Implementation of a Rapid HIV Diagnostic and Referral Strategy
An Interview With Maartje Dijkstra
Diagnosing acute HIV infection and starting treatment as soon as possible is important for both the person diagnosed as well as from a public health perspective. One study in Amsterdam deployed a strategy to identify acute HIV in men who have sex with men (MSM) and then link newly diagnosed individuals to care.
Terri Wilder: Please tell us about your study.
Maartje Dijkstra: I work with the Public Health Service of Amsterdam. What we've been trying to do is to find patients with acute HIV infection. First, we needed our men who have sex with men [MSM] population, our gay population, to know more about symptoms during acute HIV infection. So, we started a mass media campaign, informing them and linking recent sex behavior to symptoms associated with acute HIV infection. Then these men, they can go a website and fill out a self-referral tool to see whether they are eligible for testing at our clinic.
Also they can go just for a routine sexually transmitted infection [STI] screening. They can show up and then the nurse can decide, "Oh, this patient might have acute HIV." And then an MSM is tested through the strategy.
If patients are assessed eligible, first we do a rapid test, rapid antibody test, to see whether it is an established HIV infection. If there is an established HIV infection, of course, it's confirmed by western blots. So far, we have found only two out of 206. All the negative or indeterminate rapid tests are tested further to see whether there is an acute HIV infection.
We test with an RNA point-of-care test, which is a GeneXpert test by Cepheid, which gives test results within one and a half hours. At the same time, we test fourth gen. So far, we've test 204 patients that way.
Up till now, we have found two patients Fiebig stage I -- so really in the early stage of infection. So, they were RNA-positive, and all the other tests were negative. We have found eight patients Fiebig II -- so they had P24 antigen and positive RNA tests, but no antibodies yet. Then, we found seven other patients who are of a little bit further, but still recent, HIV infection.
In total, we found 17 patients out of 206, which is 8%, with an acute or recent HIV infection. They were all referred for treatment the same day and started treatments either the same day or the next day, except for two who didn't live in the Netherlands.
TW: Can you talk a little bit more about the media campaign? What does it look like? Where is it found? What might be attractive for the person to respond to the media campaign?
MD: Well, unfortunately, while I have been a proposer, I thought I had to have some kind of photo on it, but I didn't, unfortunately. It's based on a website which is called "Do I Have HIV.NL?" but it's in Dutch [speaks Dutch]. So it's patients who -- it's really focused on linking recent risk behavior to current symptoms. It looks like there is someone in bed. Half the picture, he's happy; he's having sex; he's enjoying himself. And the other half, it's the same guy, but he's sweating; he's feeling sick; he's febrile. And then it says, "Do I have HIV.NL? Go to this website."
Because we didn't want to scare patients or make people panic, "Oh, I had sex and now what?" at the website people can already do a self-assessment, whether their symptoms and their risk behavior might have an increased risk of having acute HIV. So, we didn't want them all to run to the clinic: "Oh, no! I saw this campaign! I have to get tested!" But we really wanted men just at home to have the tools to see whether they actually have an increased risk for acute HIV. And when they do have the tools, the eligibility tool on the website themselves, when they do have an increased risk, they get a referral letter. With the referral letter, they can come on the same day or the next day to our clinic to get an appointment.
TW: How many questions are on the tool?
MD: First there is a question about risk behavior. So, for example, if there is oral sex, men are not eligible because the risk is not high enough of contracting HIV. And then, there are 14 questions on symptoms -- so, a total of 15 questions.
TW: Got it. And then, you said they get a referral letter. How do they get it? Is part of the tool they put their email in there?
MD: No. They can just download it. It's not personalized.
TW: So it's populated. If it looks like they may be a good candidate for this program, it automatically populates it and then can see it.
MD: Exactly. And they can print it and take it with them. Yeah. Of course, if they really want to get an appointment, they can figure out how the tool works. But we haven't had any of those problems. And when men are coming to the clinic with the letter, they are always checked again by a nurse, whether they are eligible for testing.
TW: In terms of this campaign, what kind of funding did you have for this? I'm assuming somebody had to help design the sexy person in the bed, and that kind of stuff. So that costs money. Putting it up on media sites --
MD: True. Yeah. We received funding from the AIDS Fund, which is a Dutch NGO, who supported much of the work. And we tried to keep it as small as possible. We had a small budget. But we did have some experts designing the campaign. We came up with the tool and with the ideas, but they really helped framing it and designed all the posters, and the fliers, and the websites, as well.
TW: Any concern that you may get just a bunch of worried-well people?
MD: Yes, especially at the beginning before the start. We had lots of discussions about it. I think the nice thing is about the point-of-care RNA test. We are using it to try to find acute HIV infections. But also now, when someone comes with symptoms and the test is negative, you can really say, "You don't have symptoms because of an acute HIV infection." So, even if it's a worried well, we can still reassure him it's not HIV. I think that's a really nice side effect of this strategy.
TW: I know that your results were from August 2015 through January 2017. Is it ongoing?
MD: Yes, it's ongoing. It's currently ongoing. It's preliminary results. And, yeah, we'll keep on testing them.
TW: How long do you think the project will last?
MD: At least two years. Because it has been such a success, with such a high percentage of acute HIV infections, our head of the STI clinic is already think of implementing it into routine care.
TW: Great. If people wanted more information about this, where could they go?
MD: Well, they can come to me, of course. My email address is email@example.com.
TW: Great. Thank you so much.
MD: You're welcome.
This transcript has been lightly edited for clarity.
Terri L. Wilder, M.S.W., is a director of HIV/AIDS education and training in New York City.