Amsterdam, the capital of the Netherlands and the country’s most densely populated city, has a population of more than 800 000, of whom an estimated 6170 are living with HIV—more than one quarter of all people living with HIV in the country1,2.
Amsterdam was one of the first cities in the world to reach, and then exceed, global HIV diagnosis and treatment targets, achieving testing and treatment targets of 95–94–94 at the end of 20173.
Despite these extensive and effective interventions, an estimated 5% of people living with HIV remain unaware that they are infected, and a small number of new infections continue to occur. A particular challenge includes ongoing HIV transmission during the early stage of infection4. Another challenge is reducing the large proportion of people (32%) who are diagnosed when they already have
advanced HIV infection.
1 Personal communication with A van Sighem, August 2019.
2 HIV in Nederland. In: HIV Monitoring [Internet]. Amsterdam: Stichting HIV Monitoring; c2019 (https://www.hivmonitoring.nl/nl/resources/hiv-nederland-2, accessed 27 August 2019).
3 De Bree GJ, van Sighem A, Zuilhof W, van Bergen JEAM, Prins M, Heidenrijk M et al. Is reaching 90/90/90 enough to end AIDS? Lessons from Amsterdam. Curr Opin HIV AIDS (in press).
4 Ratmann O, van Sighem A, Bezemer D, Gavryushkina A, Jurriaans S, Wensing A et al. Sources of HIV infection among men having sex with men and implications for prevention. Sci Transl Med. 2016 Jan 6;8(320):320ra2
Amsterdam, the capital of the Netherlands and the country’s most densely populated city, has a population of more than 800 000, of whom an estimated 6170 are living with HIV—more than one quarter of all people living with HIV in the country1,2.
Amsterdam was one of the first cities in the world to reach, and then exceed, global HIV diagnosis and treatment targets, achieving testing and treatment targets of 95–94–94 at the end of 20173.
Despite these extensive and effective interventions, an estimated 5% of people living with HIV remain unaware that they are infected, and a small number of new infections continue to occur. A particular challenge includes ongoing HIV transmission during the early stage of infection4. Another challenge is reducing the large proportion of people (32%) who are diagnosed when they already have
advanced HIV infection.
HIV Transmission Elimination Amsterdam (H-TEAM) was launched in 2014 with the goal of developing and implementing innovative strategies to bridge the remaining gaps in the HIV response. A unique collaboration of key HIV stakeholders in the city working in multidisciplinary and interdisciplinary teams, H-TEAM includes representatives from affected communities in its efforts to reduce HIV incidence and improve the prognosis of people living with HIV by implementing various new strategies. This includes the provision of PrEP and various novel means of promoting earlier testing, with a focus on identifying and providing immediate treatment to all people living with HIV, including those with early or acute HIV infection.
The initiative combines research with practice, and until now, it has focused on the two main groups at high risk of HIV in Amsterdam: gay men and other men who have sex with men and migrants from regions with a high HIV prevalence. Since the start of H-TEAM, several projects have addressed specific gaps in the prevention and care cascade.
Biomedical prevention
To reduce HIV incidence, tailored sexual health services for gay men and other men who have sex with men and transgender people need to include PrEP alongside STI testing and treatment. In 2015, H-TEAM started AMPrEP, a demonstration project for 376 HIV-negative gay men and other men who have sex with men and transgender people. Its goal was to assess: (a) the uptake of (and experience with) daily or event-driven PrEP; (b) changes in sexual risk behaviour; (c) incidence of STI and HIV; (d) adherence to PrEP; and (e) overall costeffectiveness5.
During the AMPrEP study, which is the first demonstration study to offer participants the choice between daily and event-driven PrEP use, HIV incidence has remained very low, with no evidence of an increase in STI incidence over time among both daily and event-driven PrEP users6. These data—and other results from the AMPrEP project—have provided the Health Council with guidance on
how to supply PrEP within the Dutch public health system.
Finding the 5% who are unaware of their status
H-TEAM is working with the Amsterdam Health Technology Institute on a mapping project that aims to trace people living with HIV who are unaware of their status. Using a range of data sources, they have been able to estimate where current and future infections are likely to occur, and they can identify, by postal code, neighbourhoods where the risk of HIV exposure is higher. Early results show
that HIV prevalence varies from 0.17% to 2.27% across the city7. These findings provide a starting point for a geographically targeted approach to HIV testing and other interventions.
Focused awareness
Several awareness-raising campaigns aimed at gay men and other men who have sex with men have focused on barriers to the uptake of testing, prevention, early treatment and retention in care.
The campaign Do I Have HIV?, launched in 2015, raised awareness of the symptoms of acute HIV infection by means of posters, flyers, and online and offline media that focused on gay men and other men who have sex with men. A dedicated website offers information and provides a symptom checker for men who may recently have been at risk for HIV. By May 2018, the website had been visited more than 204 000 times, and the symptom checker had been completed more than 117 000 times8. Of the 371 men who visited the Public Health Service of Amsterdam for an acute HIV infection test, 30 were diagnosed as HIV positive; of those, 24 were in the acute stage of HIV infection9.
