Short history/chronology in Norway (A)

The report is to analyse in detail the situation since 1995 until today, as well as future developments, but the historical context (since the beginning of the HIV epidemic) is important as well and should be shortly described in this section.

1.1 When and how did the HIV epidemic first appear into public awareness in your country?

Increased incidence of HIV in Norway amongst men who have sex with men began at the beginning of the '80s, and amongst intravenous drug abusers in the mid '80s. Increased incidence of HIV amongst heterosexuals became evident at a later stage, and was particularly characterized by increased incidence of secondary infection from the community of drug abusers.

The general public became more thoroughly acquainted with the problems of HIV/AIDS in the mid and late '80s through the media and information campaigns arranged by the Norwegian health authorities. Among the results were the following: the control program for the AIDS disease introduced by the Public Health Department of the Ministry of Social Affairs (Helsedirektoratet) (2 ^nd> of July, 1985), the Director – General of Public Health’s plan of action to combat the HIV infection (15 ^th> of October, 1986) and the Director-General’s plan of action against the HIV/AIDS epidemics 1990-1995 (15 ^th> of November, 1990). In addition, a considerable number of circulars and materials for guidance were prepared.

The Norwegian government's first plan of action for measures against the HIV epidemic was mentioned in the government's budget proposition for 1987, and earmarked funds for HIV/AIDS prevention work in Norway were granted.

1.2 When was the first case of HIV infection diagnosed in your country (before or after awareness of the problem)?

The first known incidence of HIV in Norway was that of a man who had probably been infected in Africa in the mid '60s. He infected his wife in Norway, who in 1967 gave birth to a HIV positive child. All three of them died in 1976 with symptoms similar to what we now recognize as indentifiable with AIDS-related diseases. There are a few known cases from the second half of the 1970s of heterosexual HIV infection among sailors and men who had been working in Central Africa. Few secondary cases have been detected among these early HIV cases in Norway. The HIV epidemic among Norwegian men who have sex with men probably started in the second half of the '70s as well. In this period, most were infected abroad -- particularly in the USA.

When was the first case of AIDS disease diagnosed in your country?

In 1983, two cases were diagnosed. These were the first official cases recorded.

1.3 When was the first information campaign (mass media) developed?Who were the target groups and when was it launched?

The national information work was started on a broader scale at the end of 1985. Since 1988, solidarity and informational campaigns connected to World's AIDS Day have been arranged on and around the 1 ^st> of December in each year. An earmarked sum from the Norwegian Parliament’s annual allocation to HIV/AIDS prevention work is reserved for these activities. Government funded World AIDS Day activities are coordinated by the Norwegian Board of Health and a committee of NGOs working in the area of HIV prevention.

While prior to 1986 the focus had been on the process of getting an overview of the situation and doing something about the sources of infection, the work thereafter was directed more towards public information concerning HIV/AIDS (which was given high priority). The Norwegian Board of Health hired, in 1986, a doctor in a full-time position to be in charge of the information, training and campaign activities. The same year, an information officer was employed.

The first comprehensive information campaign was launched in 1986. The campaign, which was directed towards the general public, had "safer sex with condoms" as its theme. The main objective of the campaign was to encourage people to use condoms, but at the same time to convey knowledge about how HIV is transmitted and equally important, not transmitted. Even though the target group was the general public, emphasis was also placed upon reaching those who were sexually active and without a permanent partner. The campaign, which was primarily a billboard campaign when first launched in 1986, was developed in a context where the Norwegian authorities visualized a dramatic escalation of the HIV epidemic in Norway.

1.4 When were the first legislation, official regulations or legal framework put in place? Please give a chronology of the development.

1860 - 1994 Act of 16 May 1860 relating to health commissions and measures in connection with epidemic and communicable diseases (Sunnhetsloven)

The Act relating to health commissions and measures in connection with epidemic and communicable diseases which was adopted in 1860, introduced new principles regulating how improved hygienic conditions should be implemented, and constituted the starting point of a new era in combating communicable diseases. The act was marked by a clear understanding of the importance of preventive work in a wider sense as an important means of combating communicable diseases. The act also expressed an understanding of the need for a wide legal foundation for the implementation of measures against known and unforeseen situations which might occur as a result of epidemics. The act was changed several times as a result of the introduction of specific acts on certain communicable diseases and other issues like e.g. mandatory vaccination as well as an accompanying comprehensive set of rules and regulations. Both the Act relating to health commissions and measures in connection with epidemic and communicable diseases and similar legislation on communicable diseases provided legal basis for a number of prohibitions and the use of coercion. The remaining parts of the Act relating to health commissions etc repealed when the Communicable Diseases Control Act came into effect the 1 ^st> of January, 1995. From that point on, it has been this act (the Communicable Diseases Control Act) which has defined HIV infection as one of several generally dangerous communicable diseases.

1986 Work on a draft for act on specific measures against the HIV

The Norwegian government decided in 1986 to prepare a draft for an act on specific measures against HIV infection. The draft was sent to various bodies and agencies for comments, and a considerable number of them were basically sceptical and negative to the need for a specific act concerning HIV. A general argument was the idea that the Act relating to health commissions etc, the General Civil Penal Code and the Protection of Psychiatric Health Act comprised sufficient basis for the use of enforcement measures in cases where these might be needed. Another argument was the fact that draft preparations of a new general act on communicable diseases control had come a long way, and the introduction of a temporary specific act on HIV would therefore not be advisable. In the process of considering the Report to the Norwegian Parliament no 29 (1987-1988) on the HIV/AIDS epidemic, the Parliament was favorable to the inclusion of new regulations (guarantee of due process of law, enforcement etc) concerning HIV in the new Communicable Diseases Control Act, and requested that this work be prioritized. Consequently, no specific act on HIV came into effect in Norway.

1990 NOU 1990:2 Communicable Diseases Control Act

The last specific act in the area of communicable diseases control (Act relating to vaccination) was adopted in 1954. From then on and up until the beginning of the 1980s, when the HIV epidemic became known, there was no significant public discussion pertaining to the enforcement measures provided for in the existing legislation. The absence of such discussion may be attributed to the fact that there were very few situations where the question of use of enforcement became a real issue.

When the HIV epidemic became known in Norway in 1983 - with the dismal prognoses given then - a discussion started about the measures needed to be taken by the authorities in order to restrain the continuing increase of HIV infection, and about the adequacy/suitability of the then current Norwegian legislation as an instrument in this respect. There were intense discussions between professional specialists, between specialists and authorities, between authorities and organizations, media and public. In the course of these year-round discussions, all enforcement measures known from existing legislation on communicable diseases were rehashed. This type of discussion was not particular to Norway, and was widely discussed in international fora. Some people wanted the entire Norwegian population to be tested for HIV, and others opted for obligatory testing of risk groups.

1995 Communicable Diseases Control Act (smittevernloven)

The Norwegian government presented in May 1993 a bill for a new communicable diseases control act (Ot prp no 91 (1992-93)). Due to its considerable workload, the Norwegian Parliament did not find time to consider the bill during the Spring session of 1993. The bill was re-introduced in January 1994 (Ot prp no 29 (1993-94)). Both draft bills were based on NOU (Norwegian Public Draft Report) 1990:2. The law came into effect on the 1 ^st> of January, 1995.

The Communicable Diseases Control Act is a general act which applies to all communicable diseases. The act is general as it comprises measures directed towards persons as well as objects/surroundings. The work to control communicable diseases includes necessary measures to prevent the occurrence of communicable diseases and their containment in the population/society and, in addition, provision of communicable diseases control assistance (diagnostic services, treatment and follow-up) to each individual patient. In other words, the act comprises both preventive and curative health services, and provides an important legal basis for Norway's public health work.

A distinction is made between generally dangerous and other communicable diseases. HIV belongs to a group of diseases classified as generally dangerous communicable diseases. A number of the act's regulations apply to this classification of diseases only. Among these are regulations concerning information and personal guidance on communicable diseases, exemptions from duty of confidentiality, examination of infected persons, tracing of sources of infection, duties of persons living with generally dangerous communicable diseases, enforcement measures and extensive right to communicable diseases control assistance.

According to the act, there are four main conditions which must be met:

In addition to being the main principle of the act, voluntary participation is a non-disputable pre-condition for the implementation of measures.

Secondly, each measure must have a clear foundation which is based on professionalism.

Thirdly, the measure must be vital in terms of communicable diseases control.

Fourthly, the measure must appear as useful when considered in a total context.

The implementation of enforcement is always decided by the National Commission for Communicable Diseases Control. Reference is otherwise made to the Communicable Diseases Control Act, which is enclosed.

1.5 When was the first AIDS related NGO founded (on regional or national level) or when did existing NGO´s include or concentrate their activities on HIV/AIDS related matters? What was the reason for the founding and development of NGO´s in this area?

Representatives from the community of men who have sex with men took responsibility for HIV prevention work at an early stage. They began organizing their efforts already in 1983 through their own health committee for gays (Helseutvalget for homofile, hereafter referred to as HU). HU was first established in Oslo, but was also active in other cities and smaller municipalities early on.

