Faster and more frequent testing

The sooner HIV can be detected, the earlier treatment can be initiated. Therefore, the H-TEAM promotes ‘active testing’ by encouraging healthcare providers to offer HIV tests on a routine basis (provider-initiated testing) and by stimulating testing on the initiative of individuals (client-initiated testing) and communities themselves (community-based testing).

The H-TEAM also focuses on fostering early diagnosis by developing and implementing HIV testing strategies aimed at target groups that are difficult to reach and often enter care late. By ensuring that as many people as possible know their HIV status, the H-TEAM wants to halt the HIV epidemic.

Faster and more frequent testing: why?

Faster recognition of the early symptoms of HIV ensures that people can start treatment earlier. Early treatment prevents deterioration of the immune system and gives people an excellent life expectancy. If people are treated in time, they can live as long as people without HIV. Moreover, effective anti-retroviral (ART) treatment largely reduces or even eliminates the chance of transmitting infections.

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Faster and more frequent testing

The H-TEAM promotes testing by raising awareness of the (early) symptoms and the importance of early testing among professionals and specific target groups. The aims are:

  • More HIV testing and an increase in the percentage of people who know their HIV status
  • Being able to diagnose HIV earlier

>>> We accomplish this by focusing on:

Scroll down to learn more about these strategies and subprojects.

Provider-initiated testing

Of all HIV patients in the Netherlands, around one third are diagnosed by a general practitioner, one third at a local public health service STI outpatient clinic, and one third in a hospital. This means that GPs and hospitals play an important role in diagnosing HIV infections in the Netherlands.

However, recent studies demonstrate that many opportunities for offering HIV testing are not being identified or utilized sufficiently frequently by healthcare providers. Patients and professionals still experience barriers such as fear, stigmatization, limited risk assessment and risk perception, and lack of knowledge about new HIV treatment and prevention opportunities. Furthermore, HIV testing in case of indicator diseases is not yet standard procedure among general practitioners and medical specialists. By offering interactive training sessions, the H-TEAM aims to improve testing behavior among GPs. In addition, the H-TEAM wants to promote proactive HIV testing by medical specialists through an indicator-based testing intervention.

Interactive training sessions (Diagnostisch Toets Overleg – "DTOs")

In 2015 we developed and implemented a novel multifaceted interactive training session for GPs in Amsterdam: diagnostic consultation meetings (Diagnostisch Toets Overleg, abbreviated as DTO). These sessions are developed to stimulate responsible STI and HIV testing in order to prevent over- and underdiagnosis. Through mirroring techniques, GPs take a closer look at their test request behaviour related to HIV and other STIs and develop a practice improvement plan. By using the data on requested HIV and STI tests, the H-TEAM maps trend information.

 

The meetings are based on the “learning by teaching” principle and are moderated by GPs who have previously attended a “teach-the-teacher” session.

Results

In 2015, the first DTO’s took place. In 2018, the first follow-up training sessions were organized to monitor the implementation of the practice improvement plan and collect additional testing data to evaluate the effect of the sessions on testing practices. In 2020, the second and last follow-up training sessions took place. Since 2015, a total of 36 DTO’s have taken place, of which 22 DTO-I sessions and 14 DTO-II sessions, attended by 229 GPs. With this, the H-TEAM has retrained 43% of all GPs in Amsterdam.

 

In general, the training sessions were very well received by the GPs. The meetings were rated with an 8.5 on a ten-point scale. The GPS argued that they expected to more mindful of HIV in their practices and therefore expected to administer more HIV-tests.

 

With the laboratory data collected, we assessed trends in HIV testing by GPs in Amsterdam from 2011 to 2016. In total, Amsterdam GPs request about 10,000 HIV tests annually. In our preliminary analyses, we observed a large inter-GP and inter-practice variation. The overall HIV testing rates declined from 2011-2014 (from 38 HIV tests per GP in 2011 to 26 in 2014), stabilized between 2015-2017 (Figure 1) Currently, data between 2018-2020 is being collected and analyzed in order to make clear the effects of DTO on testing behavior by GPs.

 


Figure 1: Average number of HIV tests performed by GPs per 10,000 residents of Amsterdam per year by sex.

