When the Institute of Public Health presented the figures for sexually transmitted diseases in Norway in 2023, it was not particularly encouraging.
Not only did several of us get gonorrhea and syphilis. 332 HIV-infected persons were also registered. This is the highest number since monitoring began in 1985.
But behind the high figure hides a success story about HIV and AIDS.
Because if we disregard immigrants who brought the infection with them when they came to Norway, most of them Ukrainians, the picture is completely different.
Down and scraping at the bedrock
Among men who have sex with men, there were only 29 new cases in 2023. While among heterosexuals, the number was down to 30 new cases.
This corresponds to the situation we had before the pandemic, Øivind Nilsen tells forskning.no.
He has monitored HIV and other sexually transmitted diseases at the Institute of Public Health for almost 40 years.
The HIV epidemic is not over, but we are down and scratching at the bedrock, according to the senior adviser.
– It is under control. In the sense that HIV infection in Norway is stably low, says Nilsen.
Does not spread further
How did the numbers get so low?
Although there has been no cure, several medical breakthroughs have revolutionized HIV treatment, says Bente Magny Bergersen.
She heads the outpatient clinic at Oslo University Hospital, which treats around 1,800 of the 5,100 people living with HIV in Norway.
As long as you take HIV medication daily, the infection stops with you. In other words, the drugs neutralize the virus.
HIV-positive Ukrainians receive treatment
Therefore, HIV does not progress to AIDS either.
– In practice, you no longer die of HIV, but with HIV, says Øivind Nilsen.
The fact that many HIV-positive Ukrainians have come to Norway is unlikely to have anything to say about the infection.
Everyone is tested on arrival in Norway, and the majority are already on medication.
The rest are offered treatment straight away.
Not like a normal virus
So when exactly did the HIV drugs become so effective?
The change has not happened overnight. To understand what happened, we need to take a look at the virus itself.
It was discovered in 1984 and is not like most viruses.
If you become infected, the virus can hide in some of your white blood cells for the rest of your life.
When the virus is active, it turns the immune cells into virus factories.
These newly made viruses break out of the cell and attack other white blood cells.
Eventually, the immune system becomes so weakened that you get HIV-related diseases and eventually AIDS.
Then harmless infections can become life-threatening or fatal.
Must attack multiple points at once
In order to stop the development, the medicines have to stick sticks in the wheels of the HIV virus.
The first medicine, AZT, came on the market as early as 1987. But it alone was not enough to stop the disease.
The virus found a way around. It became resistant.
Several similar medications followed, but also did not have a long-lasting effect.
The solution turned out to be a military strategy.
You have to attack from several points at the same time to avoid resistance, says Bergersen.
– Revolutionary
When a completely new type of HIV medicine came on the market in the mid-1990s, this became possible.
Taking the new and old type of medicine at the same time was revolutionary, says Bergersen.
– Those who stood with one foot in the grave came over to the right side. So it was absolutely fantastic, says Bergersen.
If you want to know more about the science behind the breakthroughs, read this story about how modern HIV drugs actually work.
The peak of infection in 2008
Nevertheless, it would take several years before the disease was properly brought under control in Norway.
Because over the 2000s, the number of people infected with HIV increased in Norway. In 2008, it peaked with 299 new infections.
As you can see on the curve further up in the case, the majority of these immigrants were those who brought the HIV infection with them when they came to Norway. Mainly from Africa.
But also among men who have sex with men, the infection had increased considerably.
How could this happen?
Bergersen believes that part of the explanation may have been that many had lowered their shoulders. With the new medicines, HIV was no longer a death sentence.
Was not offered treatment right away
At this time, HIV-positive people also did not receive treatment until the disease had progressed quite far.
This means that they could infect others if they had unprotected sex.
– In the beginning, there were a lot of side effects. So the patients were not offered treatment because we had no evidence that it was good for them personally, explains Bergersen.
She herself took a doctorate on the side effects of HIV drugs in the early 2000s.
And they were many.
The stigma was one of the hardest things
There could be serious things such as increased cholesterol and the risk of cardiovascular disease and more visible things such as less subcutaneous fat, prominent blood vessels and a fat pad in the neck.
– One of the most burdensome things for many of the patients I met in my project had to do with body changes, says Bergersen.
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The stigma that came with it if people could see that you had HIV was therefore one of the hardest things to live with.
Determined that medication was best for the individual
But several new medicines came on the scene over time.
A variant that attacked a completely different point in the HIV virus’ life cycle came on the market in the late 2000s, and this medicine had far fewer side effects.
New generations of several of the HIV drugs have followed.
The healthcare system began to offer treatment to those who wanted it.
– Fantastic
And then in 2015, a startling study appeared in the scientific journal New England Journal of Medicine.
It stated that all HIV-positive people should be on medication from the time they receive the diagnosis. That this was the best for their own health.
– From then on, everyone had to go to treatment at once. But it took an unnecessarily long time before we got this far, says Bergersen.
When the HIV doctor looks back on the time from when she met her first HIV patient in 1992 to now, she nevertheless sees how far medical development has come.
– It has been absolutely fantastic, says Bergersen.
Today, she almost never hears about side effects from her patients either.
Norway has probably reached the WHO’s HIV targets:
Globally, 39 million people are HIV positive. Two thirds of these live in Africa, according to the World Health Organization (WHO).
Now the WHO’s goal, which is called 95-95-95, is that:
- At least 95 percent of HIV cases must have been discovered.
- At least 95 percent of these must go on HIV medication.
- At least 95 per cent of these again must have so few viruses in their blood that they are not contagious.
There is still some way to go before this applies worldwide, although there has been an improvement. In Norway, we are probably already there, says Øivind Nilsen.
In 2020, Nilsen and colleagues showed that Norway had reached the previous target, which was called 90-90-90 in a study published in the Journal of the Norwegian Medical Association.
Recommendation for men going to Thailand
But the medical treatment of HIV-positive people cannot take all the credit for the decline.
– I think that Prep took the last bit of infection in Norway, says Bergersen.
This is a preventive treatment for people in the risk group that became free in Norway from 2017.
Especially among men who have sex with men, there are more people who take such drugs to protect themselves.
– There are some people who need extra protection during periods of their lives. So that that group was given the opportunity to take something that protects them against HIV, I think it was very important, and very good that Norway was very early in giving it over the national budget, says Bergersen.
A new group is also recommended to take Prep treatment, points out Øivind Nilsen at FHI. Namely men who go to Thailand and have casual and unprotected sex.
Of heterosexuals who contracted HIV in 2023, the largest proportion were men traveling to Thailand. This has been the case for many years.
Many live with secret status
Despite good medication, HIV can still be a burden.
– What is not gone is the stigma, says Bergersen.
She believes that the silence has kept the taboo alive. Too few have come forward with the HIV diagnosis.
– And when you could get treatment, and didn’t have to tell anyone because it wasn’t really a problem, then it stopped completely, says Bergersen.
Therefore, young people have lacked faces that show that it is okay to live with the disease. Something that may have made it even more difficult to stand up, she believes.
She points out that many well-functioning people with good jobs live with a secret status.
– It is still the case that there are some who are completely anonymous with us, says the manager of the HIV outpatient clinic.
Reference
Institute of Public Health: Annual report 2023 blood and sexually transmitted infections, 2024, ISBN electronic: 978-82-8406-446-8.
