1. Hiv testing & counseling in the Netherlands Jan van Bergen, MD, MPh, PhD 12 november 2009

2. 2 From a reluctant policy towards proactive practice A historical perspective The state of the epidemic in the Netherlands T&C policy and practice Challenges

3. 3 Sweden. Data provided by D. Danielson STI epidemiology Number of reported cases of gonorroea per 100.000 inhabitants 1912 – 1995

4. 4 Bron: RIVM Soa centra STI epidemiology 2008: 88.435 consultations 9000 Ct infections ( >10%) 393 Hiv infections ( 0,2 - 3% )

5. 5 HIV in the Netherlands Concentrated epidemic Low hiv prevalence in general population (< 0,2%) 16.000 persons with HIV in care

6. 6 Policy makers MOH and Inspectorate Centre for infectious diseases (RIVM/Cib) National STI Commission (Platform of professionals and CBO) Advisory committee Active Testing and Counseling Soa Aids Nederland Expertise-centre CBO’s like Schorer (MSM) and Hiv vereniging (GNP+) New Integrated Sexual Health Policy (World Aids Day 2009)

7. 7 Policy shifts Before 1996: Reluctant test-policy 1996: Aids Fonds: more active hiv testing 1999: Revised recommendations NHC 2001: Steering committee active T&C 2004: Universal hiv –testing pregnant women 2007-2010: Roll out ‘Opt-out’ hiv testing STI clinics, proactive testing risk groups

8. 8 Starting point… ….. in 2004 42% MSM ever tested Netherl

9. 9 Did it work..? M&E of TC Practices Municipal Public Health Service 8 STI- centres

10. 10 PITC 1 Municipal Public Health Service 8 STI- centres: in first half 2009: 91% 56% 59% 72% 86% 90%

11. 11 MSM ever tested. Annual test rate = 1/2 Source: Schorer Monitor

12. 12 Universal Testing Pregnant Women 2004: Almost 100% coverage (n=185.000) Hiv-positivity: ~ 0,05%

13. 13 ‘Problem solved’ ? 16.000 persons with hiv in care New estimations: 20-25.000 Still 30-40% with hiv do not know it 75%*- 90%** of new hiv-transmissions by persons with HIV unaware 30% too late in care *Marks 2006; **SHM 2008

14. 14 PITC 2: the General Practitioner ! Health care seeking behaviour ! National Health Survey: GP sees 70% of STI consultations *van Bergen 2005, 2006

15. 15 GP: test request and test

16. 16 Very Urban Area: 10 / yr / average GP 3-5 / yr / average GP Hiv tests per 10.000 patients in GP ?

17. 17 Missed prevention opportunities in PC Proactiv testing “Talking about sexuality” More attention for sexual health in GP

18. 18 CICT Outreach testing Self-tests Internet 2009: 228.000 STI test advices

19. 19 CICT Outreach testing Self-tests Internet STI Adam 27.889 consultations 79% collects results on internet acceptability / usability ++ MtM: “One-stop shop” 2009: 228.000 STI test advices

20. 20 Quality issues HIV care in Europe: Netherlands Nr 5 “Prevention and monitoring (SHM)” Lab-issues: Quality assurance Testing issues: P 24 Rapid test in hr groups Counseling issues: internet MI http://www.healthpowerhouse.com/files/Report% 20Euro%20HIV%20index%20091008-3.pdf http://www.healthpowerhouse.com/files/Report% 20Euro%20HIV%20index%20091008-3.pdf H

21. 21 Conclusions and challenges Contextual issues Positive approach towards sexuality (The Dutch Approach)

22. 22 Conclusions and challenges M&E Testing and counseling: Integrated testing Ever tested; last ½ year Internet: “M&E in the virtual World” Primary care and the GP Quantitative… and qualitative data Are we capturing the real thing? Nr/% tests done ? Nr/% condoms given?

23. 23 Swahili proverb 1. Competence 2. Communication 3. Compassion What Counts in Counseling is Emotional Significance If you want so see with my eyes, give me your heart

24. 24 New flight instructions…..