Beginning of the end of HIV in Norway
Significant progress has been made in the fight against HIV in recent years. The strategy requires measures to increase testing, early diagnosis, and quick referrals to and follow-up by an HIV specialist following diagnosis (linkage to care), as well as primary preventive measures such as increased use of condoms and use of pre-exposure prophylaxis (PrEP) by those most at risk.
People who have been at risk of contracting HIV should always be offered an HIV test. In addition, separate HIV testing has been established specifically for men who have sex with men. Immigrants who come from countries with a high prevalence of HIV and/or who belong to traditionally high-risk groups should be offered HIV testing within three months of their arrival (14).
A variety of national measures to increase the frequency of testing in high-risk groups has been implemented, in part by expanding the availability of a low-threshold service and rapid HIV testing. For instance, services such as the drop-in testing programme Sjekkpunkt Norway have been shown to be successful in reaching men who have sex with men, a group that would otherwise be difficult to reach (15). Data from the Olafia Clinic at Oslo University Hospital show more frequent testing for sexually transmitted infections among men who have sex with men (16), and national surveys of this group indicate an increase in testing for HIV and a generally high level of knowledge about how HIV is transmitted (17). However, the most recent national survey in 2017 shows that there is the potential to increase testing activity further among men who have sex with men (17). There is insufficient data about testing for other high-risk groups, such as asylum seekers, immigrants and heterosexual men at risk of infection while on holiday in Southeast Asia.
The number of undiagnosed HIV infections has been declining in the last decade
The good results for the second and third 90–targets reflect the HIV treatment services in Norway. HIV treatment is free and entails close, specialised follow-up with free check-ups for everyone living in the country. Moreover, amended national clinical guidelines with implementation of a test-and-treat system regardless of the patient's CD4 count have contributed to quick commencement of treatment (17, 18). Through close cooperation, the various rapid testing services can also put people with positive test results in contact with the specialist health service for immediate follow-up.
A quality registry for HIV patients has now been approved and is being established at Oslo University Hospital, Ullevål. This will make it possible to collect data on the treatment status of HIV-positive individuals beyond the efforts related to the second and third 90–targets. One example is the Swedish quality registry known as InfCareHIV in which work is being done on a fourth 90–target focusing on a better quality of life for people living with HIV (19). Furthermore, a national quality registry for HIV patients, in addition to nominative reporting to MSIS, will enable the use of more advanced modelling methods and make for a more accurate estimate of undiagnosed HIV infections (8).
Condom use remains one of the most important primary preventive measures. The most recent national survey of men who have sex with men, which is most representative of gay-identified and sexually active men who have sex with men, indicates that high-risk sex with casual partners is still quite common within this group (17).
Condom use remains one of the most important primary preventive measures
Men who have sex with men are among those in Norway who can easily make use of targeted services that provide free condoms and lubricant. Use of pre-exposure prophylaxis (PrEP) is another important means of preventing HIV among people with high-risk behaviour. PrEP was made available at no cost to users in Norway in January 2017 and can effectively reduce the risk of becoming infected with HIV before actually being exposed to the virus (20). According to figures from the Norwegian Prescription Database from June 2020, 1 633 people received a prescription for PrEP at least once in 2018 and 2019. The largest number of PrEP users comes from the Olafia Clinic and are mostly sexually active men who have sex with men (21). Other important factors for preventing HIV infection include greater awareness about the risk of infection and symptoms of the disease among high-risk groups, and open communication about HIV status and PrEP use when engaging in sex with casual partners.
We are pleased that Norway has achieved the 90–90–90 treatment targets. Now we must intensify our efforts to reach the ultimate goal: No one in Norway will be infected with HIV, and everyone living with HIV in Norway will be able to live a relatively normal life.