Normalising HIV testing in general practice – An interview with Dr. Jan van Bergen
For the last 15 years, Dr. Jan van Bergen has been active in education and research in the field of sexually transmitted infections (STI’s), focusing particularly on HIV and Chlamydia. Through his work as Professor of STI primary care at the University of Amsterdam’s Faculty of Medicine (AMC-UvA), Programme Manager at Soa Aids Nederland and as STI primary care consultant for the RIVM he makes a significant contribution to the quality of STI primary care, but it is through his work as a GP that he receives direct feedback on the reality of managing STI’s at the patient level. During NCHIV 2012, Dr. van Bergen will speak on “Proactive HIV-testing by the GP: fact or fiction”. We caught up with him prior to the conference to learn more about his vision on HIV testing in practice.
Could you please explain what the current situation is in the Netherlands regarding HIV testing in primary care? What are the challenges for introducing proactive HIV testing?
A major problem that’s occurring today is that many HIV-infected people, around 30-40%, are unaware of their HIV status, and around half of these enter care too late. This underlines the urgent need for more HIV testing. We currently see that HIV testing at STI clinics is actually very high, with 98% of people visiting clinics being tested for HIV. So it is becoming more and more important to test in other primary care settings, particularly at GP’s.
Most people visit their GP at least once a year, and approximately 70% of HIV/STI consultations take place in primary care. So there are plenty of opportunities to promote HIV testing, but the challenge is operationalising HIV testing at GP’s. It is often not easy for doctors or patients to discuss sexually related matters, especially if the reason for a visit to the doctor is unrelated to these matters (for example, diabetes control). But the evidence is there that we are missing too many opportunities.
I believe there are three opportunities for discussing HIV-testing with patients. The first is with people that visit their GP with STI or HIV-related complaints, and the second is with people requesting an STI test. In both cases it is necessary to ask the right questions to find out more about that person’s sexual history so that the proper test advice can be given. The third opportunity is that doctors proactively discuss HIV testing with patients and pay more attention to the background, lifestyle and sexuality of their patients, regardless of the reason for the consultation. How to do this in a natural way is a challenge.
Could you please explain what the latest guidelines are for HIV testing in the Netherlands?
The guidelines for Dutch GP’s are currently being revised and will be available in 2013. The revised guidelines will focus on a risk group approach and on indicator conditions, giving guidance to GP’s on who to test and when to test. The aim is normalising HIV-testing in clinical care, with a low threshold for offering the test in patients with conditions like lymphadenopathy, Epstein-Barr virus (EBV) or herpes zoster (commonly known as shingles). And certainly offering HIV-testing more routinely to at-risk groups and in high prevalence areas will also be in the guidelines. I think that the real challenge will be the implementation of the guidelines to promote good clinical practice on a day-to-day basis.
What training programmes are available for GP’s concerning HIV/STI testing?
Continuous education programmes are available and are important for the introduction of new guidelines. Through seksHAG, an expert group on STI’s, HIV and sexuality set up by the Dutch Society of General Practitioners (NHG), GP’s are provided with ongoing support and education. seksHAG has a train the trainer system which allows continuous education sessions to be delivered throughout the Netherlands. To date sessions have been delivered to around 1500 GP’s annually. Other programmes are also available including e-learning sessions which incorporate audiovisual materials such as videos.
What, in your opinion, would be the ideal scenario for HIV testing?
The most ideal scenario would be to create a supportive environment for patients to get tested. Stigma, discrimination and prejudice are still major barriers for testing. Discussing sex and sexuality more openly and less judgementally is certainly a prerequisite. In the Netherlands we are already reasonably good at this, better certainly than some other Western countries. Positive attention for sexual health would enable HIV testing to become a more routine test, normalising HIV testing.