The silent revolution:
Is the HIV epidemic over in Norway?
Recent HIV figures reveal a success story.
When the Norwegian Institute of Public Health (NIPH) presented the figures for sexually transmitted infections in Norway in 2023, it was not particularly encouraging.
Not only did more individuals in Norway get gonorrhea and syphilis, 332 new HIV-infected cases were also registered. This is the highest number since monitoring began in 1985.
But behind the high number hides a success story about HIV and AIDS.
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 to 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 sciencenorway.no.
He has monitored HIV and other sexually transmitted infections at the Norwegian Institute of Public Health for nearly 40 years.
The HIV epidemic is not over, but we are down to the bedrock, according to the senior adviser.
“It’s under control. In the sense that HIV transmission in Norway is consistently low,” says Nilsen.
No further transmission
How did the numbers get so low?
Even though a cure has not been found, several medical breakthroughs have revolutionised HIV treatment, says Bente Magny Bergersen.
She heads the clinic at Oslo University Hospital that treats around 1,800 of the 5,100 people living with HIV in Norway.
As long as you take your HIV medication daily, the infection stops with you. The medication neutralises the virus.
Ukrainian HIV-positive individuals receive treatment
HIV therefore does not progress to AIDS.
“In practice, you no longer die from HIV, but with HIV,” says Øivind Nilsen.
The arrival of many HIV-positive Ukrainians in Norway is also unlikely to affect transmission.
Everyone is tested upon arrival in Norway, and the majority are already on medication.
The rest are offered treatment immediately.
Not like a regular virus
So when did HIV medications become so effective?
The change has not happened overnight. To understand what happened, we need to look at the virus itself.
It was discovered in 1984 and is not like most viruses.
If you are infected, the virus can hide in some of your white blood cells for the rest of your life.
When active, the virus transforms immune cells into virus factories.
These newly produced viruses escape from the cell and attack other white blood cells.
Over time, the immune system weakens to the point where HIV-related diseases develop, eventually leading to AIDS.
At this stage, even harmless infections can become life-threatening or fatal.
Must attack multiple points simultaneously
To stop the progression, the medications have to throw a wrench into the works of the HIV virus.
The first medication, AZT, hit the market as early as 1987. But on its own, it wasn't enough to stop the disease.
The virus found a way around. It became resistant.
Several similar medications followed, but they also lacked long-term effectiveness.
The solution was similar to a military strategy.
You have to attack from multiple points simultaneously to avoid resistance, says Bergersen.
Revolutionary
When a completely new type of HIV medication hit the market in the mid-1990s, this became possible.
Taking the new and old types of medication simultaneously was revolutionary, according to Bergersen.
“Those who had one foot in the grave came over to the right side. It was absolutely fantastic,” she says.
Peak of infections in 2008
Nevertheless, it would take several years before the disease was properly under control in Norway.
Throughout the 2000s, the number of HIV infections in Norway increased. In 2008, it peaked with 299 new infections.
As you can see in the graph earlier in the article, the majority of these were immigrants who brought the HIV infection with them when they came to Norway, mainly from Africa.
But the infection had also increased significantly among men who have sex with men.
How could this happen?
Bergersen believes part of the explanation could be that many had let their guard down. With the new medications, HIV was no longer considered a death sentence.
Not offered treatment immediately
At that time, HIV-positive individuals did not receive treatment until the disease had progressed quite far.
This meant they could transmit the virus to others if they had unprotected sex.
“In the beginning, there were many side effects. So patients were not offered treatment because we didn’t have evidence that it was beneficial for them personally,” Bergersen explains.
She herself earned a doctorate on the side effects of HIV medications in the early 2000s.
And they were many.
The stigma was one of the most challenging aspects
There could be serious issues like increased cholesterol and the risk of cardiovascular diseases, as well as more visible changes such as reduced subcutaneous fat, prominent veins, and a fat pad on the neck.
“One of the most challenging aspects for many of the patients I encountered in my project was related to body changes,” says Bergersen.
The stigma that came with people being able to see that you had HIV was one of the hardest things to live with.
New medications resulted in fewer side effects
However, several new medications were introduced over time.
A variant that attacked a completely different point in the HIV virus' life cycle came to the market in the late 2000s, and this medication had far fewer side effects.
New generations of several HIV medications followed.
The healthcare system began to offer treatment to those who wanted it.
"Absolutely fantastic"
Then in 2015, a groundbreaking study was published in the scientific journal New England Journal of Medicine.
It concluded that all HIV-positive individuals should start taking medication as soon as they are diagnosed, as this was the best approach for their health.
“From then on, everyone was to start treatment immediately. But it took an unnecessarily long time to reach that point,” says Bergersen.
Looking back from when she met her first HIV patient in 1992 to now, Bergersen sees the significant progress in medical advancements.
“It’s just been absolutely fantastic,” she says.
Today, she almost never hears about side effects from her patients either.
Recommendations for men travelling to Thailand
However, the medical treatment of HIV-positive individuals cannot take all the credit for the decline.
“I believe that PrEP took care of the last bit of transmission in Norway,” says Bergersen.
PrEP is a preventive treatment for people in high-risk groups, which became free in Norway from 2017.
Especially among men who have sex with men, many take these medications to protect themselves.
“There are times in life when some people need extra protection. Providing this group with access to medication that protects them against HIV was very important. It was also commendable that Norway was one of the first to fund it through the national budget,” says Bergersen.
Øivind Nilsen from the Norwegian Institute of Public Health notes that another group is now being advised to take PrEP treatment: Men who travel to Thailand and engage in casual, unprotected sex.
Among heterosexuals who contracted HIV in 2023, the largest proportion were men who travelled to Thailand. This has been the case for many years.
Many live with a secret status
Despite effective medications, HIV can still be a burden.
“What hasn’t gone away is the stigma,” says Bergersen.
She believes that silence has kept the taboo alive, as very few have come forward with their HIV diagnosis.
“When people began receiving treatment and didn't need to tell anyone because it wasn't an issue, everything went quiet,” she says.
Consequently, young people have lacked visible examples showing that it is possible to live well with the disease. This might have made it even harder for others to come forward, she believes.
Bergersen notes that many well-functioning individuals with good jobs live with a secret status.
“Some of our patients are still completely anonymous,” the head of the HIV clinic says.
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Translated by Alette Bjordal Gjellesvik
Read the Norwegian version of this article on forskning.no
Reference:
Norwegian Institute of Public Health: Årsrapport 2023 blod- og seksuelt overførbare infeksjoner (2023 Annual report on bloodborne and sexually transmitted infections), 2024. ISBN: 978-82-8406-446-8
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