A second campaign (Laatjesneltesten, which roughly translates as “Test Rapidly”) is running through 2017 and 2018. Focusing on the importance of rapid HIV treatment and rapid testing, it aims to alleviate fears of a positive test result by emphasizing how HIV will only have a limited effect on a person’s future life. A third campaign (HIV as a Chronic Disease) involves studies to assess perceptions related to HIV as a chronic disease, followed by a second phase that addresses knowledge gaps that are identified (for more information, please visit the H-TEAM website: https://hteam.nl/awareness-raiing-and-treatment/?lang=en).
Two studies have examined perceptions and understanding of living with HIV among both HIV-negative and HIV-positive gay men and other men who have sex with men. A planned communications campaign based on the two studies will address knowledge gaps of both groups.
Faster and more frequent testing
Among health professionals and specific target groups, H-TEAM promotes the importance of early testing by raising awareness of the potential early symptoms of acute or early HIV infection. One innovation includes an approach to identifying those at risk of acute HIV infection during the time interval when the infection may be missed by standard testing algorithms. Point-of-care RNA testing is being
used to identify the virus as early as seven days after infection. Those identified as having acute HIV infection are offered immediate start of treatment.
The acute HIV infection testing strategy involves the use of a risk score for possible acute HIV infection that weighs symptoms in combination with sexual risk behaviour. The four symptoms are oral thrush, fever, swollen lymph nodes and weight loss; the three risk factors (all within the preceding six months) are self-reported gonorrhoea, receptive condomless anal sex, and more than five
sexual partners. This risk score was implemented as an interactive online screening tool for individual gay men and other men who have sex with men through the dedicated website, and for health-care providers at the STI clinic of the Public Health Service of Amsterdam. A study showed that screening for acute HIV infection with four symptoms and three risk factors would increase the efficiency of acute HIV infection testing, potentially enhancing early diagnosis and immediate treatment 10.
Improved care trajectory for those with acute or early HIV infection
The H-TEAM acute HIV infection testing strategy ensures that newly diagnosed people with acute HIV infection receive immediate treatment. A research paper presented at the International AIDS Society Conference in July 2019 showed that the implementation of the strategy with immediate treatment resulted in an HIV positivity rate of almost 8% in men who were tested for acute HIV infection, and that it reduced the time from diagnosis to viral suppression to as little as 55 days in those with documented acute or early HIV infection11.
H-TEAM is a unique collaboration at the forefront of global HIV implementation research. While its model may be most relevant to high-income countries with a low HIV burden, its experience also has the potential to help Fast-Track the HIV response in cities around the globe.
1 Personal communication with A van Sighem, August 2019.
2 HIV in Nederland. In: HIV Monitoring [Internet]. Amsterdam: Stichting HIV Monitoring; c2019 (https://www.hiv-monitoring.nl/nl/resources/hiv-nederland-2, accessed 27 August 2019).
3 De Bree GJ, van Sighem A, Zuilhof W, van Bergen JEAM, Prins M, Heidenrijk M et al. Is reaching 90/90/90 enough to end AIDS? Lessons from Amsterdam. Curr Opin HIV AIDS (in press).
4 Ratmann O, van Sighem A, Bezemer D, Gavryushkina A, Jurriaans S, Wensing A et al. Sources of HIV infection among men having sex with men and implications for prevention. Sci Transl Med. 2016 Jan 6;8(320):320ra2.
5 Hoornenborg E, Achterbergh RC, van der Loeff MFS, Davidovich U, van der Helm JJ, Hogewoning A et al. Men who have sex with men more often chose daily than eventdriven use of pre-exposure prophylaxis: baseline analysis of a demonstration study in Amsterdam. J Int AIDS Soc. 2018 Mar;21(3):e25105.
6 Hoornenborg E, Coyer L, Achterbergh RCA, Matser A, Schim van der Loeff MF, Boyd A et al. Sexual behaviour and incidence of HIV and sexually transmitted infections among men who have sex with men using daily and event-driven pre-exposure prophylaxis in AMPrEP: 2 year results from a demonstration study. Lancet HIV. 2019 Jul;6(7):e447-55.
7 H-TEAM. In: AHTI.nl [Internet]. Amsterdam: AHTI; c2019 (https://ahti.nl/projects/h-team/, accessed 27 August 2019).
8 Symptom Checker. In: heb ik hiv? [Internet]. Amsterdam; H-TEAM (https://hebikhiv.nl/en/, accessed 27 August 2019).
9 H-TEAM website [Internet]. Amsterdam; H-TEAM; c2019 (https://hteam.nl/awarenessraising- and-treatment/?lang=en, accessed 27 August 2019).
10 Dijkstra M, de Bree GJ, Stolte IG, Davidovich U, Sanders EJ, Prins M et al. Development and validation of a risk score to assist screening for acute HIV-1 infection among men who have sex with men. BMC Infect Dis. 2017 Jun 14;17(1):425.
11 Dijkstra M, van Rooijen MS, Hillebregt MM, van Sighem AI, Smit C, Hogewoning A et al. Targeted screening and immediate start of treatment for acute HIV infection decreases time between HIV diagnosis and viral suppression among MSM at a sexual health clinic in Amsterdam. IAS 2019, Mexico City, Mexico, 21–24 July 2019.