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Try out PMC Labs and tell us what you think. Learn More. We aimed to characterise the HIV epidemic in Greenland and to determine incidence, prevalence, mortality rates MR and specific causes of deaths. The study de used was population-based nationwide cohort study. We included all patients diagnosed with HIV in Greenland before Data were obtained from patient files, death certificates and the mandatory reports of HIV cases.
We identified cases of HIV among adult Greenlanders. The median age at HIV diagnosis was 46 years interquartile range 34— The incidence increased from 3. Prevalence increased to a maximum in A total of 79 have died and 25 have emigrated.
Heterosexual contact is the main route of HIV infection and the patients are diagnosed at a median age of The incidence of newly diagnosed HIV patients has decreased markedly since year Mortality is high although declining in recent years. More than 25 years ago, the first case of HIV infection in Greenland was identified.
Initially, the virus was introduced from Denmark, through homosexual and heterosexual contacts 12. HIV infection spread fast primarily through heterosexual transmission amongst an older sub-population of individuals with low socio-economic status 3 — 6. A thorough description of the epidemic is provided in the supplementary material online. A very high incidence of sexually transmitted diseases and induced abortions in Greenland 7 suggests that risk-taking behaviour is common among the general population, and it constantly raises concern of an increasing HIV incidence and a HIV epidemic spreading to the younger population.
The aim of the present study was to characterise and to describe the HIV epidemic in Greenland from the first case of known HIV infection until today and to determine if the HIV epidemic is spreading to other groups in the Greenlandic population. Changing trends in mortality and causes of death were evaluated. We included all adult patients diagnosed with HIV in Greenland in the period — Two children, who were perinatally infected with HIV, were excluded to make the data comparable to other HIV cohort studies.
Greenland has a population of approximately 56, people; of these, around 15, live in Nuuk. The rest of Greenland's population live in smaller towns or villages. Contact with the health care system is either through a local nurse or a medical clinic in the nearest town. All patient charts are stored electronically since Prior to this, files were kept on paper. of laboratory analyses from all of Greenland have been stored electronically on a central server since This has been systemised since In some of the larger towns, a doctor travelling from Nuuk has carried out outpatient consultations every 6 or 12 months.
When HIV patients are diagnosed, medications are delivered to the local health care centre for the treatment of the specific patient. Data were collected by a systematic review of medical files, death certificates and files of the Greenland health authorities. As described in the supplementary material online, there is a mandatory notification of all HIV patients to the chief medical officer at the time of diagnosis.
By reviewing all reports ever made to the Greenlandic Health Officer, we identified 47 new cases not ly enrolled, since the Danish HIV Cohort Study only included patients diagnosed between and Data on migration and vital status were obtained from the Central Civil Registration System, which includes all residents in Greenland and Denmark. Data on causes of death were obtained from death certificates stored at the office of the Greenlandic Health Officer.
Data on Greenland's population were obtained from Greenland Statistics 9. We used the unique digit civil registration ased to all Danish and Greenlandic citizens to link data sources. All deaths caused by accidents, injury or suicide were categorised as unnatural. All other deaths were categorised as non-AIDS related. Each of the three groups were divided into specific subgroups to examine the exact cause of death within each group.
All specific illnesses, which contributed to the chain of events leading to death, were included in analyses, that is, more than one cause could be included for the death of each patient. Time was calculated from the date of HIV diagnosis until death, emigration or 1 Septemberwhichever occurred first. Kaplan—Meier methods were used to visualise mortality in Nuuk versus the rest of Greenland.
Hazard ratios HR were estimated using Cox regression, adjusted for age at diagnosis, gender, mode of transmission and race. In addition, 2 children were perinatally infected with HIV in andrespectively. One of these children died of AIDS shortly after birth and the other moved to Denmark and is therefore lost to follow-up.
Of the adults, 25 have emigrated, 79 have died in Greenland and 67 are currently living with HIV in Greenland. Eighteen were male and 16 were below 35 years of age. Sixteen were infected by heterosexual contact, 9 by homosexual contact, 1 by intravenous drug abuse, 1 by blood transfusion and 3 by an unknown route of transmission. Eleven were from outside Nuuk or Sisimiut. Of the cases identified, The majority were infected through heterosexual contact [ In the two largest towns in Greenland, Nuuk and Sisimiut, 89 Transmission is mainly seen in these towns, whereas in the rest of Greenland transmission is rare Fig.
Since then, no transmission has been recognised on the East Coast. When looking through the early reports, we noticed a trend of married men transmitting HIV to both male contacts and their wives, especially on the isolated Eastern coast.
The HIV incidence rose from 3. The prevalence increased ificantly until the end of the ties. Thereafter the prevalence still increased but at a somewhat slower rate. The highest prevalence was observed in the period — In —, the prevalence was Data concerning mortality are indicated in Table II.
Of these, 43 The median age at time of death was The specific causes of death are shown in Table II. Of the 79 patients dying in Greenland, 8 were infected through homosexual contact. Figure 2 shows the survival of patients living in Nuuk versus the rest of Greenland HR 0. We identified all persons diagnosed with HIV in Greenland since the first case was recognised in Age at diagnosis was in the interquartile range of 34—56 years and the route of transmission was primarily heterosexual.
