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Checkpoint was the name of the first rapid HIV testing facility in the Netherlands. This project, run on a voluntary basis, was based in Amsterdam. From 21 June 2002 until its closure on 27 June 2008 almost 5000 people opted for a Checkpoint HIV test.
Contents
- Background
- Aim
- History
- Features of the Checkpoint formula
- Modus operandi of the Amsterdam Checkpoint
- Advantages
- Disadvantages
- Volunteers
- Consultations and diagnoses
- Trials
- References
The rapid HIV testing employed by Checkpoint was for the whole of its existence unique in the Netherlands, because it was at that time not used by the various local health authorities. Such authorities and physicians employed the regular HIV antibody test and clients had to wait 1 or 2 weeks for the result. When an increasing number of local health authorities began using the rapid HIV test, Checkpoint had served its purpose and could be closed down. The rapid HIV test enabled a reliable outcome to be generated within 15 to 20 minutes, which in practice lowered the threshold for such testing. Because in this way more people opted for testing, more HIV-positive people could be reached. A clear advantage is that the diagnosis is made at the earliest possible stage of the infection, facilitating adequate treatment. In addition, through successful early treatment, the infectious period for HIV-positive people can be reduced. In addition to developing the rapid HIV testing methodology, now widely employed, Checkpoint was constantly engaged in promoting the introduction of this rapid testing both in the Netherlands and abroad and in lending support to such initiatives.
Background
Research conducted in 2000 revealed that in the Netherlands only 42% of men who had sex with men (MSM) had ever in their lives been tested for HIV, so the Dutch HIV Association (HVN) wanted to introduce a rapid test in the Netherlands to lower the threshold to get tested. GlaxoSmithKline provided financial assistance.
Aim
The rapid HIV test had to be on offer to everyone who had incurred a risk of HIV infection, irrespective of gender or sexual orientation. The testing procedure had to include comprehensive pre-test and post-test counselling. Knowledge gained from this form of testing had to be analyzed and eventually be communicated in a structured manner.
History
In the beginning, the mainstream bodies in this field, such as SOA Aids Nederland and GGD (the public health authorities at city or district council level) were not immediately enthusiastic and regarded the initiative with some scepticism. The following initial objections had to be overcome:
- Checkpoint had chosen for the Determine rapid HIV test, then the only reliable rapid HIV test available in the Netherlands. The reliability of this test had already been established but was not known to everyone.
- Another point of criticism was that a positive result from a rapid HIV test had first to be confirmed by a Western blot (gold standard) and was therefore a provisional result. The CDC had observed around that time that 31% of positive results were not being collected.
- More tenacious was the conviction that having to wait 7 highly worrying days for the result of an HIV test would have a preventive effect, something for which no scientific basis was ever established. In practice it turned out to be a matter of logistics. Testing a large number of blood samples simultaneously was cheaper: the cost price per test was lower. Once the laboratory had initiated the testing procedure, the results from all blood samples were known within an hour. Additionally, the laboratories would suffer a loss in income were the testing localities to require only the Western blots.
Clients quickly found out about Checkpoint and this meant that the low-threshold walk-in clinic soon had to be abandoned. During the first 26 Friday surgeries, demand was seen to be 20% higher than the then available 375 test spots. Clients regularly declared that they had been waiting years for such rapid testing.
Recognition came in 2004 when, at the 15th World AIDS Conference in Bangkok, Checkpoint was able to demonstrate that the rapid HIV test in the Netherlands lowered the threshold for MSM to have themselves tested, which meant that the second of Checkpoint's two aims had been realized.
As of 2005, the Amsterdam City Council's public health service (the GGD) started offering the rapid HIV test to high-risk visitors to the STD Policlinic. The first of Checkpoint's goals was hereby also realized.
In 2006 the RIVM (Netherlands National Institute for Public Health and the Environment) advised the Ministry of Health to encourage the use of rapid HIV testing, to make an inventory of all obstacles to this and to eliminate these obstacles.
When 60% of the local health authorities appeared to be using rapid HIV testing as part of their standard method of screening, or were busy implementing it, this project could be successfully wound up. During an extensive farewell party on 27 June 2008 the then Mayor of Amsterdam, Job Cohen, thanked all volunteers for the results they had achieved.