Men who have sex with men in Norway were well informed about the HIV-epidemic from the early '80s, through contact with professional communities and participation at conferences in the USA. A number of persons travelled privately and had contact with communities of men who have sex with men in American communities where HIV was widespread. Professional health workers with experience from the Norwegian community of men who have sex with men, came quickly into central public health positions, showed strong interests in preventive work and had good opportunities for active participation in its development. HU has been and continues to be a leading partner for health authorities in preventive work amongst men who have sex with men, and this cooperation between HU, the Public Health Department of the Ministry of Social Affairs (Helsedirektoratet) and the Oslo Health Board (Oslo helseråd) has been an important link in the overall preventive health initiatives for several years.

1.6 When was treatment for HIV/AIDS patients first available and put in practice? Which antiretroviral therapy was available and for whom was/is it accessible?

The Report to the Norwgian Parliament no. 29 (1987-88) on the HIV/AIDS epidemic (29 ^th> of January, 1988), maintains that healing/curative treatment for HIV infection and AIDS is unavailable, but that new medicines are being used which are clinically effective in terms of influencing the course of AIDS and other serious HIV infections (among others Zidovurin, previously called AZT). The report goes on to say that it is expected that several new medicines will be available in the next 2-year period (i.e. 1988-89). The Report presumes that future treatment forms will be complicated, complex and expensive,while - at the same time - non-curative.

The Report asserted that HIV-related illnesses and AIDS do not have a special status in terms of responsibility and obligations for planning, development and administration of initiatives, services and institutions at the municipal and county levels in regard to health legislation (i.e. the Act on Hospitals of 19. June 1969 no. 57 (Lov om sykehus), Act of 19 November 1982 no. 66 relating to municipal health services (Kommunehelsetjenesteloven) and Act of 16 May 1860 relating to health commissions and measures in connection with epidemic and communicable diseases (Sunnhetsloven)). Much of the health legislation has been changed since 1988. The Municipal Health Services Act of 1982 is still in effect, but a new Communicable Diseases Control Act was passed in 1995, as well as a new Act on Specialized Health Services (Lov om spesialisthelsetjeneste) in 1999. This legislation applies to persons with HIV/AIDS in the same respect as other persons needing health services in Norway.

Since the HIV/AIDS epidemic in Norway has, in many ways, been an Oslo-phenomenon, treatment of persons with HIV and AIDS has largely been confined to two hospitals -- the government-run Rikshospitalet (State hospital) and Norway's largest hospital: Ullevål sykehus (Oslo county), both of which are in Oslo. In 1987/88 all regional and larger central hospitals in Norway were given financial assistance for the purpose of improving their capacity in this area. Several hundred million Norwegian crowns were allocated to this purpose in the early phase of the epidemic.

In the course of 1996 combination therapy with antiviral remedies became available in Norway. Two types of antiviral remedies are in use: Nucleoside analogues and HIV protease inhibitors. Eight different antiviral remedies were registered in 1998. As HIV infection is classified as a generally dangerous communicable disease, it means that diagnostic work, treatment and follow-up are given to the patient free-of-charge. The Communicable Diseases Control Act is applicable to all persons with legal residential status in Norway, such that all have the same rights to HIV/AIDS diagnostic services, treatment and follow-up. See chapter 9 for further details.

1.7 When was the first needle exchange programme or any other low threshold measure for IDU´s implemented?

Because of the epidemiological development in Norway, focus on intravenous drug abusers as risk group was prioritized early on. In 1987-88 considerable funds were allocated as part of the then current plan of action to establishment of new treatment centers and fortification of existing initiatives for drug abusers, outreach and polyclinic-based programs, initiatives geared toward drug abusers in prisons, information initiatives and upgrading the qualifications of health personnel. Emphasis was, at the same time, placed upon improved availability of clean needles/syringes and condoms for this target group.

The AIDS information bus in Oslo ("Bussen") was established in 1989. The reason being the rapid spread of HIV amongst intravenous drug abusers, and that pharmacies in Oslo stopped selling needles/syringes to them in an effort to pressure the city to establish a better system for meeting the demand. The AIDS information bus has always been cooperatively financed by both the City of Oslo and the government. See evaluation of this initiative in sub-chapter 7.7.

1.8 Is there a significant shift from giving HIV/AIDS policy a special status and priority in health policy to a more normalised/equal status among other health problems? (Please give references.)

As mentioned in section 1.6 above, various HIV/AIDS-related questions and issues have been given varied emphasis. Diagnostic work, treatment and follow-up of persons with HIV/AIDS is considered to be an integrated part of the primary and specialist health care services at both the municipal and county levels as well as of communicable disease control initiatives. HIV/AIDS prevention work is also an integrated part of municipal health service entities' responsibilities according to health legislation. The municipal responsibilities in this area are clearly outlined in both the Act relating to municipal health services and the Communicable Diseases Control Act. At the same time, Norway has chosen to issue government plans of action supported by earmarked funds allocated yearly by the Norwegian Parliament. The current plan of action – Plan of Action for Combating the HIV/AIDS Epidemic 1996-2000 -- is applicable through 2000, and is the third such plan since the mid '80s. The then Minister of Health's preface to the current plan of action clearly states that a new plan of action period is truly not forthcoming. He assumes that the current plan of action will be the last of its kind, and that central health authorities, regional government administration, counties and municipalities will after 2000 assume their HIV/AIDS prevention responsibilities adequately - just as they are required to according to the Communicable Diseases Control Act. The Ministry of Health and Social Affairs has recently engaged Rogaland Research (Rogalandsforskning) to evaluate the effectiveness of the present plan of action. One of the objectives of this evaluation is to obtain a better foundation for deciding which form and content the national HIV/AIDS prevention policy and strategy will assume in the future.

We can also mention in that regard that discussion about "normalization" of HIV/AIDS policy, as well as "normalization" in terms of persons with HIV/AIDS being seen rather as persons with chronic illnesses, disabled/handicapped persons and the like is ongoing on many levels - letters to the editor and television and radio appearances by HIV/AIDS activists and organizations, meetings between Norwegian health authorities and NGOs, in international fora etc. Developments in treatment methods for persons with HIV/AIDS since 1996 and promising results in terms of reduced mortality and better health amongst persons with HIV/AIDS have also been an important contributing factor.

2 General policy on HIV/AIDS

2.1 Please list the current aims and main goals of the general policy on HIV/AIDS in your country.

The most important objectives in terms of behavioral and attitudinal work in connection with HIV/AIDS prevention initiatives have been the same for all plans for action, namely:

• To provide the population with knowledge about HIV/AIDS.
• To prevent behavior which can lead to infection.
• To prevent discrimination and exclusion of infected persons, and persons at risk for infection.
• To increase competency among health personnel and socialworkers.

In addition, the principle "Follow the virus" has been an important strategy in this work. See a description of this principle in chapter 7.

Since the HIV/AIDS epidemic first became noticeable in Norway in the early '80s, there has been comprehensive cooperation among health authorities on national, regional and local levels and with organizations and private persons who have been actively engaged in HIV/AIDS prevention work. Strategies and initiatives have been planned and developed largely by way of binding cooperation, and have been mainly administered by nongovernmental organizations. This is especially emphasized in the Plan of Action.

The Plan of Action for Combating the HIV/AIDS Epidemic 1996-2000 embraces 2 principal objectives, 12 specific objectives, 12 final objectives and, in total, 59 initiatives.

Principal objectives:

The number of people who become infected by HIV during the period 1996-2000 must be less than during the period 1990-1995. (10 specific objectives).

People with HIV and AIDS must have a better quality of life and a longer life expectancy than was the situation during the period 1990-1995. (2 specific objectives).

• The specific objectives for reduced prevalence of new infection encompass:
• Reduction of new infection primarily in known risk groups, but also among heterosexuals.
• Making sure that no blood or other human materials contain HIV.
• Making sure that good monitoring of the HIV/AIDS epidemic continues.
• Increasing the number of HIV-tests given to persons exhibiting risky behavior.
• Increasing condom use among persons exhibiting risky behavior, esp. through more availability.
• Easier access to clean needles/syringes.
• Reduced prevalence of sexually transmitted diseases.
• Maintaining the general population's understanding of HIV/AIDS. Young people and immigrants in particular.
• Providing better information about which HIV/AIDS preventive measures are most effective.

• The specific objectives concerning persons with HIV and AIDS encompass:
• Improving the financial and social circumstances of persons with HIV and AIDS. Not through special benefits, but rather by providing good information concerning rights and better availability of services in the health, social and social security systems.
• Implementation of initiatives that will influence the attitudes of personnel who come in contact with persons with HIV and AIDS to prevent discrimination and other problems. Maintain levels of competency among health and other personnel involved with treatment and care of persons with HIV/AIDS.
• Providing better medical treatment of persons with HIV and AIDS -- with documented effect.
• To stimulate research which can increase knowledge about factors which influence the course of HIV infection.
• To make special focus upon the health and living issues that concern women with HIV and AIDS.
• Strengthen the social network of persons with HIV and AIDS through e.g. financial support to organizations for HIV-positive persons.

It is important to note that principal objective 2, specific objectives, final objectives and initiatives do not encompass concrete measures related to medical treatment and follow-up by the health services network. The yearly earmarked allocations connected with the plan of action, are not meant to be used for e.g. expenses for medicinal treatment, hospital stays, curative primary health department services, or the like. These expenses are covered in the same manner as other health services: through reimbursement from the National Insurance Scheme and framework transfers respectively to county districts and municipalities.

