Medical and social differences between French and migrant patients consulting for the first time for HIV infection

TOGETHER Project to Increase Understanding of the HIV Epidemic Among Sub-Saharan African Migrants: Protocol of Community-Based Participatory Mixed-Method Studies

Background

Sub-Saharan African Migrants (SAM) are the second largest group affected by HIV/AIDS in Belgium and the rest of Western Europe. Increasing evidence shows that, more than previously thought, SAM are acquiring HIV in their host countries. This calls for a renewed focus on primary prevention. Yet, knowledge on the magnitude of the HIV epidemic among SAM (HIV prevalence estimates and proportions of undiagnosed HIV infections) and underlying drivers are scarce and limit the development of such interventions.

Objective

By applying a community-based participatory and mixed-methods approach, the TOGETHER project aims to deepen our understanding of HIV transmission dynamics, as well as inform future primary prevention interventions for this target group.

Methods

The TOGETHER project consists of a cross-sectional study to assess HIV prevalence and risk factors among SAM visiting community settings in Antwerp city, Belgium, and links an anonymous electronic self-reported questionnaire to oral fluid samples. Three formative studies informed this method: (1) a social mapping of community settings using an adaptation of the PLACE method; (2) a multiple case study aiming to identify factors that increase risk and vulnerability for HIV infection by triangulating data from life history interviews, lifelines, and patient files; and (3) an acceptability and feasibility study of oral fluid sampling in community settings using participant observations.

Results

Results have been obtained from 4 interlinked studies and will be described in future research.

Conclusions

Combining empirically tested and innovative epidemiological and social science methods, this project provides the first HIV prevalence estimates for a representative sample of SAM residing in a West European city. By triangulating qualitative and quantitative insights, the project will generate an in-depth understanding of the factors that increase risk and vulnerability for HIV infection among SAM. Based on this knowledge, the project will identify priority subgroups within SAM communities and places for HIV prevention. Adopting a community-based participatory approach throughout the full research process should increase community ownership, investment, and mobilization for HIV prevention.

Differences in recourse to HIV testing according to migration origin in the Paris metropolitan area in 2010

In France, HIV prevention within Maghrebi or French of Maghrebi origin has been seldom studied. The purpose of this study is to compare the recourse to HIV test according to nationality and origin. Data were from the 2010 SIRS cohort, which included 3,006 households representative of the Paris metropolitan area. Results of the study show comparatively low HIV testing rate among Maghrebi and French of Maghrebi origin compared to French with French parents.

Time since the last HIV test and migration origin in the Paris metropolitan area, France

In France, the newly diagnosed infection rate was 372/100,000 for African immigrants versus 6/100,000 for the French-born population in 2008. In addition, people from sub-Saharan countries were at higher risk for late diagnosis than native-born French despite their more frequent use of HIV testing. The purpose of this study was to compare the mean time since the last HIV test according to migration origin. This study used data from the SIRS (a French acronym for health, inequalities, and social ruptures) cohort, which, in 2005, included 3023 households representative of the greater Paris area. HIV testing uptake and the time since the last test were studied in relation to socio-economic factors, psychosocial characteristics, and migration origin. Multivariate ANOVA analyses were performed using Stata 10. People from sub-Saharan Africa were more likely to have been tested in their lifetime (78.51%) than those of French (56.19%) or Maghreb (39.74%) origin (p<0.0000). The mean time, in years, since the last HIV test was shorter among sub-Saharan immigrants and Maghreb immigrants (2.15 and 2.53 years, respectively) than among native-born French (4.84 years) (F=12.67; p<0.0000). These differences remained significant even after adjusting for gender, age, number of steady relationships, time lived in France, and difficulty reading and/or writing French (F=5.73; p=0.0007). A gender analysis revealed the same pattern for both sexes, with greater differences in the mean duration by migration origin for women. These results and recent epidemiological data seem to show that since the early 2000s, measures aimed at increasing HIV testing and decreasing late diagnosis in sub-Saharan immigrants have been effective.

