dr. Marc van der Valk has been professor of internal medicine, in particular the treatment of HIV infection, since June 2021 (University of Amsterdam). He recently delivered his inaugural address entitled HIV care 3.0. That title says a lot about Van der Valk’s ambitions for the further improvement of this care.
Photo: Monique Kooijmans
Van der Valk was 17 when the daughter of one of his mother’s best friends died of AIDS. And while this didn’t directly affect his study choice, it did play a role. “I grew up in a time when AIDS was very prominent,” he says. “Everyone of my generation was afraid of it and with this it came very close.”
Yet it did not directly determine his choice of study. After quickly abandoning the idea of sports medicine, he chose internal medicine. It was not until his doctorate that the subject of HIV came emphatically to the fore. The Amsterdam Cohort Study became very important at that time, because it led to an endless stream of studies that radically changed the HIV field. “It is an excellent example of what you can achieve by working together with multiple disciplines,” says Van der Valk. “I want to commit myself to that in my professorship, both from Amsterdam UMC and from my position at the HIV Monitoring Foundation.”
Attention to Prep
In his inaugural address, Van der Valk emphasized the HIV prevention pill PrEP. The Netherlands is hopelessly behind in its implementation, he says, while the added value for the patient and the cost-effectiveness are clear. PrEP costs EUR 25 per patient per month, the estimated cost of lifelong HIV care is EUR 250,000 to EUR 300,000. “Of course there are other means,” he says, “such as condoms, only having sex with your own partner, or abstinence. But PrEP is a very effective and valuable addition to this arsenal of biomedical interventions.”
Together with GGD Amsterdam and postdoc Maarten Bedert, he is investigating reasons for stopping PrEP in men who have used it in the recent past and who have been diagnosed with HIV afterwards. “It’s very important to provide insight into that,” he says. “People can stop because they have a steady partner, for example. But it can also be related to risk perception. If everyone around you is using PrEP, it is imaginable that you think you are safe. In addition, it is possible that someone does not yet know that they have HIV. 50% has a flu-like picture in the acute phase, but after that someone can be symptom-free for an average of 7 years. What really does not help is that the GP does not see it as his task to prescribe PrEP and that the GGD is bound by a limited number of places for PrEP care by the government, leading to enormous waiting lists. That surprises me, because promoting health is pre-eminently a task of the general practitioner and public health.”
Complementary care
The Netherlands is also lagging behind in the field of peer-to-peer support. In England this is already a structurally complementary part of HIV care. Van der Valk: “We are developing a toolkit as an aid to make it clear to healthcare professionals and people with HIV what complementary care is available, because there are quite a few initiatives. Bringing them together can help improve access to them.”
Evaluating the added value of complementary care is more difficult. “The group that uses it suffers from a stigma and therefore makes no sense to fill in questionnaires from scientists,” explains Van der Valk. “It would therefore be good if the providers themselves also researched it, then the threshold would be lower. We are of course dealing with health insurers who say: first prove what it is worth. I understand that, but it is a volunteer fee and therefore not really large amounts. It has long been common in Africa, and there it appears to have a positive impact on the quality of life of patients.”
Get patients in the picture faster
Together with the Amsterdam Health & Technology Institute, Van der Valk and the HIV Monitoring Foundation will conduct research into the group of people who are diagnosed late with HIV. “We want to learn to recognize patterns,” he says, “such as healthcare consumption in the period prior to diagnosis. How much healthcare consumption, what did it cost, are there patterns? CBS data can be very helpful in this regard, especially if they are linked – anonymously, of course – with data from the HIV Monitoring Foundation. This will become even more the case if it is possibly ever processed whether people have visited the occupational health doctor. I think this research can be very valuable, that we can learn a lot from it about what else is going on about health problems and healthcare consumption than we are told in the doctor’s office. Perhaps it also offers a hook to develop other strategies, for example to reach people who have stopped using PrEP.”
Learning from hepatitis C
The approach adopted in the NoMoreC project to disseminate risk-reducing strategies and innovate hepatitis C testing capabilities has proven to be successful in detecting hepatitis C early and curing it through treatment. In view of the overlap between hepatitis C and HIV, Van der Valk sees an interesting possibility for HIV as well. “Like hepatitis C, HIV has a unique genetic code,” he says. “If you do that real time monitor, you can see more quickly that there is an outbreak to which you can respond more quickly.”
Something like that really needs to be set up together with the community, says Van der Valk. “At NoMoreC, that was the basis for success,” he says. “Developing a targeted campaign with a task that the target community understands and appeals to is not something you can do as scientists or with a communication agency. I saw how you can miss the point in my outpatient clinic with the communication about the covid vaccination. ‘Discuss with your medical specialist whether you can get this vaccination if you have another condition’, was that communication. Many people simply waited until they had the next appointment with their specialist, even if that was only six months later.”
Individual approach
Consultations become more effective if the patient completes a questionnaire beforehand. The challenge is to match this with the patient’s education and culture, says Van der Valk. These questionnaires are usually digital and that is not feasible for everyone. “This target group requires solutions other than an app,” he says, “such as a diary with illustrations.”
It is an example of more individualized care. According to Van der Vak, this is needed on several fronts. “The demand for care is changing rapidly now that the virus has been successfully suppressed,” he says. “People with HIV are getting older with more disabilities. Healthcare must respond to this, including nursing home care. People do not always dare to say that they are living with HIV when they go to a nursing home.”
Optimistic realistic
In his inaugural lecture, Van der Valk said that he is an optimist but also a realist about the healing and vaccine research that is taking place. “I think the road to developing strategies to cure HIV is very long,” he says. “The first step is to find the reservoirs in which the virus hides in the body. That is what the investigation is now focusing on.”
He is more optimistic about functional healing. “Medicines are emerging that only need to be given to patients once every six months and that can be used to achieve immunological control for a very long time,” he says. “At the same time, there is also a potential problem in arriving at the next step. After all, it’s up to the community to determine if they’re interested in a more intensive treatment that offers complete cures, if a drug is already available that suppresses the virus for a longer period of time, so they only have to take it once or twice a year. .”
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