2.1.1 Is there any predominant influence of either the Parliament, or governmental co-ordination, or non-governmental initiatives, or the law and justice system, or the churches, on HIV/AIDS policy?

Not to any apparent degree. After so many years with a national policy for HIV/AIDS prevention as well as a formidable and stable epidemiological situation, compared to many other countries and sectors of the world, relatively little attention is afforded HIV/AIDS issues. The Norwgian Parliament considers the Government’s proposals regarding earmarked allocations to prevention work each year, but there are otherwise few cases presented the Parliament which concern HIV/AIDS. One possible exception is the presentation of questions to the Parliament's "question time", but HIV/AIDS-related activity has been minimal, nonetheless, in recent years.

2.1.2 Did you observe or do you expect a significant change of policies following the last national elections or changes in government?

No. The HIV/AIDS prevention policy has been largely the same since the mid '80s, despite a variety of governments with varied political backgrounds and compositions. No major changes are expected as a result of municipal and county council elections in the autumn of 1999.

2.1.3 Is there any theoretical framework behind the general policy (like e.g. the Health Belief Model, the Social Cognitive Theory, the Theory of Reasoned Action, or the Diffusion Theory)?

No.

2.1.4 Is there any other important factor(s) of influence on your countries policy to mention?

No.

2.2 Is there a strategic plan or any other national document available, which describes the HIV/AIDS politics and policy? (Please send a copy of the actual version).

Enclosed is the Norwegian Ministry of Health and Social Affairs' Plan of Action for Combating the HIV/AIDS Epidemic 1996-2000. An abridged version, translated to English, French and Spanish, is also enclosed. Please note that these translated versions are directed to foreign language speaking persons in Norway.

2.3 How are national policies formulated?

The work process exemplified by the Plan of Action for Combating the HIV/AIDS Epidemic 1996-2000 is a good example of how we work in Norway. It was organized in the following way:

The Ministry of Health and Social Affairs led and administered (with a secretariat) a steering committee consisting of experts from the Ministry of Health and Social Affairs, the National Institute of Public Health and the Norwegian Board of Health. A large reference group was also involved in this work. The reference group consisted of approximately 40 participants representing a broad range of professionals and other interested parties (NGOs, county medical officers, hospitals, primary health services, outreach programs, immigrant communities etc.). Four full meetings between the reference group and the steering group were held. The reference group was also invited to the Norwgian Research Council’s presentation of an evaluation project concerning HIV/AIDS prevention work up until 1995. Much of that which is written in the Plan of Action reflects the magnitude and variety of persons involved in the working process, and further shows that there have been extensive possibilities for expression of varied interests and freedom of opinion in the course of the work.

2.3.1 Please describe the influence, if any, from vulnerable groups on national policies.

We thus refer the reader to chapter 1, to the introductory comments to sub-chapter 2.3 and to other parts of the report.

2.3.2 Are international organisations’ (EU, UNAIDS, WHO, etc.) policy recommendations instrumental to policy changes in your country? If yes, please describe.

Yes, and no. Norway is a participant in five of the European Union's public health programs, one of which concerns prevention of AIDS and certain other communicable diseases. The National Institute of Public Health participates in several international programs and projects in the area of communicable diseases. The director of the Norwegian Board of Health is a member of WHO's board, and is Norway's formal representative (member of the Executive Board). The Norwegian Board of Health has participated for many years in international HIV/AIDS work, both through WHO and UNAIDS (in cooperation with the Ministry of Foreign Affairs and NORAD). The Norwegian Board of Health is currently cooperating with Botswana on a project concerning, among other things, HIV/AIDS. The degree to which international contact (oral and written) has influenced and influences Norwegian HIV/AIDS policy is difficult to measure.

2.3.3 Is there any other country, which influenced your national policy in terms of being used as a model? If so, which?

No one country in particular but we have, through the years, obtained information, inspiration and ideas from Denmark and Sweden, which have both similarities and dissimilarities to Norway.

2.4 Please describe the development of policy since the emergence of the HIV epidemic and identify relevant influences contributing to evident changes.

2.4.1 Are there some links with policies and practices concerning other communicable diseases (STD's, viral Hepatitis, TB etc.) If yes, please describe.

Yes. We too (in Norway) have become increasingly concerned with grouping HIV/AIDS prevention and prevention of sexually transmitted diseases under the same umbrella. Much of the HIV/AIDS prevention work will become a part of the prevention work directed at sexually transmitted diseases and Hepatitis, and vice versa. This is expressed in the Plan of Action, and is otherwise exemplified in the way that HIV/AIDS prevention work is organized at a central level.

2.4.2 Are there links with other subjects of health promotion/education (sexual education, prevention of unwanted pregnancies etc.). If yes, please describe.

Yes. We have had, for many years now, plans of action for prevention of unwanted pregnancies and abortion, and it has always been presumed that the same type of efforts for the same target groups would be coordinated with the Plan of Action for Combating the HIV/AIDS Epidemic. This is particularly relevant in regards to young people - through school and teaching. However, we have not been as successful as we would have liked to have been in this particular area.

2.5 Has there been an evaluation process of national prevention measures? Who is responsible for those evaluations (independent or external body, etc.)? (Please send a copy of one of the recent national evaluation reports).

The Norwegian Board of Health's HIV/AIDS prevention work up until 1994 was evaluated in 1994-95 by Rogalands Research (Rogalandsforskning), the Hemil Center (Hemil-senteret), the University in Bergen and the University in Oslo's Institute for Sociology, on behalf of the Norwegian Research Council (Norges forskningsråd).

Several independent evaluations of many of the larger organizations and initiatives have been undertaken in the past couple of years. We can mention, in particular, evaluation of HIV prevention work as regards men who have sex with men (projects/initiatives conducted by HU and Pluss), evaluation of the AIDS information telephone and the AIDS Information Bus ("Bussen").

This autumn, the Ministry has contracted Rogalands Research to conduct an independent evaluation of the policy effectiveness of the Plan of Action for Combating the HIV/AIDS Epidemic 1996-2000. An interim report will be available by the end of the year (i.e. 1999), and the principal report is to be finished by the 1 ^st> of December, 2000. All of these evaluations are financed by earmarked funds allocated to HIV/AIDS prevention work, and have come about upon assignment from either the Ministry of Health or the Norwegian Board of Health. These evaluations have been undertaken by professional research and evaluation institutions.

Some of the NGOs have (by their own initiative) arranged for evaluations of parts of their operations. These evaluations are also mostly financed by government allocations to HIV/AIDS prevention work. Enclosed are examples of evaluation reports which exemplify both the quality of evaluation and range of projects evaluated. We would otherwise direct the reader to 7.7, concerning "Bussen".

2.6 Are some national policies triggered from the bottom (vulnerable groups, communes or regions)? How?

We direct the reader to several of the points above. Groups at risk have always been involved in HIV/AIDS prevention work, and have often started up projects at their own initiative.

In the earlier phase of the epidemic it was more common that municipalities, county districts, county medical officers, outreach programs etc. took initiative in terms of designing strategies and starting projects. The City of Oslo has been especially active, due to the disproportionately large incidence of the epidemic experienced in Oslo as compared with the rest of the country.

The African communities have been active since the summer of 1996 and have, eventually, received quite a lot of funding from governmental health authorities.

3 Institutional structures of policy implementation

3.1 Which institutions/organizations are responsible for policy implementation (on the national and/or on the regional and/or on the local level) and how do they have policy implemented? What are their roles (auditing, enforcement, limitations, etc.)?

The Ministry of Health and Social Affairs is responsible for policy development, allocation of funding to underlying public service units and coordination of HIV/AIDS prevention policy. The Norwegian Board of Health and the National Institute of Public Health are delegated responsibility for enactment of political initiatives. The Norwegian Board of Health is allocated most of the Norwegian Parliament’s yearly appropriation for this purpose. These funds are further allocated (upon application) to nongovernmental organizations, the Info-phone on AIDS, the AIDS information bus project, the City of Oslo, the Community Outreach resource group for AIDS, county medical officers, etc. The Norwegian Board of Health has administrative responsibility for recipients of public health assistance funds, gives professional advisement and guidance, and follows up on accounting and professional reports. The National Institute of Public Health conducts its own research and planning activities, administers the MSIS health surveillance system (Norwegian Surveillance System for Communicable Diseases) and AIDS information entity, etc.

As of this year, the Oslo county medical officer has been given responsibility for following up several of the entities which conduct preventive health work in Oslo.

We do not have a detailed overview of the specific activities in each of the country's cities and towns. The HIV/AIDS issue is not equally relevant in all municipalities, and each municipality (naturally) makes its own priorities amongst those areas of most concern in their community. We do know that work geared toward surveillance of communicable disease and emergency readiness is not adequate everywhere, and that it is in many places difficult to realize professional competency and continuity in the provision of health services. It is, therefore, a considerable challenge to enable the cities and towns to fulfill their obligations in this area as fully as possible.

3.2 How are the roles distributed between different types of organisations (public institutions/NGOs) and between national, regional and local levels? Is there a co-ordination between the different levels?

See table 7.4 and the plan of action which explain who has primary responsibility, supporting responsibility etc. for each short-term and final objective.