For one more year, foreign rapid HIV testing projects were supported. All source documentation was made available in digital form. The Checkpoint formula was adopted not only in the Netherlands, but in many other cities: Aarhus, Athens, Barcelona, Basel, Cologne, Copenhagen, Dublin, Geneva, Helsinki, Lisbon, Ludwigshafen, Malmö, Mannheim, Munich, Nuremberg, Odense, Paris, Riga, Thessaloniki, Zagreb and Zürich. The Checkpoints in Denmark, France, Sweden and Switzerland received extensive support from Checkpoint Amsterdam. The Swiss Checkpoints have gone a step further, developing into Gay Health Centres. Not only do they perform tests for STDs and HIV, they also offer support for HIV-positive persons and in general for coming out, general psychological care for gay men, training in safe drug usage and assistance with cessation of smoking and alcohol abuse. In 2012 Checkpoints opened in Bern and Lausanne.
Features of the Checkpoint formula
Checkpoint was established primarily from the client's point of view. Where, when, by whom and how would he wish to be tested.
Modus operandi of the Amsterdam Checkpoint
When the service began, everyone could attend without appointment. However, demand exceeded supply, so it became necessary to work by appointment. HVN volunteers maintained the appointments schedule. When making an appointment over the phone, clients were asked whether or not they belonged to a high-risk group and about the risk they had experienced; they were informed about the window period. This information enabled a better match to be made between a doctor or nurse and the client for the Friday evening.
A volunteer trained in the paramedical field registered the client, talked about safe sex and gave a condom demonstration.
After this, a nurse or doctor gave pre-test counselling, conducted the HIV test and communicated the outcome 15 minutes later.
If the client tested positive or the result was ambiguous, a blood sample was taken for a Western blot and an appointment was made for receipt of the confirmatory result a week later.
In 79% of cases the confirmatory result was received in person a week later. In contrast to the previous week, clients were noticeably less emotional at this second talk and had highly specific and practical questions to ask. Although initially a point of criticism, this second post-test talk was in fact regarded by the doctors, nurses and clients as having added value.
Advantages
Disadvantages
Volunteers
This project was run by 43 volunteers. Once selected, volunteers followed an internal training programme, depending on their experience and duties, before being allowed to operate independently. In 2007 Checkpoint became the second voluntary organization in Amsterdam and the 25th in the Netherlands to receive the Goed Geregeld [well organized] award from the Dutch Association of Voluntary Organizations (NOV): an award reflecting the high quality achieved.
Consultations and diagnoses
Content can be sorted per column using the arrows in the headings. GGD Amsterdam refers to the local public health authority Gemeentelijke Gezondheidsdienst
It appears that, in the years of its operation as given above, Checkpoint was better able to reach higher-risk groups than was the Amsterdam Public Health Service (GGD). In 2002 and 2008 Checkpoint was operational for 26 Friday evenings. For comparison, the corresponding results per group are given for the Amsterdam Public Health Service's STD Policlinic. More detailed results (Dutch language) are to be found in '6 jaar Checkpoint, een samenvatting' [6 years of Checkpoint: a summary].
Trials
Detuned ELISA
Until early 2006 a Detuned ELISA test could still be requested in addition to a Western blot. This indicates whether the infections had occurred less than 6 months earlier or longer ago than this. It turned out that 63% of the infections were not recent.
General practitioners (family doctors)
A few GPs used the rapid HIV test in their practice. They noted that this encouraged patients who were otherwise reluctant to face a general STD investigation.
Mister B
In this Amsterdam leather and fetish shop a surgery was held on Sunday afternoons. In this way Checkpoint hoped to reach more effectively the MSM who visited leather bars. This turned out not to be the case, but it was attractive for less well educated men who were taking high risks, regularly experimenting with recreational drugs and not resident in Amsterdam. The incidence rate among these clients was 5.6%.
Oral fluid
In collaboration with OraSure a pilot was conducted with 1000 OraQuick ADVANCE® Rapid HIV-1/2 oral fluid tests. Initially this appeared to form the ideal HIV self-test, but during this pilot two false-negative outcomes were discovered. In a slightly smaller-scale pilot in London a false-negative was noted on three occasions.