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Despite availability of pre-exposure prophylaxis (PrEP), the incidence of HIV-1 in Europe remained stable the past decade. Reduction of new HIV-1 infections requires more knowledge about the profiles of high-risk transmitters and late presenters (LP).


We aimed to investigate risk factors associated with HIV-1 transmission clusters and late presentation with HIV-1 in Denmark.


Blood samples and epidemiological information were collected from newly diagnosed HIV-1 patients between 2009 and 2017. We genotyped pol genes and performed phylogenetic analyses to identify clusters. Risk factors for clustering and LP were investigated with partial proportional odds and logistic regression. Covariates included transmission mode, HIV-1 subtype, age, origin and cluster activity.


We included 1,040 individuals in the analysis, 59.6% identified with subtype B and 48.4% in a cluster. Risk factors for clustering included Danish origin (odds ratio (OR): 2.95; 95% confidence interval (CI): 2.21–3.96), non-LP (OR: 1.44; 95% CI: 1.12–1.86), and men who have sex with men (MSM). Increasing age and non-B subtype infection decreased risk (OR: 0.69; 95% CI: 0.50–0.94). Risk for late presentation was lower for active clusters (OR: 0.60; 95% CI: 0.44–0.82) and Danish origin (OR: 0.43; 95% CI: 0.27–0.67). Non-Danish MSM had a lower risk than non-Danish heterosexuals (OR: 0.34; 95% CI: 0.21–0.55).


HIV-1 transmission in Denmark is driven by early diagnosed, young, subtype B infected MSM. These may benefit most from PrEP. Non-Danish heterosexual HIV-1 patients could benefit from improved communication to achieve earlier diagnosis and treatment.