As previously mentioned several places in this report, virtually all HIV/AIDS prevention work is conducted by external agencies and organizations. With the exception of the work of the National Institute of Public Health (see 3.1 and table 7.4), national governmental institutions do not participate actively with this work but rather channel resources and professional expertise to 1) nongovernmental organizations, 2) municipal agencies and 3) county medical officers.

The Norwegian Board of Health has previously had regular yearly meetings with the county medical officers, but there is little need for such as the epidemic in Norway has remained stable and the level of prevention activity has been reduced accordingly nationwide. At this point in time, there is no regular established coordinating forum where the various HIV/AIDS agencies and organizations can meet. However, the Ministry of Health and Social Affairs plans to hold two meetings per year on a regular basis where issues of common interest can be discussed. Recipients of public health assistance funds have continuous contact with the Norwegian Board of Health and have also periodic direct contact with the Ministry of Health and Social Affairs. Many of the largest recipients of public health assistance funds have had meetings with the Minister of Health on specific issues.

3.3 Are there structural deficiencies, or barriers? If yes, please describe.

There are diverse opinions concerning this question. An illustration of various problem areas follows:

Employment of time and resources to wind down initiatives is equally as important as setting new initiatives into motion.

When the HIV/AIDS epidemic was considered to be a larger societal problem, and considerable funds were allocated to prevention, corresponding resource levels were readily available in terms of (among other things) personnel allotment. The stable and relatively favorable situation we have attained has understandably led to reductions in both societal and political engagement in accordance with the resulting consequences for employment of government resources. This pertains as well to reductions in funding and personnel on a central level. This is perceived to be a reasonable development. However, it is possible that given the phase that we are now in, with the winding down of 15 years of government plans of action, there should be allocated greater personnel resources in order to prepare more adequately the process of winding down and transition to something new in a good and professionally justifiable manner. Much of the HIV/AIDS prevention work in Norway has been in the form of projects which have not been followed up after they have been concluded. Much has fallen away without a trace, without being made into permanent initiatives. We hope, among other things, that the ongoing evaluation will contribute to a satisfactory and smooth transition from project to process.

Unclear relationships amongst governmental health authorities regarding responsibility and tasks.

The government's responsibility for protection from communicable diseases, here specifically HIV/AIDS, has in part been characterized by lack of clarity for many years. Even though we have in the plan of action attempted to establish primary responsibility, co-responsibility and supporting responsibility for short-term and final objectives and initiatives, some clarification work remains. What shall be the responsibilities of the Ministry of Health and Social Affairs, the National Institute of Public Health and the Norwgian Board of Health in the time to come?

The gap between desire and governmental allotments.

In the epidemic's earlier phases, the two previous plans for action called for considerable employment of government funds. It was easy to obtain funding for projects, and there were formidable conditions for testing and error. Year after year there were large sums of government monies which were not used, but rather transferred to the budget for the upcoming year. The situation at hand is now reversed. There is little room for testing new initiatives without at the same time winding down / reducing something else. That is to say that we now, in many ways, are standing still and have few resources at hand for innovation.

The relationship between governmental health authorities and nongovernmental organizations.

Some of the nongovernmental organizations desire a direct relationship with the Ministry of Health and Social Affairs instead of the Norwegian Board of Health. The large nongovernmental organizations which are wholly or partly financed by the national budget are understandably concerned about their levels of funding from one year to the next. All of these organizations are very worried about what will happen from the year 2001, when the current plan of action period is over. Several of these organizations have in the past couple of years sent in appeals for reconsideration of funding allotments. There have also been appeals directly to the Parliament and to the Parliamentary Committee on Social Affairs.

Competition between organizations.

There has been a certain competition for government funds between the larger public assistance recipients, and there has also been registered competition among initiatives in equivalent areas. For quite some time, there has been criticism from various entities that prevention work aimed at men who have sex with men (through the Gay Men's Health Committee) is so highly prioritized, while other organizations which are concerned with other target groups are consistently given less priority.

Will the municipalities prioritize HIV/AIDS prevention work?

See mention of this concern in subparagraph 3.1.

Uncertainty concerning policy and strategies from 2001.

Everyone is uncertain about what will happen from 2001 onward. There is no question that the government will have an HIV/AIDS policy and strategies to realize policy objectives. However, structure, content, organization and financing issues are yet to be clarified.

4 Please summarise the legal aspects regarding:

The Norwegian General Civil Penal Code (Straffeloven) is a general statute. It does not include any special provisions in regard to HIV/AIDS. However, to knowingly expose another (person) to a sexually transmitted disease and generally dangerous communicable disease is, according to The Communicable Diseases Control Act §1-3 no. 3 cf. no. 1, always considered as significant harm to human body and health as per The General Civil Penal Code's chapter 19 on sexual offenses and is thus subject to the law's jurisdiction (The General Civil Penal Code of 1902, 22 ^nd> of May no. 10). HIV is as mentioned above a generally dangerous communicable disease. There have been very few such cases in Norway: only one case since 1995.

The Communicable Diseases Control Act is also a general statute which does not have any special provisions for HIV/AIDS. The Norwegian Social Security Act (Folketrygdloven) is referred to in section 9.3. The act provides all persons with legal residence status in Norway with the right to benefits.

4.1 Drug use (pharmaceutical regulations, criminal acts or customs regulation)

The General Civil Penal Code § 162 penalizes as narcotics offenses with fines or with incarceration that person who illegally manufactures, imports, exports, keeps in their custody, sends or transfers substances considered to be narcotics.

The Act on Pharmaceutical Medicines (Legemiddelloven) provides that the King establishes which narcotic substances are encompassed by the act. It provides regulations on manufacture, trade, and so on. (The Act on Pharmaceutical Medicines of 1992, 4 ^th> of December no. 132, chapter VIII). The Act on Tariffs (The Act on Tariffs of 1966, 10 ^th> of June no. 5 (Tolloven)) encompasses import of narcotics.

4.2 Homosexual/bisexual behaviour (age of consent, recognition of gay marriages)

The minimum legal age for sexual consent in Norway is 16 years. This applies regardless of sexual orientation. (The General Civil Penal Code of 1902, 22 ^nd> of May no. 10).

The Act on Partnership (The Act on Partnership of 1993, 30 ^th> of April no. 40 (Partnerskapsloven)), which came into effect August 1, 1993, gives provision for registration of partnership between two persons of the same sex and with the same sexual orientation, with full legal effect according to the act The Act on Adoption's (The Act on Adoption of 1986, 28 ^th> of February no. 8 (Adopsjonsloven)) rules on married partners do not apply to registered partners.

4.3 Sex workers (legal status, measures of mandatory health control)

It is not illegal to sell sexual services, and neither are commercial sex-worker activities seen as an income giving profession for taxation purposes. It is not illegal to buy sexual services, but it is a criminal offense to earn money from others' sex-worker activities (i.e. pimp operations). There is no provision for health control and the like for persons who sell sexual services. (The General Civil Penal Code of 1902, 22 ^nd> of May no. 10).

4.4 Youth (regulation of legal drug use, sexual behaviour, sex education)

The age of majority in Norway is 18 years. Upon attainment of majority age one is recognized as an adult with voting rights, the right to marry, liability to military service and so on. (The Act on Guardianship (Vergemålsloven) of 1927, 22 ^nd> of April nr. 3).

One exception is that sale, serving or delivery of liquor is prohibited to persons under 20 years of age. The sale of beer and wine is, meanwhile, permitted to persons 18 years of age and older. (The Act on Alcohol (Alkoholloven) of 1989, 2 ^nd> of June no. 27).

The age of criminal responsibility is 15 years. That is to say that no one under the age of 15 years can be penalized for criminal activities under the General Civil Penal Code.

Education concerning sexuality, cohabitation and the like is given to a certain degree at the primary school level, and is an obligatory subject at the secondary school level. (The Act on Teaching (Opplæringsloven) of 1998, 17th of June no. 61).

4.5 Migrants (obligations to undergo any form of health screening on entering the country)

Apart from obligatory control for tuberculosis, there is no obligatory health examination upon arrival in Norway. Immigrants/refugees/asylum-seekers are offered a health examination, including an HIV-test, upon arrival. It is easier to reach those who arrive at centers for asylum-seekers and refugees with this type of offer of medical examination. Again it must be emphasized that this constitutes an offer of services, and not a coerced examination.

The following questions specifically address changes of the legal aspects with respect to HIV/AIDS.

4.6 Have there been changes of laws / regulations as described above in response to HIV/AIDS?

No, not since The Communicable Diseases Control Act came into effect on the 1 ^st> of January in 1995. (The Communicable Diseases Control Act of 1994, 5 ^th> of August no. 55) cf introduction.

4.7 Prisoners (mandatory screening, availability of condoms and needles/syringes)

Non-obligatory testing of HIV-status. It is forbidden to use narcotics in Norwegian prisons. There is to be the possibility of cleaning needles/syringes in prisons, even given that needles/syringes are not allowed. There is no special provision for dispensing condoms in Norwegian prisons.

4.8 People living with HIV/AIDS (disability act, active-discriminatory act etc.)

There are no laws/resolutions which concern persons with HIV/AIDS specifically.

4.9 Health care professionals (regulation on hygiene, screening)

See mention of this under 9.1.

