HIV care in Curaçao: an evaluation by Gonneke Hermanides
The data collected by Stichting HIV Monitoring (SHM) make an important contribution to national and international research into HIV and AIDS, such as that carried out by Gonneke Hermanides as part of her PhD. Dr Hermanides was recently awarded her PhD at the Rijksuniversiteit in Groningen, the Netherlands. In her thesis, entitled ‘The Curaçao Cohort Studies: an analysis of the implementation of combination antiretroviral therapy in Curaçao’, based on SHM data, Dr Hermanides makes a number of important recommendations to optimise HIV care in Curaçao.
Worldwide, more than 10 million people use antiretroviral combination therapy (cART). Although, in Curaçao, cART has been in use since 1996, its availability did not become more widespread until 2002. At the time, there was little information about the clinical follow-up of individuals infected with HIV and about the effect of cART. To address this issue, in 2005 the Curaçao Red Cross Blood Bank set up a collaboration with the Sint Elisabeth Hospital Curaçao and SHM. Based on the data collected as a result of this collaboration, the first SHM Monitoring Reports revealed that people with an HIV infection in Curaçao tended to start cART too late and achieved sub-optimal viral suppression after starting cART. This showed that treatment outcome could be improved and Dr Hermanides therefore undertook to evaluate the HIV care in Curaçao.
Treatment in Curaçao remains suboptimal compared to the Netherlands
To gain further insight into the effect of cART in Curaçao, Dr Hermanides compared the outcome of cART in the HIV population treated in Curaçao with that in three different HIV populations receiving treatment in the Netherlands: individuals of Dutch origin, individuals of Surinamese origin and individuals of Antillean origin. This comparison confirmed that outcomes with cART in Curaçao were poorer than those seen in the Netherlands. In particular, many patients were found to discontinue treatment prior to or during cART or to start treatment too late due to a late diagnosis or an excessively long period of time between diagnosis and start of treatment. In addition, younger individuals or those not born in Curaçao were also more likely to discontinue treatment. The figures also show that discontinuing treatment or starting cART too late has resulted disease progression and reduced survival in HIV patients in Curaçao, with a higher rate of AIDS-related death in Curaçao than in Western countries, such as the Netherlands.
A new model for HIV care
“We would like to improve cART-associated outcomes in individual patients: longer survival with fewer complications. In addition, we would like to achieve a preventative effect of cART in Curaçao”, explains Dr Hermanides. “Based on scientific data and taking into consideration the setting, we have proposed a new model for HIV-related care. This model aims to achieve early identification of individuals with an HIV infection, immediate start of cART after diagnosis, and guaranteed life-long follow-up.”
Early identification and immediate start of cART
In the Caribbean region, late diagnosis of individuals with an HIV-1 infection is a major obstacle for timely initiation of cART. Dr Hermanides’s work revealed that most individuals in Curaçao with an HIV infection enter HIV care through primary health care. With each step that patients have to take through the continuum of HIV care in Curaçao, at least 25% are lost in the subsequent step. This is particularly high prior to starting cART. Therefore, by starting cART immediately after diagnosis, fewer people will discontinue care prior to starting treatment, suggests Dr Hermanides: “More rapid identification and immediate start of cART after diagnosis in the primary health care setting will improve the outcomes of cART in Curaçao”. Another important factor in improving cART outcomes is continuity of monitoring, with life-long follow-up. According to Dr Hermanides, continuity of HIV care after starting cART should, in particular, target younger patients and those not born in Curaçao.
Long-term developments
Dr Hermanides concludes that integrating HIV care into the healthcare structure in Curaçao is important for the further long-term development of HIV care. “Curaçao has a well-functioning primary health care structure. Transferring certain aspects of HIV care to primary health care seems to be a logical step in further optimising the effect of cART in Curaçao. For example, wider-scale HIV testing, starting first-line cART and providing continuity of care could all be shifted to the primary care setting in the new HIV care model”, says Dr Hermanides. A test-and-treat pilot study, currently comprising three general practices, will confirm whether this transfer of tasks will have the desired effect.