In 2010, there were 258 new HIV cases diagnosed in Norway, 173 men (67 per cent) and 85 women. This is a moderate decrease from 283 diagnosed cases in 2009 (Fig. 1), mainly due to fewer cases being detected among immigrants who were infected before coming to Norway.
|Figure 1. HIV infection in Norway 1984-2010 by year of diagnosis.|
Among men infected homosexually, HIV figures are persistently high. Among heterosexually-infected people who were resident in Norway when they were infected, HIV figures are the highest number in any year. The prevalence of HIV among drug addicts in Norway remains at a stable low level (Table 1). In total, there are now 4 627 people diagnosed as HIV positive in Norway, 3 105 men and 1 522 women.
|Table 1. HIV infection in Norway by means of infection and diagnosis year.|
Men who have sex with men
Among men who have sex with men (MSM), 85 new HIV cases were detected in 2010 compared to 88 in 2009. Although the number of confirmed HIV cases in the group has declined slightly over the last two years from the peak year of 2008, we consider the epidemiological situation in this group to have remained unchanged with consistently high infection figures. Of the 2010 cases, 60 per cent were infected during the last two years. Figure 2 shows that the vast majority of MSM were infected in Norway. Domestic infection among MSM accounts for 70 per cent of cases since 1995. Oslo dominates as a place of infection with 76 per cent of the domestic transmission cases. Also in 2010, Oslo is reported as the most common place of infection among MSM, with 46 of the 85 cases, while 12 were infected elsewhere in Norway, of which five were in Bergen. The number of MSM infected abroad has also increased since 2003. Of the 26 who reported that they were infected abroad in 2010, 12 were infected in Europe, six in America, and four each in Africa and Asia. In one case, the place of infection was unknown.
The proportion of HIV-positive MSM with an immigrant background has been increasing in recent years. Of the 85 cases reported in 2010, 30 people were immigrants, of which 18 were infected while living in Norway and 12 were infected before immigration (Figure 2). These are evenly divided between Western and non-western countries.
|Figure 2. HIV infection among MSM from 1995 to 2010 by year of diagnosis and place of infection|
Ever since 2003 when the HIV-figures among MSM began to increase sharply in Norway, the infection situation among MSM have been characterised by the fact that many are infected by casual or anonymous sex in Norway or abroad. In 2010, fifty-nine (69 per cent) of the newly diagnosed people said that they were infected by a casual partner, 13 by a regular partner and in 13 cases the relation to the source of infection is unknown.
The indications for taking the HIV test were in 36 of the cases (42 per cent) at the patient’s own request, 25 were tested due to clinical symptoms of HIV (five of whom had AIDS and 10 had an acute HIV infection), and 19 were due to another routine examination by a health care provider. Only 5 people were identified as HIV positive as part of infection tracing. For 34 (40 per cent) the HIV test was performed by a general practitioner, 28 were tested at clinics for sexually transmitted infections, 22 were tested in a hospital / clinic and one person was tested at a health clinic for adolescents. The median age of the HIV-positive MSM has for many years remained stable at around 36 years, but for the 2010 cases this has dropped to 32 years (16-69). Of the cases reported in 2010, fourteen people were 25 years or younger at the time of diagnosis.
A large majority of heterosexual HIV infection detected in Norway is among immigrants. Based on information from MSIS about previous negative HIV tests and a comprehensive infectious medical history, one can largely determine whether people are infected before or after arrival in Norway. To give a better picture of the HIV epidemic among heterosexuals, we have divided people who were heterosexually infected into two groups; those who were resident in Norway when they were infected (Table 2) and those who were infected before arrival in Norway (Table 3).
Infected while living in Norway
In 2010, 57 people (37 men and 20 women) were diagnosed after heterosexual infection while resident in Norway. This represents a clear increase compared to the previous five years of statistics. On average, 41 cases per year have been reported in this group. Until a few years ago, most people in this group of people were ethnic Norwegians, but the number of people with immigrant backgrounds who were infected while living in Norway has increased in recent years and now accounts for about one third of the cases infected heterosexually. In 2010, there was an increase in the number of cases among persons with a Norwegian background and a continued increase in the immigrant group. Ten of the 20 women and seven of the 37 men reported in 2010 had an immigrant background. These 17 cases with an immigrant background were generally infected in the immigrant community in Norway or during a visit to their former homeland.
As in previous years in Norway, most women are infected by their spouse or regular partner, who themselves were infected heterosexually. Of the 20 women diagnosed in 2010, seventeen were infected in Norway and thirteen were infected by their spouse or regular partner. As shown in Table 2 heterosexual transmission has rarely been detected from bisexual men and drug addicts in Norway in recent years.