4.10 Other vulnerable groups (specify for example street children, refugees, people with STD’s (sexually transmitted diseases), children in institutions etc.)

There are no new legal resolutions, regulations or the like concerning HIV/AIDS and specific groups.

5 Epidemiology

5.1 How are the epidemiological data on HIV/AIDS in your country fed back to the users, and used or not for decision-making at the different levels of the system (local/communal/vulnerable groups, regional/intermediary, national)? If not: reasons, plans?

Regular updates on the HIV/AIDS situation in Norway are included in the weekly MSIS (Norwegian Surveillance System for Communicable Diseases) report, which is sent to the nation's physicians, hospitals, local and central health authorities, organizations working with HIV/AIDS issues, the most important news media etc. The report is also available on internet. At least twice a year the HIV/AIDS situation is presented in a more thorough manner with analyses and commentaries concerning the epidemiological development and recommendations for preventive measures. Data on HIV/AIDS is systematically presented in the national plans of action against the HIV epidemic and in national budgetary documents. The data is frequently presented in medical journal articles, and in other specialist periodicals for the health sector. HIV/AIDS data is also regularly presented in the news periodical "AIDS-Info" (National Institute of Public Health), and is often cited by local and national news media.

5.2 Please outline any possible developments in HIV prevention policy arising from:

a) The evolution of the epidemic (in the population at large and among specific groups)

In Norway we have consistently attempted to prioritize and direct prevention measures toward the most vulnerable groups, while at the same time maintaining a high level of consciousness concerning HIV/AIDS in the general population. Public plans of action and economic appropriations have been adjusted yearly in proportion to the epidemiological situation. See the chapters on prevention and sub - chapter 6.3 for further details.

b) The epidemiological trend (prevalence and incidence data on HIV infections, AIDS cases and deaths). Please specify if any changes in the definitions of HIV or AIDS occurred (which, when, and effect in interpretation of data)

See the above paragraph concerning changes in epidemiological trends and the consequences for HIV prevention. Norway has consistently employed the European definition of AIDS. Changes in diagnosis criteria have not led to considerable higher incidence of AIDS, and have therefore not influenced the prevention strategy either.

c) Advances in anti-viral therapies (e.g. has the introduction of new drug treatments had any negative effects on HIV prevention interests, support etc. - Please describe)

The good effect of the new treatment forms against HIV is actively promoted by health authorities in order to stimulate possible HIV infected persons to be tested. The health sector is encouraged to increase efforts for faster diagnosis of HIV positive persons by way of active infection source tracking, etc. It appears as though the somewhat ideologically contingent resistance to HIV testing ("there is no curative treatment anyway") within specific risk groups and their interest organizations has also been reduced, and that there is more active promotion for taking HIV tests. There exists no documentation of possible negative effects for HIV prevention, as connected to the new HIV treatment forms.

d) Other remarks (if any)

No additional remarks.

6 Surveillance System

6.1 Please describe the surveillance and monitoring system of HIV and AIDS in your country

HIV infection and AIDS are overseen in Norway by the National Institute of Public Health through the Norwegian Surveillance System for Communicable Diseases (MSIS).

Obligation to report HIV infection was put into effect in August 1986, and was given retroactive status. Everyone who has been diagnosed as HIV positive in Norway since HIV testing began in 1985 is, therefore, registered in the system. HIV infection is reported by the patient's physician on a specific form, but without specification of the patient's name and complete date of birth. The data specified includes gender, month and year of birth, city or town of residence, indication of the HIV test, clinical conditions, date of any previous negative HIV tests, as well as detailed information regarding presumed terms of infection, place of infection and time of infection. The report form for HIV infection is sent to the HIV positive person's physician from one of the country's five reference laboratories, which shall always confirm an HIV positive test. Each HIV report form is given a unique number. The reference laboratory concurrently sends notice to MSIS which states which physician shall receive the report form, the report form number, the patient's gender, month and year of birth, as well as information concerning any previous negative HIV tests for that particular patient. This enables the possibility of contacting the physician, should MSIS not receive a report within a reasonable period of time. The report coverage is therefore 100% in practice. All incoming HIV reports are carefully controlled against previous reports to exclude double reporting. In cases of doubt or where the HIV form has not been satisfactorily completed, the physician who has submitted the report is contacted.

Obligation to report AIDS incidence in Norway has existed since the first cases were diagnosed in 1983. AIDS is reported on a specific form and with the patient's full name. In addition to clinical information concerning the basis for the AIDS diagnosis, corresponding epidemiological information is given on the HIV report form. Also given is information on previous HIV reports so that this information can be coupled with information in the AIDS report. In Norway, AIDS diagnosis and treatment are, in practice, centralized to our five university hospitals or a few larger central hospitals with infectious disease units. This makes possible close contact between MSIS and infectious disease unit personnel in order to ensure 100% report coverage, good quality of data and continuous updates regarding mortality amongst AIDS patients.

As a component in its surveillance of HIV incidence and prevalence in the general population, MSIS also continually gathers data regarding the number of HIV tests undertaken by the country's laboratories as well as the results of HIV screening of blood donors, pregnant women and military recruits.

A short summary of the epidemiological situation: As of December 31, 1998 MSIS has reported all in all 1869 HIV positive persons and 639 cases of AIDS, whereof 509 are reported as deceased. The HIV situation in Norway has in the 1990s been quite stable, with around 100 new HIV cases diagnosed each year. The estimated HIV incidence in the Norwegian population is also around 100, with the following distribution: 40-50 new cases amongst men who have sex with men, 10-15 amongst intravenous drug abusers and 20-30 amongst heterosexuals. The incidence is, in all probability, slightly on the incline amongst heterosexuals; but amongst men who have sex with men and intravenous drug abusers the incidence has been either stable or slightly reduced. Extensive outbreaks of hepatitis A, B and C amongst intravenous drug abusers since 1995 causes concern for increased HIV infection in that group. Screening of blood donors, pregnant women and military recruits has not shown increasing prevalence of HIV in the 1990s and gives indication of low HIV spreading in the general population.

The yearly incidence of AIDS in Norway was around 50-60 up until 1997, but went down to about 30 cases in 1997 and 1998. Yearly case fatality rates were also reduced by 50%. The "three-years-survival with AIDS" incidence increased from 20% for those who were diagnosed with AIDS before 1996 to 62% for those who were diagnosed with AIDS after 1996.

The enclosed report "Surveillance of communicable diseases in Norway 1998" gives an overview of the HIV/AIDS situation in the country as of 31.12.1998.

6.2 Describe the strengths and weaknesses: Any parallel system(s), redundancies, etc.?

We consider the Norwegian surveillance of HIV/AIDS to be optimally developed and adapted to the possibilities and benefits connected with a wealthy country with a small, relatively homogenous population and with a well-developed public health service. It is emphasized that surveillance not compromise protection of privacy or make testing of persons at risk for HIV infection less attractive. Close cooperation between MSIS, the laboratories and the physicians that diagnose HIV/AIDS assures a very high level of quality of epidemiological data. In practice we can, with a high degree of confidence, calculate incidence and prevalence of HIV infection and the number of undiagnosed HIV infected persons, both within specific risk groups and in the total population. There is no parallel surveillance of HIV/AIDS in Norway. The anonymous HIV report can point to a possible weakness which requires resources in order to exclude double reporting. Anonymous reporting also limits the possibility of coupling the HIV register with other registers in regard to research. Also, due to reasons based upon protection of privacy, copies of HIV or AIDS reports are not sent to municipal health authorities (as is the case with reports of other serious communicable diseases). This can lead to local communicable disease control physicians not being as actively involved in HIV prevention and follow-up of HIV infected persons as would be desired. All in all, we still consider the benefits of anonymous HIV reporting to be greater than the disadvantages.

6.3 Please outline any possible developments in HIV prevention policy arising from the Surveillance Systems(s).

National and local strategies and plans of action for HIV prevention have been continually related to the epidemiological situation. Examples being a strong focus on such risk groups as men who have sex with men and intravenous drug abusers from the mid-80's to increasing focus upon heterosexual infection, in the 90's especially related to Norwegians infected with HIV while residing i high-endemical areas or refugees/immigrants who come to Norway from high-endemical areas. The governmental earmarked allocations to HIV/AIDS prevention have been generally reduced in the 1990s as the epidemic proved to be much less widespread than previously presumed, both in the general population and amongst those social groups most at risk. At the same time, efforts have been made to protect prevention measures aimed at those groups most at risk from further budget cuts.

7 Please describe the system of primary HIV prevention in your country (information/ education, counselling, means of protection)

7.1 In terms of strategies, programmes and activities, what are the policy priorities? Are there any gaps between policy priorities and the implementation of those? If yes, please describe and comment on the possible reasons.

See chapters 1-6 for further particulars concerning strategies, programs and activities, and the epidemiological situation. The principle "Follow the Virus" has been, and is, one of the strategies emphasized in HIV prevention work in Norway. The principle involves identifying where the virus is, or where it will most likely spread to, and setting initiatives in motion accordingly.

7.2 Are there priority (or special/vulnerable/risk) groups? If yes, what are the policy priorities for those? Are there any gaps between policy priorities and the implementation of those? If yes, please describe and comment on the possible reasons.

