Successes and Challenges of the Dutch HIV Response: An Interview with Maria Prins

The number of HIV diagnoses decreased, but not in Amsterdam. That is why about ten years ago, HIV researchers, people from the gay community and doctors came together in the capital. What else could they do? They came up with one online campaign in which they called on men who had had unprotected sex and had a fever – and therefore possibly had contracted an acute HIV infection – to be tested. They could go to the GGD extra quickly and immediately receive a result and, if necessary, treatment.

“This was ultimately implemented in all Centers for Sexual Health in the Netherlands,” says Maria Prins, professor of public health and epidemiology of infectious diseases at Amsterdam UMC. Earlier this year, she resigned as head of infectious diseases at the GGD Amsterdam after more than twenty years.

The Amsterdam partnership, that H-TEAM was mentioned, turned out to be a breeding ground for these types of innovations. It characterizes the Dutch HIV response. Prins started at the GGD Amsterdam in 1992. She first focused on people who used drugs and contracted HIV through contaminated needles and syringes. The Netherlands was the first country to provide clean needles and methadone. Nowadays, almost no one in the Netherlands gets HIV this way.

On the eve of World AIDS Day (December 1), the annual figures on the HIV epidemic in the Netherlands were released last week. Once again they are favorable: the number of estimated infections in 2022 was 141, a decrease of 85 percent since 2010. However, this will be disappointing for some: the city of Amsterdam had announced a decrease of 95 percent in September.

When asked why Amsterdam is at the forefront, Prins immediately talks about the H-TEAM, but also about the political involvement in the city. “Mayors and councilors really stood on stages for HIV.” GGD Amsterdam started a study on the provision of the HIV prevention pill PrEP five years earlier than the national government. The municipality has its own HIV policy: zero infections by 2026. Prins mentions the Amsterdam Cohort Studies, in which thousands of men are followed, since the start of the epidemic in the 1980s. “That generates a continuous stream of important information. I have great admiration for the participants who have been donating blood and completing questionnaires for almost forty years.”

How do you think the HIV approach is going in the Netherlands?

“It’s going in the right direction. If we continue like this, or perhaps a little more intensively, then the end is in sight.”

What clues did you see in the latest figures for what still needs to be done?

“You see that young people are doing a little less well, they are tested less often and use less PrEP. How can you approach them in a way that appeals to them? Maybe we’re too classic. In the Netherlands you could not test yourself for HIV for a long time. It was legally required to take a test under the supervision of a professional. Now we could distribute self-tests more often in places where the community comes. With corona, tests have been done through letterboxes or given to markets.

“Innovations for trans people are also important. We saw too little of them at the GGD. The GGD Amsterdam now holds consultation hours in the Trans United Clinic.

“There are still people who receive care too late. They are sometimes already ill and can pass on HIV. [Mensen met goed behandelde hiv kunnen het virus niet meer overdragen, red.] The total group of people who do not know they have HIV is getting smaller, so it is becoming increasingly difficult to locate and motivate them to get tested. It is a very diverse group, including straight women who have had risky contact. Or people who do not know that they have been at risk. Good data remains extremely important. Then you know what to bet on.

“GPs can play a role, but they already have a full package. In London, everyone who comes into A&E is tested for HIV unless they object. We could do that too, but of course it would cost money.”

What is the greatest success of the Dutch HIV response?

“We have continuously looked for innovations, in collaboration with the community. For example, hormone therapy is super important for trans people. If you integrate that with sexual health care in one place, such as at Trans United Clinic, then that is much better. This also applies to sex workers: they have one place for all facilities in Amsterdam.

“Of course we have good preconditions in the Netherlands, such as legislation and the healthcare system. The Netherlands tolerates drug use, prostitution is regulated. This helps combat the stigma of getting tested. In Russia, infections are now rising among the LGBTI community as they are pushed to the margins of society.

“I am concerned about the Netherlands. About how the elections will affect HIV prevention and care. I don’t know whether a right-wing government wants to release the same amount of money for HIV care or PrEP. Polarization has not made it easier for LGBTI people or people with a migration background.”

Would you call PrEP a success?

“It has proven to be a success story, but the speed and scale could have been much greater. It took forever before we could start the PrEP study in Amsterdam. And then we had a national pilot, even though we already knew that it worked. The waiting lists were horrible; In the new figures you see that people on the waiting list have contracted HIV. That wasn’t necessary. Now PrEP will be available to everyone next year, which is great, but you have to pay for your pills yourself. Are people going to be left out again?”

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Where did that slowness come from?

“I have seen political leadership more at the city level than nationally.”

The Netherlands wanted to know for sure whether PrEP also worked here.

“That’s a bit arrogant, right? As if PrEP would not be cost-effective in the Netherlands, while this has already been demonstrated in six other countries. I understand that you have to make choices in healthcare. But prevention is so important. That ends up being so much cheaper.”

How long do you have to spend millions of euros to detect or prevent those last few infections?

“Fair question. It is becoming increasingly difficult to find infections, so it costs proportionately more and more money. You have to keep looking at how you can do that cost-effectively. There is a danger that if you let it go, epidemics will arise again. You can’t stop. In addition, the Netherlands can play an exemplary role and inspire other countries, like: look, it is really possible.”

Maria Prins (1964) started in 1992 as researcher at the infectious diseases department from the GGD Amsterdam and became head of department in 1999. She obtained her PhD from the UvA. In 2010 she was appointed professor of public health, in particular epidemiology of infectious diseases, at the Amsterdam UMC, where she has worked one day a week since 2006.

2023-11-26 13:00:17
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