New cases of HIV infection are close to being eliminated in Amsterdam, having fallen from 201 in 2010 to nine infections in 2022. Currently, 98% of all people living with HIV have been diagnosed, 95% of those diagnosed are on antiretroviral treatment and 95% of those on treatment have achieved viral suppression.
In October, the Eurosurveillance journal published an article titled, A 95% decline in estimated newly acquired HIV infections, Amsterdam, 2010 to 2022, authored by the HIV Transmission Elimination AMsterdam (H-TEAM) Initiative.
Many factors contributed to the decline in HIV, but the work of the H-TEAM is an inspiring part of the picture. We spoke to Dr Godelieve de Bree, H-TEAM project leader, about what the initiative has done so far and its plans for the future.
What was the starting point for the H-TEAM initiative?
The project evolved around 2012 and was prompted by the HIV incidence and prevalence figures in Amsterdam. At that time there had been a gradual decline in new HIV diagnoses from the 2000s to 2010, but we felt it was too slow.
Amsterdam has a history of providing HIV services and working with communities, since the beginning of the epidemic in the early 1980s. There was a successful harm reduction programme in place, there were good HIV test-and-treat facilities at STI clinics, in hospitals and at primary care services. These provisions should ensure that everybody with HIV had access to treatment. Nevertheless, we felt we weren’t making a real difference in getting the numbers of HIV diagnoses and transmission down and that was the starting point of the H-TEAM initiative.
We started thinking about how to better use the city infrastructure in Amsterdam and to determine where the gaps in the HIV care continuum were. An important realisation was that we could improve the collaboration between the diverse stakeholders in HIV prevention and care, and therefore the first step was to bring everybody together. This was probably easier in Amsterdam than it would be in larger cities. It is a small city and it was achievable to bring all the stakeholders involved around the table, including people from the affected communities.
What interventions did you use – the acute test-and-treat strategy sounds unusual?
We sat around the table with all the stakeholders, and we started to design and integrate interventions. We thought about how the interventions could be aligned to one other, but also about making sure we were targeting every pillar in the continuum of care. We looked at prevention, PrEP provision, test and treat for acute HIV infections and strategies to better reach out to people with HIV.
The rationale behind an acute test-and-treat strategy evolved from a study done in collaboration with the group led by Dr Oliver Ratmann at Imperial College London, where we looked at the role of acute infections in forward transmission among men who have sex with men (MSM) in Amsterdam. We found that around 60% of all newly acquired HIV was driven by acute infection. These data prompted us to design an acute HIV test-and-treat campaign.
We met with the communication experts at Soa Aids Nederland and community groups, and we designed a campaign that focused on recognising symptoms of acute HIV infection.
We built in an action perspective in the campaign – if people recognise the symptoms of an acute infection, they can get an immediate referral to the sexual health clinic. There is a dedicated desk at the clinic, where people can get their acute HIV test results in around an hour, from an RNA-based test.
If the test result is positive, then the clinic contacts one of the hospitals providing HIV treatment and the person can be seen the same day. In practice, the median time between diagnosis and starting treatment is around one day, so the majority of people who test positive start treatment very rapidly. At the start, we were a little reluctant to offer same-day test-and-treat services for people with acute HIV, but in our experience this is a very well accepted service.
There’s a story behind the development of the acute HIV test algorithm. My colleague and founder of the H-TEAM initiative, Joep Lange, unfortunately died in the MH17 plane crash in 2014. One of his students, Dr Maartje Dijkstra, contacted me, because she needed a new supervisor. Maartje was working with a group in Kenya and they had developed an algorithm they hoped would prompt people to test for malaria. But it turned out that the majority of people who came forward for screening didn't have malaria, they had an acute HIV infection. Dr Dijkstra looked at adapting that algorithm to fit the population we are working with. We made some changes and validated the algorithm and it is still being used in the Netherlands now. It's a nice example of how we can learn from each other.
How did the H-TEAM work with primary care?