7.3 For each of these priority groups what strategies, programmes and activities are they involved in, or how are they approached?

In accordance with the "Follow the Virus" strategy, we have ranked the various groups according to risk:

Men who have sex with men is the group which has been most highly prioritized since the mid 80s. This group is reached by way of various information channels, including HU (Helseutvalget for homofile) which is financed by government funds, and which works solely with sexually transmitted diseases. Pluss (nationwide interest and self-help organization for HIV-positives) has its own activities directed toward men who have sex with men. There are, otherwise, several other organizations for men who have sex with men and women who have sex with women which have initiatives concerned with HIV and AIDS. A monthly newspaper (Blikk) and a periodical (Løvetann) - both directed toward men who have sex with men and women who have sex with women - have earlier written about HIV on a regular basis. More recently there has been less attention given to HIV/AIDS in these publications.

Intravenous drug abusers. The incidence of new infection amongst this group has decreased significantly in recent years. It is assumed that important factors leading to a limiting of risky behavior include the following: distribution of clean needles/syringes and condoms, a well-organized arrangement for returning used needles/syringes and the personal practices of the intravenous drug abusers (including being "open" about their HIV status, and using the needle/syringe last if it is not possible to avoid sharing). The spread of Hepatitis A and B indicates that many in the intravenous drug abuser community share needles/syringes, and that continued prevention work is necessary. Needles/syringes are distributed free of charge or at a minimal cost by several means: automated vending machines, low-cost (health services) outlets or, as in Oslo, by way of a mobile unit ("Bussen"). Condoms and lubricants are also distributed. See also sub-chapter 7.7.

A significant number of Persons with HIV/AIDS are members of the nationwide interest and self-help organization Pluss-LMA. Up until July of 1999, these were two separate organizations with two different purposes: Pluss and Landsforeningen mot AIDS (the National Association against AIDS). Pluss is highly prioritized in terms of HIV prevention work. The organization conducts information initiatives (internally and externally), and spreads information about safer sex and what it is like living with HIV/AIDS. The organization has support and care functions for its members, and works with prevention in many diverse ways. LMA has been an umbrella organization for various types of larger and smaller member organizations, and has primarily had as its objective to mobilize the public, increase knowledge about HIV/AIDS through information and awareness campaigns, and so on. The new combined organization has retained both of the previous organizations' objectives. Pluss-LMA is central in providing persons with HIV/AIDS with a mouthpiece and a positive group identity in the greater society.

Asylum-seekers, refugees and immigrants with limited knowledge concerning Norwegian language and culture have had more difficulties in terms of gaining information about HIV/AIDS than the Norwegian population. Some persons in this category come from countries with a high prevalence of HIV, and some may be infected. Proper attention to the needs of this group upon arrival in Norway is therefore of utmost importance. Foreign language speaking information specialists and health personnel have provided information about HIV/AIDS and control of communicable diseases to these persons in many ways for several years, including information campaigns held at numerous refugee centers and language/cultural training institutions for immigrants. In recent years – namely since 1996 - there has been much activity within the African community in terms of initiatives directed towards increasing knowledge about HIV/AIDS. Most of this work has been done through outreach programs by and for Africans. We can name, among others, African Health Team (a project of Olafiaklinikken - the City of Oslo's sexual disease prevention/treatment clinic) and the Oslo Red Cross International Center - both of which are quite central to this work.

Sex workers are a very important target group since many sex workers are, in addition, intravenous drug abusers. Sex workers who have several customers could represent a major risk element in terms of further transmission of HIV by way of unprotected sex. We have seen very little spread of infection in Norway from this community, and we continually emphasize the importance of maintaining adequate levels of prevention work where sex workers are concerned. In addition to the ordinary city-sponsored initiatives directed toward this group, PION (the Sex Workers' Interest Organization in Norway) is very active in terms of HIV/AIDS prevention work. They conduct outreach programs several places where female sex workers operate: on the streets, at massage parlors and clubs, and also work actively at reaching out to foreign women who are working as sex workers in Norway. They also work actively with male sex workers. Another active organization is Oslo's PRO-center. This center is a competency and resource center for issues concerning sex workers in Norway, and runs a day center and overnight shelter for sex workers.

Foreign aid workers. In the middle of the 1990s a number of foreign aid workers were found to be HIV positive (through heterosexual transmission). These were primarily persons who had worked over a longer period of time in countries with a high prevalence of HIV, and where the risk of infection was, therefore, higher than other places. A specific plan of action was developed, in cooperation with NORAD, where foreign aid workers in countries with a high prevalence of HIV were instructed as to how they could better protect themselves from the virus.

Intravenous drug abusers in prisons. Use of narcotic substances is not permitted in Norwegian prisons. There is, therefore, no legal access to clean needles/syringes in the prisons. Nonetheless, it is widely known that intravenous drug abuse occurs in Norwegian prisons. As part of their measures to prevent further transmission of infection in the prisons, health authorities have introduced various prevention initiatives, including providing access to possibilities for cleaning used needles/syringes.

Health workers. This group is primarily at risk for HIV infection by way of accidental skin punctures at work. The general hygienic measures and work methods shall be so certain that HIV transmission by way of direct contact with infected blood does not occur in one's work environment. Health workers are also expected to have knowledge about the usage of secondary prophylactics, and they shall have access to post exponential prophylactics, as described in chapter 9.

Young people have seldomly been infected by HIV in Norway. Approximately 50.000 young persons have their sexual debut each year, and the health authorities in Norway have placed great emphasis upon the importance of the coming generations having basic knowledge about sexually transmitted diseases, so that they know how to protect themselves against diseases such as HIV. This information is given primarily through schools, and social and health initiatives directed towards young people. In many municipalities public health centers for young people have been established, where issues such as STDs and HIV/AIDS are discussed and worked with. Sex education courses and initiatives meant to prevent unwanted pregnancies at learning institutions also focus upon STDs, including HIV. Many outreach programs aim to reach youth at special risk.

The general population. Health authorities are very much aware of the importance of the general population obtaining good knowledge concerning what HIV is, and how the virus is (and is not) transmitted. That portion of the population which is sexually active shall have adequate knowledge concerning how one can protect oneself. The general population is continually updated concerning transmission patterns, such that one can have the possibility of having insight regarding levels of risks in the various situations one eventually may find oneself in. Each year, UNAIDS’ World Aids Day is celebrated nationwide. This is the largest yearly campaign concerning HIV/AIDS. Last year (1998) there were 31 events held at 13 different geographical areas in Norway. Media coverage and the high level of public participation at the various events is an important factor in maintaining consciousness about HIV in Norway, and the need for solidarity throughout the world. The events planning committee consists of 10 organizations who work in the area of HIV prevention. The Norwegian Board of Health coordinates the work. The AIDS information telephone is a government-run "hotline/helpline" to which the general population can call in order to pose questions concerning risk of HIV infection.

7.4 Who does what? (public sector, e.g. different Ministries, and private sector, e.g. NGOs: Non-Governmental Organisations, PVOs: Private Voluntary Organisations, Associations, Businesses etc.) Please give quantitative information (e.g. how many NGOs…), as well as qualitative information (e.g. role of some of the key actors from the public and private sector).

See table 74. Otherwise see earlier chapters.

7.5 Which campaigns have been carried out or are on-going since 1995, their target groups, and their effects (if known)? Please set a chronological list, if possible.

The most important campaigns are presented in table 7.5. It is often difficult to make a distinction between campaigns and ongoing information initiatives. For that reason, this overview is far from exhaustive.

7.6 What are the main preventive messages for the campaigns focused on today? Please specify (e.g. knowledge of the disease, knowledge of the correct/ incorrect modes of transmission, accessibility to testing, limiting the transmission of the virus…)

See the above chapters. The continuous prevention work directed toward the groups who are supposedly at highest risk should be carried on. As mentioned earlier, the information directed towards the general population is not as focused as was the case when the HIV epidemic first started in Norway. Many are of the opinion that this work must be strengthened and given a higher priority in prevention policy.

7.7 Please describe 1 to 3 examples of the best and most recent small or large scale prevention projects (information/education campaigns, counselling, means of protection), including the materials and/or media used (leaflets, posters, TV spots, radio, printed media advertisements, arts…) identifying the aim of the project (changing knowledge, attitude, practice…), and the targeted groups (general, priority groups…).

Example of best projects: needle exchange, prevention and commercial sex, holidays for HIV positive persons, etc.

Central health authorities have undertaken a number of independent evaluations of HIV prevention initiatives in Norway. Giving examples of several of these would take up too much space.

We have, in that regard, chosen the AIDS information bus ("Bussen") in Oslo as an example of a prevention initiative.