As in previous years, most men are infected abroad, with 57 per cent of cases in 2010. Thailand still dominates as the most common place of infection, with 12 cases in 2010.
The median age for men at the time of diagnosis was 45 years (19-71) and for women 32 years (23-71). Two of the men and four of the women were 25 years old or younger at the time of diagnosis.
|Table 2. Place of infection and source partner’s infection route for people who were infected with HIV heterosexually while resident in Norway, by year of diagnosis.|
Infected before arrival in Norway
This group consists mainly of people who come to Norway as asylum seekers or for family reunification. In 2010, a hundred new HIV cases were diagnosed in this group, 62 women and 38 men, compared with 126 cases in 2009. This decline must be viewed in the context that 7 000 fewer asylum seekers came to Norway in 2010 compared to 2009; 10 064 in 2010 compared with 17 226 in 2009 (figures from UDI). The vast majority of this group (75 per cent in 2010) came from Africa, most frequently from East Africa. Most immigrants from Asia were Thai women (12 in 2010) who came to Norway as part of family reunification to be with a Norwegian husband. The median age for the 2010 cases was 37 years (21-58) for men and 31 years (21-48) for women.
|Table 3. Area of origin for heterosexuals infected with HIV before arrival in Norway, by year of diagnosis.|
Injection drug users
Of the 11 cases reported in 2010, eight were men and three were women and five of them were immigrants infected in their country of origin before they came to Norway. Four came from Eastern Europe. Of the six cases infected in Norway, three were infected in Oslo, and the other three in various municipalities. The median age of cases in 2010 was 38 years (26-52). The proportion of HIV positive drug users infected before arrival in Norway has increased over the past 10 years, with 28 per cent (35) of the 126 HIV cases detected among drug users in total in this decade. Of the 35 cases infected before arrival in Norway, 69 per cent come from countries in Eastern Europe.
Other cases reported in 2010
One child with perinatal HIV infection in 2010 was born in Africa. The last confirmed case of perinatal infection in infants born in Norway was in 2000. Among the four cases with other / unknown infection origin, two are Norwegian-born men and the other two are men with immigrant backgrounds in which the means of transmission is still not clarified.
It is still the number of newly arrived asylum seekers / immigrants and the asylum situation in the counties that has the greatest impact on annual fluctuations in HIV figures in the individual counties. In both Oppland and Nordland, the increase in 2010 was in the group of asylum seekers or immigrants. Similarly, the reduction in Sogn og Fjordane and Østfold in 2010 was due to a decline in this group. Beyond this, there have been no significant changes in any county in recent years (Table 4).
|Table 4. HIV infection in Norway by county of residence at diagnosis (cumulative rate per 100 000 inhabitants).|
After a peak in 2008, the number of newly diagnosed HIV cases in Norway has shown a slight decline over the past two years. This is mainly due to a decrease in newly arrived HIV-infected asylum seekers and family migrants. For MSM, the situation remains very worrying. The number of newly diagnosed cases has remained consistently high over the past eight years. In addition, we have seen a corresponding increase in the number of reported cases of syphilis and gonorrhoea in the group. The same trend is seen in most Western countries. The main challenge in preventive work for this group is now, in light of the serious epidemiological situation, to the large group of MSM who have chosen not to use condoms to realise the need to do so. Early diagnosis is also a priority in prevention efforts. MSM should be offered regular screening to detect sexually transmitted infections when consulting a doctor or other health services. Sexually active MSM are encouraged to have annual check-ups, and men with multiple partners should do more often. Openness about and acceptance of, the patient’s sexual orientation is a prerequisite when sexual health topics are discussed.
There were more HIV cases in 2010 than in any previous year among heterosexuals living in Norway. It is too early to say whether this represents a general trend of increasing heterosexual spread in the Norwegian population, but the situation must be closely monitored. The number of heterosexuals with HIV is increasing year by year, both in Norway and abroad, and a continued low threat perception in relation to infection risk and low condom use in casual sex increases the vulnerability of this group.
The number of HIV-positive immigrants will vary from year to year depending on the number of asylum seekers and family migrants who come to Norway. The NIPH estimates that about 1 200-1 400 HIV-positive immigrants are now living in Norway. An important goal of the preventive work will still be to ensure early diagnosis and proper follow-up of people infected with HIV in this group and to ensure that the large immigrant population in Norway has adequate knowledge about HIV to meet the increasing burden of infection both within immigrant communities in Norway and while travelling abroad.