Presentation by Saskia Bogers about the results of the Interactive Training Sessions (DTOs) at the online NHG-Wetenschapsdag 2021 (in Dutch)

Indicator-based testing by medical specialists

Research shows that the presence of certain diseases may suggest an underlying HIV infection. the individual may have an underlying HIV infection. These diseases are called indicator conditions, and include cervical cancer, tuberculosis, hepatitis B or C and lymphoma. Performing an HIV test in patients with an indicator condition (indicator-based or IC testing) could reduce the number of undiagnosed HIV patients and thus put a halt to transmission of the virus. However, European studies show that HIV testing in the presence of indicator conditions is not yet standard procedure.

 

By carrying out an intervention study, the H-TEAM aims to improve IC testing by medical specialists. We will assess barriers and facilitators to IC testing at the level of the patient, the healthcare provider and the medical department. The findings of this research will serve as input for a targeted intervention to improve IC testing. The goal is to stimulate medical specialists to test for HIV upon diagnosis of an indicator condition within their specialty.

 

The effect of this intervention will be evaluated. We hope IC testing will become routine procedure among all medical specialists in the Netherlands, so that HIV infections can be detected sooner, and further transmission of the virus can be prevented.

Results

In order to increase awareness about IC-based testing in hospitals in Amsterdam, in 2015 the H-TEAM developed a flyer listing all indicator conditions that should warrant HIV testing according to the ECDC guideline on indicator-based (IC-based) testing. On the flyer, indicator conditions were categorized by hospital specialty. All departments that were likely to encounter patients with an HIV indicator condition in six hospitals in Amsterdam received a letter from the H-TEAM about the need to accelerate indicator-based testing.

 

In 2019, the H-TEAM launched a new intervention study to promote testing in six hospitals in and around Amsterdam (Amsterdam UMC, locations AMC and VUmc, OLVG Oost, OLVG West, Flevoziekenhuis and BovenIJ ziekenhuis). Initially this project focuses on 7 indicator conditions within 5 clinical specialties: pulmonary disease, gastroenterology, hematology, gynecology/obstetrics and neurology/neurosurgery. The selected ICs are tuberculosis, hepatitis B, hepatitis C, cervical carcinoma including cervical intraepithelial neoplasia grade III, vulvar carcinoma including vulvar intraepithelial neoplasia grade III, malignant lymphoma and peripheral neuropathy.

 

Thus far, 4331 patients were included in the study. HIV test ratios were highest among tuberculosis patients (range 74-94%, figure 1). The test ratio varied considerably across hospitals and ICs. Overall, eleven patients tested HIV positive within 3 months around IC diagnosis through IC-guided testing, yielding an overall positivity percentage of 0.8%. These results show large differences regarding HIV testing among the different ICs and that IC-guided testing can identify people with previously undiagnosed HIV-infection, but is inconsistently and insufficiently practiced across hospitals for the selected ICs. From June 2020 onwards, education interventions are being implemented in each participating hospital in order to optimize IC-based testing. This intervention will subsequently be evaluated. In addition to the educational intervention, structural solutions for improved HIV testing strategies are investigated and –where possible- implemented, such as automated warnings for HIV testing indications, and adding HIV testing recommendations to relevant specialty guidelines.

 

Figure 1: HIV test ratio within 3 months around diagnosis by study site and indicator condition. CIN: cervical intraepithelial neoplasia. NTH: non-teaching hospital. TH: teaching hospital. UH: university hospital. VIN: vulvar intraepithelial neoplasia.

The Last Mile

In 2016, in Amsterdam approximately 350 persons were not aware of their HIV infection (6% of the total number of people estimated to be living with HIV in Amsterdam, SHM Monitoring report 2016). “The Last Mile” refers to finding and diagnosing this last 6%, and particularly those who are at risk of presenting with a late-stage infection.

We still know too little about people who enter care late. To develop a successful strategy, we need more detailed insight into the different characteristics of this highly diverse group. In phase 1 of the project, these characteristics will be investigated in several subprojects. Based on the collected data, innovative interventions will be developed together with specific key population groups in phase 2.

Scroll down to learn more about the three subprojects.

GIS: the HIV epidemic at city level

The objective of the geographical information system (GIS) subproject is to map “hotspot” areas in Amsterdam with a higher proportion of undiagnosed HIV infections. For this purpose, Amsterdam is divided into 80 postal code 4 (PC4) areas (Figure 2), which are analyzed using a statistical method (INLA). The model uses data from Stichting HIV Monitoring, the City of Amsterdam’s section Onderzoek, Informatie en Statistiek (OIS; Research, Information and Statistics), NIVEL and the STI outpatient clinic of the Public Health Service Amsterdam (GGD Amsterdam).