"Bussen" is a mobile unit established in 1988 and developed from the understanding that intravenous drug abusers are especially at risk for HIV-infection as a result of sharing needles/syringes. The objective of this initiative is to prevent the spread of the HIV virus among intravenous drug abusers by contributing to reduced risky behavior by way of providing better access to clean needles/syringes and condoms, and by providing information about infection risks and how infection can be avoided. "Bussen" distributes needles/syringes, condoms and lubricants - free of charge An arrangement providing for return of used needles/syringes allows for the possibility of exchanging used needles/syringes with clean ones. "Bussen" is well-known in the drug abuser communities and it is open for operation during the time period when the pharmacies do not sell needles/syringes, i.e. from afternoon to midnight. In 1985-87 the prevalence of HIV-positive persons within this group averaged 79 each year. The spread of HIV among intravenous drug abusers has since decreased, and the level is now at a low and stable level. In the past seven years, the yearly incidence of newly infected intravenous drug abusers has been 7-12. Much of this success is accredited to the formidable access to clean needles/syringes provided by "Bussen". Those who avail themselves of these services are in agreement with this assessment. Eighty percent of the total number of needles/syringes used by intravenous drug abusers were distributed by "Bussen". In 1998 "Bussen" had 113.000 personal inquiries and distributed 1.9 million needles/syringes.

7.7.1 How were the objectives useful to respond to an area of great need?

7.7.2 What are the main reasons for the success of this approach?

Need and availability are the reasons for the popularity of "Bussen". Drug abusers acknowledge the danger of infection and wish to protect themselves. The service is free of charge. Those who use "Bussen" do so with a high level of trust, and the unit is placed in areas of downtown Oslo where intravenous drug abusers often tend to congregate. It should be mentioned, however, that there are frequent political discussions regarding where "Bussen" should be placed. No one desires it as a neighbor. This is, of course, because of discomfort or the fear of discomfort regarding placement: fear of used needles/syringes, intoxicated persons, criminal behavior and so on.

7.7.3 Was it formally evaluated or not, or what is the current status of this project (funding requested, just funded, 1 to 2 years implementation…) If measured or evaluated, what was the impact (positive or negative) of each of these projects? (please give a summary and send the evaluation report(s))

The initiative was externally evaluated in 1998. The conclusion was that "Bussen" is an important measure with infection-preventive effect, and that the initiative should be continued. "Bussen" is cost-effective compared to what each individual new incidence of HIV would cost society. The availability of low-cost outlets should remain the same in the future as now. In addition to daytime sales at pharmacies, automatic vending machines for needles/syringes can constitute a viable supplement in terms of preventive preparedness late at night.

7.7.4 What are the lessons learnt from this project (if any)?

It is often difficult to reach drug abusers with health services measures. It is our experience that this particular measure provides the possibility for important contact between health and social workers and the community of drug abusers. The result is a mutual exchange of knowledge/information which is of benefit to both parties.

7.7.5 What are (for this project) the policy implications for the country?

Risk-reducing initiatives have been an important part of HIV prevention among intravenous drug abusers. The country's municipalities are encouraged to provide intravenous drug abusers with easy access to clean needles/syringes and condoms. It is our experience that Norwegian cities with a significant degree of narcotics addiction approach this challenge in diverse ways, such as distributing free needles/syringes from a communicable disease control center or pharmacy, or by installing automatic vending machines for needles/syringes. A measure such as "Bussen" would constitute an over-dimensionality of the problem and solution, if introduced in smaller towns.

7.8 If possible, can you describe the main current primary prevention approach: pragmatic, legal, public health, persuasive, directive, moralistic, technical, other (please specify)?

The methods used in terms of approaching the various groups who are most at risk have been mainly characterized by dialogue, discussion and cooperation. There has been a tremendous degree of openness concerning the HIV/AIDS problem, and all who work with HIV/AIDS prevention and care issues are continually provided with updated epidemiological statistics.

8 Describe the particular social and economic measures of support for HIV positive persons

There are no special social or economic measures/benefits which concern HIV-positive persons solely.

9 Describe HIV/AIDS treatment and care in your country

9.1 What is the national policy? Are there national guidelines for the organisation of treatment and care? If yes, please summarise shortly.

The Health Services System's initiative for persons with HIV and persons with AIDS is initially anchored in ordinary health and social services at the municipal, county and regional levels. The Plan of Action for Combating the HIV/AIDS Epidemic 1996-2000 speaks of initiatives in the coming years concerning medical treatment. It is emphasized that there will be need of increasingly complicated and resource demanding treatment procedures which will require significant expertise of the responsible clinics. Highly specialized laboratory services will be essential for diagnosis as well as for continuous monitoring of ongoing treatment initiatives. This means that the regional hospitals will have a central place in the treatment of persons with HIV within their respective health arenas. The Ministry is of the opinion that, should the regional hospitals not receive the necessary resources to provide optimal treatment for their HIV patients, compared with other western countries, the consequences for quality for this type of treatment could be quite serious. (Ministry of Health and Social Affairs of 1996; Plan of Action for Combating the HIV/AIDS Epidemic 1996-2000, 60-63).

Our leading experts on HIV/AIDS research and medical treatment have engaged themselves in the serious side effects which often accompany the new treatment regimes. There have been reports of increasing problems with abandoned therapy, resistance development and serious side effects connected with the new medications. This requires a great deal of both the patients and their physicians. Professor Stig S. Frøland, one of the country's leading experts, expressed in a recent interview that modern treatment of HIV is amongst the most complicated (treatment forms) within today's medical practice, and it requires significant experience and knowledge in order to be able to follow up a patient over a long period of illness. He said that such treatment should not be given by just any physician, but by specialists within infectious diseases. He said that he would go so far as to say that not even all specialists acquire a broad enough experiential foundation to adequately meet this responsibility. (The National Institute of Public Health, Aids-Info no. 2 1999; Heidi Sandvik; Når målet helliger middelet: Moderne hivbehandling i nytt lys (When the goal consecrates the remedy: Modern HIV Treatment in a New Light). 8-9).

The National Institute of Public Health makes the following recommendations in its Municipal Health Care Handbook on Control of Communicable Diseases 1999-2000:

Diagnostic Methods

Positive diagnosis of HIV-1 and HIV-2 is normally achieved through demonstration of antibodies. Primary positive HIV antibody demonstration must be confirmed through further examination in the reference laboratory. In order to rule out blood sample mix-up, two separate blood samples should be taken from the patient. Most of them will show a positive HIV antibody test 3-4 weeks after the risk situation, should contagious transfer have taken place. In order to be able to rely upon the results of an HIV test, there should be a 3 month time period lapse between risk situation and test.

Treatment

Treatment of opportunistic infections with antibiotics, antiviral medications and yeast remedies. Upon development of AIDS or prognostically weakened immunological or viral markers, combination therapy with antiviral remedies is given. Combination therapy is in mono, double or triple form. Emphasis is placed upon psycho-social support in the course of treatment. The effect of treatment is measured by, among other factors, CD4 counts and HIV-RNA quantification ("viral load"). Treatment is considered to be effective when less than 50 virus particles per ml. plasma are measurable. Asymptomatic HIV positive persons should have regular control tests measuring CD4 counts ca. every sixth month, including eventual HIV-RNA quantification. Consultations, medicines and the like are refundable from the National Insurance Scheme. Pneumococcal vaccine is recommended to all persons with HIV, and is also refundable from the National Insurance Scheme.

Preventive measures

Use of condom is recommended with coitus and oral sex, and that blood stains are removed with chlorine-based disinfectant and that clean needles/syringes are used with intravenous drug abuse. Treatment of HIV-positive pregnant women (usually from the third trimester) with antiviral remedies is standard treatment procedure. The risk of contagion from mother to child is now at 10-15 percent.

Accidental puncture and post-exposure prophylactics

Norwegian health authorities recommend post-exposure prophylactics with antiviral remedies for health professionals who have accidentally punctured their skin, when the source of infection is surely an HIV-positive person. The chemical prophylactic should be administered as soon as possible -- hopefully within 2 hours of the time of the accident. Prophylactics are not recommended if more than 1-2 days have passed since the time of the accident. There are currently no recommendations from Norwegian health authorities concerning usage of post-exposure prophylactics in situations other than puncture accidents in the health services sector.

The National Institute of Public Health recommends such measures in the case of one-time occurrences or outbreak: Each physician who diagnoses a case of HIV infection is obligated to attempt to trace the source of infection. This obligation applies until the physician has (eventually) referred the patient to the municipal physician.

Recommendations concerning counselling/advisement for persons with HIV

Upon newly diagnosed HIV-positive status, the patient shall be given thorough information and be offered access to psycho-social support services. The person with HIV shall be advised that he/she must not donate blood or other human materials, and that he/she must avoid the possibility of others coming in contact with his/her blood. Blood stains should be disinfected with a chlorine-based disinfectant. Needles/syringes must not be shared with others. The HIV-positive person must always inform his/her sexual partner about his/her HIV-status, and always use condoms when engaging in sexual contact which is potentially risky. Questions concerning pregnancy should be discussed with a doctor wherever applicable. Newborn children of HIV-positive mothers should not be breastfed.

Regarding HIV-positive status and profession, the National Institute of Public Health maintains that persons who are HIV-positive can continue working in all professions (including handling of foodstuffs) with the exception of infected health workers who perform risky, invasive surgical operations. These persons shall be continuously monitored by infectious disease physicians who will assess their capability to securely carry out their work tasks. The Norwegian Board of Health has established a working group which can advise about whether (or not) it is necessary to make changes in the infected health worker's work situation.

(National Institute of Public Health. Hans Blystad, ed. Control of Communicable Diseases 1, Primary Health Care Departments' Handbook on Control of Communicable Diseases 1999-2000. Oslo 1998; 58-59).