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  1. Antiretroviral Therapy Cohort Collaboration. Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. Lancet. 2008;372(9635):293-9.  https://doi.org/10.1016/S0140-6736(08)61113-7  PMID: 18657708 
  2. Teeraananchai S, Kerr SJ, Amin J, Ruxrungtham K, Law MG. Life expectancy of HIV-positive people after starting combination antiretroviral therapy: a meta-analysis. HIV Med. 2017;18(4):256-66.  https://doi.org/10.1111/hiv.12421  PMID: 27578404 
  3. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493-505.  https://doi.org/10.1056/NEJMoa1105243  PMID: 21767103 
  4. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Antiretroviral therapy for the prevention of HIV-1 transmission. N Engl J Med. 2016;375(9):830-9.  https://doi.org/10.1056/NEJMoa1600693  PMID: 27424812 
  5. Connor EM, Sperling RS, Gelber R, Kiselev P, Scott G, O’Sullivan MJ, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS clinical trials group protocol 076 study group. N Engl J Med. 1994;331(18):1173-80.  https://doi.org/10.1056/NEJM199411033311801  PMID: 7935654 
  6. Chou R, Evans C, Hoverman A, Sun C, Dana T, Bougatsos C, et al. Preexposure prophylaxis for the prevention of HIV infection: evidence report and systematic review for the US preventive services task force. JAMA. 2019;321(22):2214-30.  https://doi.org/10.1001/jama.2019.2591  PMID: 31184746 
  7. Cambiano V, Miners A, Dunn D, McCormack S, Ong KJ, Gill ON, et al. Cost-effectiveness of pre-exposure prophylaxis for HIV prevention in men who have sex with men in the UK: a modelling study and health economic evaluation. Lancet Infect Dis. 2018;18(1):85-94.  https://doi.org/10.1016/S1473-3099(17)30540-6  PMID: 29054789 
  8. European Centre for Disease Prevention and Control (ECDC) and World Health Organization. (WHO) Regional Office for Europe. HIV/AIDS surveillance in Europe 2018–2017 data. Copenhagen: WHO Regional Office for Europe; 2018. Available from: https://www.ecdc.europa.eu/en/publications-data/hivaids-surveillance-europe-2018-2017-data
  9. Pineda-Peña AC, Pingarilho M, Li G, Vrancken B, Libin P, Gomes P, et al. Drivers of HIV-1 transmission: The Portuguese case. PLoS One. 2019;14(9):e0218226.  https://doi.org/10.1371/journal.pone.0218226  PMID: 31568476 
  10. Fearnhill E, Gourlay A, Malyuta R, Simmons R, Ferns RB, Grant P, et al. A phylogenetic analysis of human immunodeficiency virus type 1 sequences in Kiev: findings among key populations. Clin Infect Dis. 2017;65(7):1127-35.  https://doi.org/10.1093/cid/cix499  PMID: 28575385 
  11. Petersen A, Cowan SA, Nielsen J, Fischer TK, Fonager J. Characterisation of HIV-1 transmission clusters and drug-resistant mutations in Denmark, 2004 to 2016. Euro Surveill. 2018;23(44):1700633.  https://doi.org/10.2807/1560-7917.ES.2018.23.44.1700633  PMID: 30401010 
  12. Paraskevis D, Beloukas A, Stasinos K, Pantazis N, de Mendoza C, Bannert N, et al. HIV-1 molecular transmission clusters in nine European countries and Canada: association with demographic and clinical factors. BMC Med. 2019;17(1):4.  https://doi.org/10.1186/s12916-018-1241-1  PMID: 30616632 
  13. Antinori A, Coenen T, Costagiola D, Dedes N, Ellefson M, Gatell J, et al. Late presentation of HIV infection: a consensus definition. HIV Med. 2011;12(1):61-4.  https://doi.org/10.1111/j.1468-1293.2010.00857.x  PMID: 20561080 
  14. Mocroft A, Lundgren J, Antinori A, Monforte Ad, Brännström J, Bonnet F, et al.Late presentation for HIV care across Europe: update from the collaboration of observational HIV epidemiological research Europe (COHERE) study, 2010 to 2013. Euro Surveill. 2015;20(47):30070. PMID: 26624933 
  15. Audelin AM, Cowan SA, Obel N, Nielsen C, Jørgensen LB, Gerstoft J. Phylogenetics of the Danish HIV epidemic: the role of very late presenters in sustaining the epidemic. J Acquir Immune Defic Syndr. 2013;62(1):102-8.  https://doi.org/10.1097/QAI.0b013e318276becc  PMID: 23075917 
  16. Guaraldi G, Zona S, Menozzi M, Brothers TD, Carli F, Stentarelli C, et al. Late presentation increases risk and costs of non-infectious comorbidities in people with HIV: an Italian cost impact study. AIDS Res Ther. 2017;14(1):8.  https://doi.org/10.1186/s12981-016-0129-4  PMID: 28209189 
  17. Pacheco PRG, Zara ALSA, Silva E Souza LC, Turchi MD. Late onset of antiretroviral therapy in adults living with HIV in an urban area in Brazil: prevalence and risk factors. J Trop Med. 2019;2019:5165313.  https://doi.org/10.1155/2019/5165313  PMID: 31080478 
  18. Audelin AM, Lohse N, Obel N, Gerstoft J, Jørgensen LB. The incidence rate of HIV type-1 drug resistance in patients on antiretroviral therapy: a nationwide population-based Danish cohort study 1999-2005. Antivir Ther. 2009;14(7):995-1000.  https://doi.org/10.3851/IMP1412  PMID: 19918103 
  19. van de Laar MJ, Bosman A, Pharris A, Andersson E, Assoumou L, Ay E, et al. Piloting a surveillance system for HIV drug resistance in the European Union. Euro Surveill. 2019;24(19):1800390.  https://doi.org/10.2807/1560-7917.ES.2019.24.19.1800390  PMID: 31088600 
  20. Petersen A, Cowan SA, Nielsen J, Fischer TK, Fonager J. Characterisation of HIV-1 transmission clusters and drug-resistant mutations in Denmark, 2004 to 2016. Euro Surveill. 2018;23(44):1700633.  https://doi.org/10.2807/1560-7917.ES.2018.23.44.1700633  PMID: 30401010 
  21. Abdissa A, Yilma D, Fonager J, Audelin AM, Christensen LH, Olsen MF, et al. Drug resistance in HIV patients with virological failure or slow virological response to antiretroviral therapy in Ethiopia. BMC Infect Dis. 2014;14(1):181.  https://doi.org/10.1186/1471-2334-14-181  PMID: 24708645 
  22. Tamura K, Stecher G, Peterson D, Filipski A, Kumar S. MEGA6: Molecular evolutionary genetics analysis version 6.0. Mol Biol Evol. 2013;30(12):2725-9.  https://doi.org/10.1093/molbev/mst197  PMID: 24132122 
  23. Ragonnet-Cronin M, Hodcroft E, Hué S, Fearnhill E, Delpech V, Brown AJL, et al. Automated analysis of phylogenetic clusters. BMC Bioinformatics. 2013;14(1):317.  https://doi.org/10.1186/1471-2105-14-317  PMID: 24191891 
  24. Pineda-Peña A-C, Theys K, Stylianou DC, Demetriades I, Abecasis AB, Kostrikis LG. HIV-1 infection in Cyprus, the Eastern Mediterranean European frontier: a densely sampled transmission dynamics analysis from 1986 to 2012. Sci Rep. 2018;8(1):1702.  https://doi.org/10.1038/s41598-017-19080-5  PMID: 29374182 
  25. Delgado E, Benito S, Montero V, Cuevas MT, Fernández-García A, Sánchez-Martínez M, et al. Diverse large HIV-1 non-subtype B clusters are spreading among men who have sex with men in Spain. Front Microbiol. 2019;10:655.  https://doi.org/10.3389/fmicb.2019.00655  PMID: 31001231 
  26. Fabeni L, Alteri C, Berno G, Scutari R, Orchi N, De Carli G, et al. Characterisation of HIV-1 molecular transmission clusters among newly diagnosed individuals infected with non-B subtypes in Italy. Sex Transm Infect. 2019;95(8):619-25.  https://doi.org/10.1136/sextrans-2019-054017  PMID: 31076456 
  27. Sasse A, Florence E, Pharris A, De Wit S, Lacor P, Van Beckhoven D, et al. Late presentation to HIV testing is overestimated when based on the consensus definition. HIV Med. 2016;17(3):231-4.  https://doi.org/10.1111/hiv.12292  PMID: 26222266 

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