Most infected individuals were Greenlandic and most were infected in Greenland. MR was high although declining in recent years and no ificant differences were seen between mortality in Nuuk versus the rest of Greenland. Early waves of transmission occurred either homosexually or bisexually but have changed into predominantly heterosexual transmission. This is possibly due to the small homosexual milieu in Greenland, making it attractive for homosexual individuals to move to a larger city, for example, Copenhagen. Also, no intravenous drug abuse exists in Greenland 10resulting in zero transmission by this route.
Only half of the persons infected are women, which could be explained by under-reporting of bisexual transmission or that some HIV-infected women transmitted the disease to more than one man. In the first clusters, many were infected bisexually, with men acquiring HIV through sex with men and transmitting it to their wives. Transmission happened mainly on the West Coast in Nuuk and Sisimiut, where the majority of the HIV-infected individuals are living today.
Almost all patients from the East Greenlandic cluster have either died or moved to Denmark after receiving the diagnosis, and there have only been small clusters in other towns or settlements. Being infected by HIV in a small settlement could possibly result in social and sexual isolation, which is probably why transmission is no longer occurring there. Why transmission happened mostly among older adult individuals could be explained by simple coincidence: if HIV is introduced into this population and sexual contact is most common among age-matched individuals, transmission will most likely be limited to this population.
The prevalence is slowly decreasing, which in the presence of declining MR reflects the declining incidence. The Greenlandic HIV incidence of 0. The rates of unnatural and non-AIDS-related deaths did not change throughout the study period. Surprisingly no ificant difference in mortality was found between patients living in Nuuk versus the rest of Greenland, even though outpatient consultations are organised on a more regular basis in Nuuk. The s are small, and even though there was a tendency towards a lower mortality outside of Nuuk, the association was not statistically ificant.
This tendency could be attributed to a larger of HIV-infected individuals living in smaller settlements moving to Denmark after diagnosis, which affects our estimates of MR. In contrast to the low HIV incidence and decreasing prevalence are the incidences of other sexually transmitted diseases STDs.
Also, a high prevalence of Mycoplasma genitalium 13hepatitis B 1415 and high abortion rates 7 adds to this perception. In this scenario, it is quite interesting as to why HIV is still a low endemic disease in the Greenlandic population. Maybe it is simply due to the fact that STDs in general are still most common amongst the young and HIV most common among a group of older adult individuals. But since most HIV transmissions occur heterosexually and a high of STDs are also seen in the adult population, some transmission should be expected.
Many factors contribute to the rate of HIV transmission, for example, the prevalence, sexual habits, migration and travel, but also how contagious each patient is and for how long. Our study confirms earlier findings, last evaluated inconcerning age and mode of transmission 4 — 6.
In our study, no parameters of social status were included, but the fact that HIV patients belong to this marginalised group probably explains some of the low transmission. The large fraction of sexually inactive persons could explain some of the slow HIV transmission in Greenland, though an alarming of non-adherent persons reported unsafe sex. It has earlier been shown that HIV patients in Greenland are diagnosed at an early stage of infection 6which is supported by our finding of only Treatment of HIV patients in Greenland has been reported to begin at a later stage of disease and has been implemented at a slower pace compared to Denmark, yet showing marked improvements after High mortality among Greenlandic HIV patients before has been reported Our study revealed that indeed mortality was high in the pre- and early-HAART periods but decreased dramatically since then.
In —, life expectancy in Denmark was We aimed to include all patients ever diagnosed with HIV in Greenland, and we are confident that we have fulfilled this purpose. We have included patients from the earlier clusters who were not included in reports 5618 and all cases ly identified are included in the present study. A limitation in our analysis is the inconsistency with which HIV patients are seen as outpatients, especially outside of Nuuk 5. The small of patients gives a statistical uncertainty, and since only patients attending outpatient consultations have CD4 counts measured, missing data for non-compliant patients is likely to bias analysis.
In conclusion, the HIV transmission in Greenland still occurs mostly heterosexually but is not, as ly described, limited to an elderly group of persons. Yet, the rate of transmission is low, and despite a possible high level of sexual risk-behaviour in the population, HIV incidence is declining slightly, and the epidemic is under control. Mortality among HIV patients in Greenland has declined substantially in recent years with a marked decline in AIDS-related deaths, probably due to improved treatment.
All of the authors contributed to the conception and de of the study and the analyses and interpretation of the data. The manuscript was drafted by KBM and MH and was critically reviewed and subsequently approved by all authors. We also thank Marie Dehnfeld for her tireless help with the collection of data.
To access the supplementary material to this article please see Supplementary files under Article Tools online. No funding sources were involved in study de, data collection, analysis, report writing, or the decision to submit the paper. National Center for Biotechnology InformationU. Int J Circumpolar Health. Published online Feb Author information Article notes Copyright and information Disclaimer. : lg. This is an open-access article distributed under the terms of the Creative Commons Attributionwhich permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
This article has been cited by other articles in PMC. Abstract Introduction We aimed to characterise the HIV epidemic in Greenland and to determine incidence, prevalence, mortality rates MR and specific causes of deaths.Local sex Greenland Michigan
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The HIV epidemic in Greenland – a slow spreading infection among adult heterosexual Greenlanders