9.2 List the existing services providing treatment and care.

1. Primary Health Care Department (municipal physician, communicable disease control physician, medical doctors in private practice, fysiotherapy services, domiciliary services, community nursing services, health station, school health services).
2. County Health Care Department (polyclinics, laboratories, local and central hospitals, regional hospitals, university hospitals, specialist health care services outside of institutions).
3. Government Health Care Department (Rikshospitalet, Radiumhospitalet)

In September of 1999 Aksept kontaktsenter for HIV-positive persons and their relatives/support network opened their 24-hour branch (hospice) in addition to their day center. The initiative is sponsored by Kirkens Bymisjon (the Church's City Mission) in Oslo and is financed by the City of Oslo. Pluss-LMA administers a volunteer program directed at helping persons with HIV, which is partly financed with government funds. Ullevål Hospital has a home treatment team for persons with HIV and AIDS who are ill, but who can live (and be treated) at home. The team is financed by the City of Oslo as a part of the hospital's operations.

9.3 Are there any obstacles in accessing care/ treatment (financial, legal, etc.) for the general population and for different vulnerable groups (e.g.: unemployed persons, prostitutes/sex workers, illegal migrants)?

Aside from foreigners who reside in Norway illegally, everyone who resides in Norway is obligated to be a member of the National Insurance Scheme. Membership gives rights to a number of benefits (disability insurance and retirement pension, supporter supplements, benefits to persons residing in institutions such as hospitals, occupational injury, unemployment insurance, benefits to persons who are ill (medical assistance, medicines, physical therapy and the like), sickness and rehabilitation benefits, basic benefits and help benefits and the like). A person is considered to be a "resident" of Norway when he/she is intended to or has resided in Norway for a minimum of 12 months. A person who moves his legal residence to Norway is considered a resident from the date of arrival. One must be a legal resident of Norway in order to qualify for membership in the National Insurance Scheme. (The National Insurance Act of 1997, 28 ^th> of February, no. 19)

This precludes persons without legal residence, i.e. illegal immigrants. However illegal immigrants who reside in Norway have the right to immediate health care. The provisions of The Communicable Disease Control Act relating to services and measures apply to every person residing in Norway. The situation is somewhat unclear for asylum seekers and refugees who have not yet received judgment on their application for asylum. There are no provisions, either in law or regulation form, which particularly addresses HIV-positive asylum seekers. There is very little practical experience in this area. A positive HIV-status cannot, by itself, constitute a basis for denial, or granting, of asylum. However, a positive HIV-status can constitute one of many elements taken under consideration when deciding whether (or not) a residence and/or work permit shall be granted as per The Act on Immigration (Utlendingsloven) § 8.2 paragraph. The condition here is that there exist "strong humanitarian considerations. In evaluating that which may constitute "strong humanitarian considerations", all aspects of the applicant's life situation must be seen as a whole.

9.4 Please describe 1 to 3 examples of specific HIV/AIDS treatment and/or care programmes dealing with prevention (e.g.: day-care, home-care, etc.) in your country, specifying by whom they are run, etc.

Due to shortage of space, we have chosen not to describe these programs here. We refer the reader rather to descriptions already given in 9.2.

10 Please give an estimation of the overall expenditures of the HIV/AIDS epidemic in your country at governmental and (if possible) non governmental levels (please specify):

This is rather difficult to assess. It is a simple matter to assess government allocations (from the budget of the Ministry of Health and Social Affairs) to HIV/AIDS prevention initiatives. However, assessment of absolutely all expenses in connection with HIV/AIDS is an impossible task. The total comprehensive picture regarding such expenditures would include expenditures for medicines, health services in and outside of institutions, expenditures in connection with financial compensation under illness-related leaves of absence, rehabilitation and disability insurance, etc. In addition there are various expenses which are classified under other ministries' areas of responsibility. As mentioned several times elsewhere in this report, we have no specific provision for special care for persons with HIV/AIDS, and there is neither need nor desire to accentuate the expenditures for this patient group specifically.

10.1 How is AIDS prevention financed?

The Norwegian Parliament makes an annual allocation of funds to the Plan of Action for Combating the HIV/AIDS Epidemic 1996-2000, surveillance of communicable diseases, etc. This has been the practice since the mid-80's.

10.2 What are the overall expenditures (if known)

Governmental

The 1999 allocation to HIV/AIDS prevention (by way of the Ministry of Health and Social Affairs’ budget) was NOK 16.6 million.

Local and regional (i.e. municipalities and counties)

There is no comprehensive assessment of this. The resource statistics concerning communicable disease control are generally weak, thus giving little specific information about HIV/AIDS.

10.3 What are the expenditures for information/education measures per annum?

There is no comprehensive assessment of this. The National Institute of Public Health was allotted NOK 2.5 milllion for this purpose in 1999.

10.4 Are the trends going up- or downwards?

Table 10.4 gives an overview of the development since 1991. The table clearly shows that the yearly allotment has been reduced significantly in the course of this period. The allotment for 1999 is somewhat larger than in 1998. It is difficult to determine the levels to expect in the coming years, i.e. after the current plan of action period is over.

Table 10.4: Overview of development in government earmarked allotments for the period 1991-1999.

Source: Proposition No. 1 to the Parliament on the Ministry of Health and Social Affairs for the budget years 1991-1999.

10.5 Are there any reports on expenditures or any documented estimates?

(If so, please attach them.)

None, except for the annual budget proposition, accounting figures and internal case documents.

11 Are there research projects on risk behaviour and behavioural changes?

11.1 Did your country undertake KABP Studies (Knowledge Attitude Behaviours and Practice)? Are other behavioural research reports available? If so, please summarise the most important findings and send a copy of the most recent reports.

In Norway the KABP studies have been regularly conducted since 1987. Investigative studies have also been undertaken to understand the reasons behind risky behavior. Several of these studies have been published (see enclosure 11.1). One extract from the studies shows that the Norwegian population's attitudes in connection with HIV/AIDS issues revolve around the moralistic-religious axis in the Norwegian society. There is little foundation to support the hypothesis concerning a linked relationship between knowledge and attitudes and potentially risky sexual behavior. Sexual habits are more distinguished by stability than change. One change is that men and women have become more alike in regard to sexual behavior, and it is women who have experienced the greatest change. Sexual intercourse which involves potential risk of sexually transmitted diseases is widespread. An increase in the usage of condoms in potentially risky situations has been demonstrated. There are indications that interventive measures in schools are positive methods for promoting condom usage amongst youth. Blood donors have the same sexual behavior patterns as the general Norwegian population, but a somewhat lower incidence of behavior which can involve risk of infection from sexually transmitted disease. Mathematical models based upon data from the 1987 sexual practice inquiry showed that a major HIV epidemic amongst heterosexuals in Norway was not to be expected.

11.2 Are there indicators on behavioural change documented on a national basis, i.e. sales rates of condoms, provision rates of needles/syringes, acceptance of counselling and anonymous testing? If so, please summarise the most recent data.

There is no reliable data available concerning sales of condoms in Norway. A coarse indicator would be the wholesale dealer import figures, which from the period 1985 to 1990 were stable at 9-10 million condoms per year, and thereafter have fallen to around 7 million in 1999. There is also no reliable data concerning sales or dispersal of hypodermic paraphernalia to intravenous drug abusers. "Bussen" in Oslo, which disperses free user paraphernalia to the capitol's drug abusers has increased dispersal of hypodermics each year: from 200.000 when they first began in 1989 to 1.9 million in 1998. The extent of shared usage of hypodermic paraphernalia in the drug abuser community, and eventual changes over time, is unknown. Extensive outbreaks of hepatitis A, B and C in the drug abuser communities in Norway since 1995 is a confirmation that needle-sharing is still a frequent occurrence. The incidence of genital chlamydia infection has been stable in the '90s, with around 12.000 diagnoses yearly. These indications show relatively unchanged behavior amongst persons under the age of 25. The number of persons seeking HIV consultations from the health sector is unknown, but the indications are that there has been a proportional decrease (thus attributed to the fact that the tremendous focus upon the HIV epidemic has slackened in the course of the 1990s). Anonymous testing is available, but has been in little demand in Norway, and exact data is not available.

11.3 Are there other "independent" indicators of the increase or decrease of risk behaviour, i.e. through anonymous testing of blood donations, random samples of sub-populations such as soldiers, prisoners, etc.? If so, please summarise the recent data.

HIV screening of blood donors has taken place in Norway since 1986. Around 100.000 blood donors are tested each year. From 0 to 1 positive donor is found each year, i.e. a total of 8 in the period 1986-1998. Pregnant women have been offered HIV tests in the early stages of pregnancy since 1987. An average of 70.000 women are examined yearly, and the percentage of those who have been tested for HIV has remained stable at around 96%. From 0 to 7 new HIV positive persons from this group are found each year, i.e. a total of 42 in the period 1987-1998. Military recruits have been offered HIV tests since 1987. Around 25.000 recruits are examined each year, and the percentage of those who have been tested for HIV has remained stable at around 90%. Only three recruits have been found to be HIV positive in the period 1987-1998, the last one in 1989. One the whole, these studies give a good indication that HIV prevalence in the general population is very low and that incidence has not changed into the 1990s. Prevalence is currently, however, too low to be able to measure eventual changes in the population's sexual behavior.