drug classes targeting the integrase gene (Integrase Strand Inhibitors; INSTI) is also included in the surveillance, as this drug class is frequently used in treatment, and there have been concerns about an increasing prevalence of INSTI resistance internationally (HIV drug resistance – brief report 2024). Therefore, the numbers for INSTI resistance are small for the period, but among the five newly diagnosed who were tested, one had INSTI resistance.

The Danish Health Authority recommends Pre-Exposure Prophylaxis (PrEP) for use by individuals in specific risk groups. PrEP (Truvada®) consists of the two nucleoside inhibitors (NRTI) emtricitabine (FTC) and tenofovir (TDF). Among the newly diagnosed during the period, four individuals had a resistance score ≥15 against TDF and one had a resistance score ≥15 against FTC.

Although none had resistance against both FTC and TDF with a resistance score ≥15, the four with TDF resistance all had a potentially low level of resistance (score 10) against FTC. There is no in-formation that any of these individuals had received PrEP.

HIV-1 subtypes among newly diagnosed patients

Among newly diagnosed individuals infected in Denmark, HIV-1 subtype B accounted for 40% in 2022, but fell to 27% in 2024. For individuals infected abroad, subtype B accounted for 41% in 2022 and fell to 10% in 2024. Subtype A6 has previously only been seen sporadically in Denmark but accounted for 24% of all genotypes among individu-als infected abroad in 2024. A6 is the dominant subtype in, among others, Ukraine and Eastern Europe, and the cases in 2022 are also among individuals infected in Ukraine. Subtype A6 can contain the compensatory mutation L74I in the integrase gene, which can promote INSTI resistance. Additionally, the proportion of unknown recombi-nants in 2024 is the second largest group (after A6) among those infected abroad. However, fluctuations in the dis-tribution of subtypes and CRF have also been seen from year to year, EPI-NEWS 44/2019.

There has been ongoing contact throughout the year between SSI and the infectious disease and clinical microbi-ology departments regarding the submission of samples in relation to the new regulation on the now mandatory surveillance of HIV-1 resistance. For practical information on sample submission, delimitation, and order codes, re-fer to page 42 in the handbook, which can be accessed via this link: Surveillance Analyses.

The work of collecting and updating epidemiological information is ongoing between reports in EPI-NEWS; there-fore, there may be changes in data in later publications.

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This annual report is also mentioned in EPI-NEWS 48/2024.