 

The analyses of the GIS project will provide insight into the distribution of the HIV epidemic across the city and will help to identify trends. Based on epidemiological data from 2011-2016 and demographic data, the number of undiagnosed people will be estimated for each PC4 area. This estimate will subsequently be compared to non-communicable diseases prevalence, HIV test density and demographic and socio-economic similarities and differences between neighboring PC4 areas. The outcomes of these statistical analyses will yield a prognosis of those PC4 areas where undiagnosed infections might be found and where transmission is likely to occur.

 

Figure 2: Postal code 4 areas in Amsterdam

Results

The project started in 2017 and will last about three years. All project activities including data collection and analysis will continue after this time.

 

Until now (medio 2020), we have found that new HIV diagnoses and late presentations are unequally distributed across Amsterdam. The 10 target areas are mostly clustered in Centrum, Zuid-Oost and West. Although the average amount of tests per GP was slightly higher within target areas than within non-target areas, this difference is not statistically significant (p-value = 0.062, Wilcoxon test). We also found significantly higher variance in testing practices within target areas than within non-target areas (p-value = 0.007, Wilcoxon test). Of note, data on testing are incomplete and results therefore preliminary.

Late presentation

The aim of this subproject is to obtain a clear in-depth insight into the reasons and individual motives for taking or not taking an HIV test. This investigation will be carried out among people living with HIV in Amsterdam. Using data from the Stichting HIV Monitoring, we aim to include a diverse group of participants who were at a late stage of infection at the time of their diagnosis. In addition to individual motives and barriers, the investigation will concentrate on understanding structural and contextual factors that contribute to the decision to take an HIV test. The output of the investigation will be used for the development of an intervention that promotes faster testing.

 

For this study, we will interview men and women who were diagnosed at a late stage of their HIV infection (CD4 count < 350 cells/mL or AIDS related illness). The interviews will be qualitative in-depth interviews with open questions. The course of the interview is dependent on the participant’s own experiences. The analysis of these qualitative data will provide insight into the complexity of the experiences of people living with HIV in Amsterdam and is necessary for a better understanding of the motives for (not) taking an HIV test.

Results

The results of the study on late presentation have shown that health system factors and psychosocial factors influenced delayed testing behavior:

  1. Health systems-related factors are structural and inherent in the way health care is organized. A first factor concerns the health system capacity of HIV testing. A second system-related factor reflects missed opportunities when receiving primary and secondary health care, including in general practitioner’s practices.
  2. Psychosocial factors concern aspects that are related to personal dispositions or to the social networks and communities that people identify with. Four main factors were identified: lack of perceived health problems, limited communication with primary health care providers, including GPs, perceived low risk of HIV infection among MSM, and high levels of fear for the clinical and psychosocial consequences of an HIV infection.

These findings warrant addressing the following misperceptions among healthcare providers:

  1. People test for HIV following risk.
  2. People can test for HIV on their own initiative.
  3. There are seemingly no more barriers for testing now that HIV can be easily and effectively treated.

Our findings suggest that the potential for a more social and systematic approach to HIV testing is recognized. Therefore, we suggest a strategy that can best be summarized in three main categories:

  1. General: continued efforts to reduce stigma.
  2. Health care professionals: further training and increased sensitization for timely HIV-testing among health care professionals.
  3. MSM: community based participatory research/action intervention.

Roadmap: migrant transmission network study

About half of new HIV diagnoses occur among people with a migration background. In recent years, the number of new diagnoses within this group has barely dropped (SHM Monitoring Report 2018). In addition, almost half of this group enters care at a late stage of infection. To improve this situation, insight into transmission networks is needed.

 

The innovative Roadmap study combines phylogenetic analysis of the HIV virus (analysis of the development of the virus) with geospatial mapping to gain a more detailed view of the HIV epidemic among people with a migration background in Amsterdam.

 

These methods are used to:

  • Estimate the number of HIV infections acquired by people with a migration background in Amsterdam (post migration)
  • Map areas in Amsterdam with a high prevalence of HIV and localize possible transmission hotspots
  • Identify sources of new infections acquired post migration among people with a migration background in Amsterdam

With the results of this study, the H-TEAM hopes to develop more targeted testing interventions tailored to inhabitants of Amsterdam with a migration background.

Results

The study started in the first half of 2019 and will last three years.

Client-initiated / community-based testing

H-TEAM encourages communities to address the need for HIV testing from within the community itself, with an emphasis on testing for, by, and in the community itself.

