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Interventions for infectious diseases

How can we ensure people are able to get tested for HIV in good time? What barriers do health professionals face when trying to implement new guidelines, and how can they be overcome? Nicole Dukers (CAPHRI) studies this. As an epidemiologist and associate professor, she looks, amongst other things, at ways to prevent infectious diseases such as HIV and hepatitis and to reduce the burden of the disease. Nicole: “Our research teaches us what effective strategies are for reaching certain groups, encouraging testing behaviour and detecting infections.”

Nicole focuses on prevention. "I study what keeps people healthy and how we can prevent illness. For me, health is physical, mental and social. Our team conducts innovative research into social health: connection with others, the quantity and diversity of your contacts, support and the quality of relationships. Social contact directly influences your health, for example through your immune system and mental well-being, and indirectly, for example through such as lifestyle and vaccination behaviour. Social health is crucial in the prevention of infectious and chronic diseases, but has long been overlooked. There is much to be gained for healthcare and public health in this area."

 

Interaction with the living environment

"What makes my work particularly interesting is the interdisciplinary approach. A randomised controlled trial (RCT) often does not work in this field because you isolate only one factor. That is why an RCT does not teach you how something will work in practice, because there are many factors involved. We take a broad view of these factors, because health arises from interaction with your living environment: the neighbourhood where you live and the people around you. Do you have a green, safe environment, support from your social network and sufficient resources to keep up with daily life? Or is that lacking? That makes a world of difference to health, resilience, lifestyle and access to information and care. Solutions therefore often lie in that interaction, rather than in the individual alone. Prevention also remains very much needed. We see this in the recent reversal of the long-term decline in new HIV diagnoses, in high rates of loneliness and social disconnection, and in the growing differences between groups in access to a healthy living environment, care and health."

Many people think HIV is no longer really present in the Netherlands.

HIV

One of Nicole's specific research topics is infectious diseases. "I mainly research bacterial and viral infections, such as HIV or hepatitis. Many people think HIV is no longer really present in the Netherlands, but more than 400 people are newly diagnosed each year and around 25,000 people are living with HIV. Within this group, there are also people who do not know they have HIV. If you know this and act quickly, you receive effective treatment, which means you’ll have the same life expectancy as someone without HIV and you cannot transmit the virus anymore. That is why it is very important that we reach these people, and ensure more people get tested in time. Now, half of the new diagnoses are late infections. Testing is therefore an effective prevention strategy for HIV."

Limburg4Zero

"Together with the community, we have therefore set up Limburg4Zero at the Public Health Service (GGD), in collaboration with the university and the hospital. This is an accessible home-based care intervention including self-collected samples for home use. It is truly integrated into healthcare, which we are the only ones in the Netherlands to have done so far. This means people are also referred for treatment and receive tailored sexual health advice based on research we have conducted in practice with doctors and healthcare professionals. In addition to HIV, we test for gonorrhoea and other STIs. Half of the people who use this home-based care had never been tested before. So we are removing barriers to reaching people who do not know they have HIV; for example, they do not have to go to a specific location.”

Hepatitis

“We are also conducting research into hepatitis B and C, with PhD candidates Chrissy Moonen and Elfi Brouwers. The percentage of people who are unaware that they have these infectious diseases is higher than for HIV, at around eighty per cent worldwide. Testing is therefore important. We looked at where the risk of these infections may be higher and where people are not always effectively reached with testing, for example in certain communities. We offered them a test, which sounds simple, but it isn't. The communication really has to resonate with the people we want to reach, with clear and understandable information that helps make testing an easy step. Our starting point is that we first assess who we want to reach and then adapt the care-offer and the communication strategy accordingly. In this case, we had a lot of contact with the community itself and removed any potential barriers up front, which resulted in a fairly high turnout. This is not only important for the research, but especially because it means that people are guided towards care."

“We also investigated integrated testing within existing healthcare, for example in the mandatory tuberculosis screening for migrants. Together with healthcare practitioners, we added an additional test for hepatitis B, C and HIV and assessed whether this was acceptable to patients and feasible for the healthcare system. This proved to be the case, so  such an approach can be a valuable addition to identifying unknown cases and referring them to healthcare.”

With the coronavirus we saw how important social contacts are, also for our own and social resilience.

Discontinuing chlamydia testing

Furthermore, Nicole also conducts extensive research into implementations and de-implementations. "I find it interesting to examine what is required for healthcare professionals to adopt new guidelines. What barriers exist and how can they be overcome? For example, the Netherlands is the first country in the world to discontinue testing for chlamydia in people without symptoms as of 1 January 2025. Extensive testing did not lead to a decrease in transmission, and the risk of long-term complications was lower than we thought. Stopping asymptomatic testing at the GGD is a major shift, as it had always been done previously. Together with postdoc Zoïe Alexiou, we are mapping out what is needed for that change observing how it is unfolding in practice. Feeding back the insights into practice helps to make the change. When implementing a change or intervention, communication before, during and after is crucial, both to healthcare providers and to the public.”

Societal awareness

Nicole hopes her research will lead to fewer people contracting serious infectious diseases and fewer people being unaware of having them. "Some people and groups have less access to prevention and care due to various barriers. With our research and through what we do in practice, we are trying to bridge that gap. It teaches us effective strategies for reaching certain groups, encouraging testing behaviour and detecting infections. It also contributes to national and European guidelines, from the National Institute for Public Health and the Environment (RIVM) or the European Centre for Disease Prevention and Control (ECDC).”

“In addition, I hope that the social aspect of health and the living environment will receive more attention. We are doing a lot of research into this, for instance with PhD candidates Senne Wijnen and Lynn Theunissen: not only with data and figures, but also by collaborating with and listening to citizens, health professionals and policymakers. With the coronavirus, for example, we saw how important social contacts are, also for our own and social resilience. I would like to contribute to this theme receiving more attention in society, care, policy and research.”

 

Text and photo: Joëlle van Wissen

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