The team talked about what the HIV epidemic actually looks like in Amsterdam. The majority of people with HIV, around three-quarters, are MSM. But another key group are heterosexual people who present for care late – around 40 to 50% present with a low CD4 count or an AIDS-defining illness. To a large extent, people in this late presenting group are being seen by GPs, maybe initially with symptoms that are not recognised as an AIDS-defining illness. With that in mind, Professor Jan van Bergen, a GP involved in H-TEAM, developed a training programme for GPs. It aimed to create awareness and also to support GPs in understanding that there should be a low barrier to asking questions about sexual behaviour and offering HIV testing.
Alongside this teaching element, it also provides direct feedback. Over six months or a year, GPs receive the results of the tests they have ordered in their clinic, the positivity rates, and how these compare to other GPs in Amsterdam. That feedback mechanism has worked very well.
What other interventions are part of the H-TEAM design?
The interventions mentioned above are the main ones – awareness of acute and chronic infection among healthcare providers and communities; acute HIV test-and-treat services, and providing PrEP.
The Amsterdam PrEP demonstration project (AMPrEP) started in 2015 as part of H-TEAM. It had high uptake by men who have sex with men and transgender people. The results from AMPrEP, along with other PrEP studies led to the Ministry of Health rolling out PrEP in the Netherlands. In 2019, subsidised PrEP and related care was made available for 8500 people in the Netherlands, including 2900 in Amsterdam.
The other key component in H-TEAM is gathering a more detailed insight into HIV incidence and prevalence in Amsterdam. This is not just in terms of numbers but also trying to gain insight on the geographical distribution of the HIV epidemic. In what parts of the city do people with undiagnosed HIV live and where do people who present late to care live? Can we get insight in their background, maybe in terms of migration, socioeconomics, or language barriers? If we want to reach out to people, we have to use a language they understand.
This is what we’re working on now, using geographic information system (GIS) mapping to see if we can get a granular insight into where people live, at postcode area level. We want to be able to say something about HIV prevalence, stage of diagnosis, and hopefully also phylogenetic linkage in different areas. I hope connecting these data will help us to better target communication strategies to reach out to the small proportion of people we currently miss.
Given the very small numbers we're talking about now, we may have to change our thinking. We have traditionally spoken about groups we need to reach, but now it's more about individuals we need to reach and the challenge will be to really get to know who we are missing.
For that, we need another type of research that is more explorative, for instance, doing interviews with people who present to care late and may know other people in similar circumstances. We may find barriers that we are not aware of yet and that information, at an almost individual level, will inform new communication strategies.
What have you learned that might help people working in another city?
In the past, I've discussed city approaches, for instance with colleagues in Paris. In these conversations, it became evident that while we have similar problems, like the need to better reach out to people to provide services, a city like Paris is so different to Amsterdam.
Everything is on a much larger scale and people move around more fluidly. Someone might live in the suburbs of Paris for six months and then move to live with family in North Africa and then move back again. Of course, there’s no wall around Amsterdam, but it's smaller and people tend to stay in the same place. There are important differences in every place that make it difficult to directly translate lessons from Amsterdam.
Despite these differences, there are lessons we learned and that may be relevant for other cities. An example is the early involvement of local government, city council. In the early stage of H-TEAM we started the initiative with health care providers, researcher and community groups. It was only at a later stage that we reached out to the city council to convince them to formally support the H-TEAM initiative. Especially in a larger city, I think early involvement of government organisations would be key, because you need the infrastructure and you need the support. They need to help normalise HIV, because that's by far the largest barrier in all the interventions.
Of course, there are challenges and things we can do better. In Amsterdam, we need to do better at addressing and involving transgender individuals, and we have started doing that.
Given the present-day worldwide problems that lead to migration flows we need to consider new groups of refugees and migrants and how we can incorporate them in the care. This will be an important challenge, not only for Amsterdam, but for other cities too.
One of the things that I think have been most impactful in this project is learning that you can work together in a city, with a diverse group of people, to develop a shared strategy. We performed proof of principle, we showed that it can work.
This feature first appeared in the December 2023 edition of the Sexual Health and HIV Policy Eurobulletin.