HIV testing week

In the context of community-based testing, H-TEAM developed the annual HIV testing week. The HIV testing week aims to encourage inhabitants of Amsterdam to take an HIV test. During this HIV testing week, everyone in Amsterdam can have a free and anonymous test by taking a rapid HIV test at general practices, at the STI outpatient clinic of PHSA, in hospitals and at outreach locations.

Results 2015/2016/2017

In December 2015, H-TEAM implemented a large-scale HIV testing week for the first time. During this week, 1231 people were tested and 3 HIV infections were found. In 2016 the HIV testing week was organized for the second time, this time with a focus on normalizing HIV testing. Posters were distributed throughout the city, carrying the text: ‘Doe jij het ook?’ (“Are you doing it too?”). In the streets, people were actively approached to have themselves tested for HIV, for example at markets in the center of Amsterdam and in Amsterdam Southeast. The free testing locations were also promoted on social media. During the 2016 HIV testing week, 806 people were tested and no HIV infections were found.

 

Given the low positivity rate and limited year-through awareness of the HIV testing week it was decided to discontinue the HIV testing week. The experience gained through the testing weeks fueled the development of more community-based testing strategies. Click on The Last Mile to find out more.

 

The HIV testing weeks attracted local and national publicity for accelerated HIV testing. The positive experience of the HIV testing weeks was the commitment and increased awareness of participating GP practices in Amsterdam Southeast. To maintain this commitment, an HIV “light” testing week was organized in 2017, during which over 800 people were tested and 3 HIV infections were found. In 2018, this version of the HIV testing week was taken over and carried out by Soa Aids Nederland.

 

Two evaluation papers were published on the HIV testing weeks in 2015 and 2016.

Pilot project Optimization Partner Management

Partner notification

Data from 2017 and 2018 from the Amsterdam STI outpatient clinic show that HIV and HCV prevalence among notified sexual partners of recently diagnosed persons is very high: 4.8% for HCV and 8% for HIV. In 2017, the Amsterdam STI outpatient clinic set up Team Partner Management (Team PM). This team, consisting of 8 nurses, works on all follow-up activities towards sexual partners in case of a positive test result.

 

However, treatment centers in Amsterdam do not make optimal use of this team of experts when it comes to partner management, which implies that not all sexual partners of recently diagnosed persons are currently reached.

 

To address this, H-TEAM and the MC Free (Amsterdam MSM Hepatitis C Free) consortium have initiated the Pilot Project Optimization Partner Management Amsterdam. The goal of the pilot is to effectuate quick and effective notification of sexual partners of recently diagnosed men who have sex with men (MSM) in treatment centers in Amsterdam, and to facilitate testing, treatment and/or referral. It aims to do so primarily by optimizing the process of sharing contact details of newly diagnosed MSM with team PM at the STI outpatient clinic, so that notification of sexual partners and further partner management can be initiated as quickly and adequately as possible.

Results

Early 2019, a meeting was held with all relevant stakeholders in Amsterdam to discuss the strategy of this pilot project. The consensus was that the project should aim to improve linkage between the treatment centers and Team PM. A protocol describing this linkage process in detail was subsequently developed. The protocol is an addendum to the existing RIVM protocol ‘STI and HIV Partnermanagement’ (Dutch only).

 

The pilot started in July of 2019 and will last two years. During the pilot, team PM will share interim results with the treatment centers.

Team

  • Wim Zuilhof
    Wim Zuilhof

    Member
    Soa Aids Nederland

  • Adrie Heijnen
    Adrie Heijnen

    Member
    SCA

  • Ard van Sighem
    Ard van Sighem

    Member
    Stichting Hiv Monitoring

  • Kees Brinkman
    Kees Brinkman

    Member
    OLVG

  • Godelieve de Bree
    Godelieve de Bree

    Member
    Amsterdam UMC
    AIGHD

  • Udi Davidovich
    Udi Davidovich

    Member
    GGD Amsterdam

  • Jan van Bergen
    Jan van Bergen

    Project Leader
    Soa Aids Nederland
    Amsterdam UMC
    Huisartsenpraktijk

  • Suzanne Geerlings
    Suzanne Geerlings

    Member
    Amsterdam UMC

  • John de Wit
    John de Wit

    Member
    Utrecht University

  • Saskia Bogers
    Saskia Bogers

    Member
    Amsterdam UMC

  • Nina Schat
    Nina Schat

    Project Coordinator
    AIGHD

  • Alexandra Blenkinsop
    Alexandra Blenkinsop

    Member
    AIGHD
    Imperial College London