Interview with Jan van Bergen: the GP's role in HIV care
Jan van Bergen holds an endowed professorship in HIV and sexually transmitted infections (STI) in primary care at the University of Amsterdam (AMC-UvA) Faculty of Medicine. He also works as a general practitioner (GP) Amsterdam. We talked to Professor van Bergen about the role of the GP in the HIV field and his vision for optimising HIV detection by GPs.
Could you tell us how, as a GP, you came to be involved in HIV and STIs?
My involvement with HIV and STIs goes back to the tropics. I worked as a doctor specialised in tropical medicine in Nicaragua and Africa, where I was confronted with HIV and other STIs. In fact, at the time, a study by the World Bank showed that STIs were the biggest cause of disease and death in women in developing countries. I subsequently moved to the London School of Hygiene and Tropical Medicine, where I continued to work on HIV and STIs by investigating the role of STIs in HIV transmission and how treatment of STIs could be improved.
After a while I tired of all the travelling and decided to work in the Netherlands. Since I was keen to continue to my affinity with HIV and STIs, I started work as a GP in a healthcare centre in there Amsterdam Bijlmer area. Between 75-80% of my patients are Surinamese, Antillean or Ghanaian. This is what makes it interesting for me: not only do the roots of my interest in HIV and STIs lie in these people’s countries of origin, but HIV infections and STIs are also more common in these groups.
Once an HIV infection is diagnosed, the patient enters the HIV treatment process. What role does the GP play in this process?
The GP’s main task is to identify HIV infections, since more than 30% of HIV infections are detected by a test carried out in the general practice setting. As such, GPs play quite an important role. However, other than this, the GP’s role in HIV care remains small at present.
Nonetheless, I envisage that, in the future, GPs will start to play a bigger part in the treatment process. In recent years, treatment has become simpler, and, in developing countries, treatment is already being carried out by health assistants. I don’t see why a GP in the Netherlands can’t do this too, if people with less training are doing it in other countries. Another good model for HIV care is the diabetes care model. We’re not there yet, but I believe it will happen at some point. I also believe that it is important for the GP to have more contact with HIV patients, particularly since these patients are now reaching older age and will require the GP’s services for the various age-related diseases they may develop (regardless of whether these diseases are related to HIV).
An estimated 24% of all HIV-infected individuals in the Netherlands remain unaware of their HIV status. How do you think GPs can contribute to lowering this figure?
I think it’s very important to normalise the HIV test, not only for GPs but also for patients. There is still a taboo surrounding HIV amongst patients, particularly in certain ethnic groups, and this raises the barrier to being tested.
I believe GPs shouldn’t just wait for patients to request the test, but should also be more proactive in testing. Proactive testing is now part of the revised guidelines for GPs and can be approached in different ways. First, testing could be done as standard procedure when a patient presents with indicator conditions that may signal an HIV infection, particularly in at-risk groups. This has been shown to be effective: my PhD student, Ivo Joore, investigated how often patients visited the surgery prior to being diagnosed with an HIV infection. He found that they had come at least once a year and that, in the five years preceding the HIV diagnosis, 60% of these patients had presented with an indicator condition during these prior visits. Had we done the test immediately, we could have known far earlier that they were HIV-positive. This is particularly important for people from HIV-endemic areas, as more than 60% of these people enter care too late, with a CD4 count below 350. Secondly, GPs could carry out the HIV test as part of the standard blood work-up in patients from HIV-endemic areas. I myself aim to have my patients from HIV-endemic regions tested at least once. I think that this proactive approach to testing should become just as normal as doing a diabetes test now is in a person of Hindustani origin. A third option is to follow the guidelines recently issued by the UK’s National Institute for Clinical Excellence, which state that HIV tests should be carried out at the introductory visit of all new patients if the general practice is located in an area with a prevalence of more than 2 per 1000. In my opinion, this is best done as part on an integrated health check-up, based on risk profiles.
This proactive approach won’t happen overnight. GPs in the Netherlands will need to be motivated and informed. As chair of the Dutch Society of General Practitioners (NHG) expert group on STIs, HIV and sexuality, I am involved in various activities. For example, we have set up an e-learning programme in which we teach GPs which STI tests they should carry out and where we emphasise how important the GP is in establishing the correct diagnosis. In addition, 18 months ago we developed a new standard for STI consultations in which active or proactive testing for HIV and hepatitis are at the forefront. This standard is also new in that there is now far more evidence supporting the importance of GPs actively detecting HIV or hepatitis infections to ensure early treatment. This is important for both the patient and society as a whole, since it can prevent transmission. Ultimately, my aim is to reach as many GPs and trainee GPs through this expert group. They can then share their knowledge with colleagues, thereby keeping the ball rolling.
A second project that aims to stimulate a proactive approach is the H-TEAM (HIV Transmission and Elimination in Amsterdam). The H-TEAM project was set up to reduce HIV incidence amongst at-risk groups, improve the prognosis of HIV-infected individuals and lower transmission rates in risk groups in Amsterdam. All parties involved, from GPs to the public health service and the HIV treating physicians themselves will have to contribute to achieving these goals. For example, GPs and specialists should carry out more tests with the aim of prevention, the public health service should expand its outreach activities and the HIV treating physicians will have to ensure patients are placed on treatment earlier. In other words, an integral approach to reducing the number of new infections, where all parties work together and new prevention initiatives are set in motion.
The H-TEAM projects have recently started. What will these entail for Amsterdam GPs?
I am involved in the project group that aims to increase active detection of HIV infections. Again, the focus is on stimulating GPs, but also other parties such as the public health service, to be more proactive. We’re also planning to work on the continuing medical education of GPs in Amsterdam with a practice-based approach to improve testing, where GPs receive feedback on their STI and HIV testing behaviour. Over-testing and under-testing is discussed and GPs are stimulated to be more proactive in HIV testing and more alert in recognising possible cases of (acute) HIV infection.
In addition to GPs, hospital specialists will also be targeted and encouraged to carry out HIV tests in the case of indicator conditions. In addition, our plan is for HIV-treating physicians to act as ambassadors within hospitals to encourage other specialists to look out for these indicator conditions. Finally, in 2016 we are going to organise a free HIV test week in Amsterdam.
What is your vision for HIV care in the future?
As I said, I think that there will be a shift in medical care tasks, including prevention, diagnostics, treatment and support, with those associated with chronic care returning to the GP. There will also be many changes in terms of technology. For professionals, there will be changes in the clinician decision support systems. For patients, we can expect to see internet-based testing becoming available, where, for example, an STI or HIV test can be done using a mobile smart phone. Experiments are already underway with Google Glass, allowing saliva-based diagnosis, and with small devices that allows a person to carry out their own lab test.
All in all, we’ve come a long way, but there’s still room for improvement. I am interested to see what the next 10 years will bring us.