"It's better not to know": perceived barriers to HIV voluntary counseling and testing among sub-Saharan African migrants in Belgium

This study explored perceptions, needs, and barriers of sub-Saharan African migrants in relation to HIV voluntary counseling and testing (VCT). Using an inductive qualitative methodological approach, data were obtained from focus group discussions. Results showed that participants were in principle in favor of VCT. However, they indicated that barriers outweighed advantages. Such barriers included fear of positive test results and its related personal and social consequences, lack of information, lack of preventive health behavior, denial of HIV risk, and missed opportunities. Limited financial resources were only a concern for some subgroups like young people, asylum seekers, and recent migrants. This study identified multiple and intertwined barriers to VCT from a community perspective. In order to promote VCT, interventions such as raising awareness through culturally sensitive education should be adopted at community level. At level of service provision, provider initiated HIV testing including target group tailored counseling should be promoted.

[Epidemiology of HIV infection in immigrants in Spain: information sources, characteristics, magnitude and tendencies]

Lately Spain, the proportion of immigrants has increased in both general and HIV-infected populations. Nevertheles, data on the temporal trends of the epidemic in immigrants and on their sociodemographic, epidemiologic and clinical characteristics are scarce and are scattered in various information sources that cover complementary aspects of this issue. The objectives of the present study were to analyze the available information sources that allow the epidemiology of HIV infection in immigrants in Spain to be studied, and to describe the current situation of HIV infection in immigrants, based on the available information sources.

HIV testing strategies across European countries

With universal access to effective combination antiretroviral therapy (ART), people in need can gain effective treatment but are only able to benefit from these advances if they are aware of their serostatus and have effectively accessed testing services. Despite the expectation that ART would lead individuals to seek earlier testing, this trend has not been observed in practice, with stable or even increasing rates of late diagnosis in Europe being witnessed. Ahead of a gathering of key European stakeholders in Brussels in November 2007, we reviewed testing strategies across European countries. We show differences in policy and practices. Moreover, HIV testing strategies are changing, in line with new global guidelines issued by World Health Organization headquarters, and a number of countries are promoting an expansion of routine and opt-out testing. However, gaps in our understanding of effective testing strategies remain and, as a consequence, national policies across Europe remain incoherent and often lack an evidence base. This is likely to have serious public health implications.

Prevention of mother-to-child HIV transmission: similar access for sub-Sahara African immigrants and for French women?

OBJECTIVE

: To investigate whether mother-to-child transmission (MTCT) management and rate differed between African immigrants and French-born women delivering in France.

METHODS

: MTCT strategies were studied among human immunodeficiency virus type 1-infected women delivering between 1984 and 2007 in the multicenter French Perinatal Cohort, according to geographical origin.

RESULTS

: Among 9245 pregnancies (in 7090 women), the proportion of African mothers increased from 12% in 1984-1986 to 64% in 2003-2004. African women had later access to care than French women, even in recent years (1997-2004). They more often discovered their HIV infection during pregnancy (40.6 vs. 11.5%, P < 0.001), started prenatal care in the third trimester (14.1 vs. 9.8%, P < 0.001) and started antiretroviral therapy after 32 weeks gestation (7.6 vs. 4.1%, P < 0.001). The association with late treatment initiation disappeared when adjusted for late HIV diagnosis and prenatal care (adjusted odds ratio 1.0, 95% confidence interval 0.7-1.4). African and French women did not differ in terms of access to highly active antiretroviral therapy, nor for substandard management such as vaginal delivery with uncontrolled viral load, lack of intrapartum and postpartum treatment or breastfeeding. The MTCT rate was higher for African than for French women receiving antiretroviral therapy (1.8 vs. 0.8%, P = 0.02), but the difference was no longer significant after adjustment for main transmission risk factors (adjusted odds ratio = 1.7, 95% confidence interval 0.8-3.7, P = 0.17). MTCT did not differ among 2110 term deliveries with maternal viral load less than 400 copies/ml, (0.8 vs. 0.6%, P = 0.5).

CONCLUSION

: African immigrants more often had late HIV screening in pregnancy than French-born women, but had similar access to MTCT prevention, once the infection was diagnosed.

Late HIV diagnosis of people from culturally and linguistically diverse backgrounds in Sydney: The role of culture and community

In Australia more than 85% of newly diagnosed HIV infections in 1999-2003 were homosexually acquired. In contrast, among people from culturally and linguistically diverse backgrounds, there is a much higher proportion of heterosexual exposure and many of the heterosexually acquired infections are diagnosed 'late', with people sometimes presenting with symptoms of AIDS. This paper reports on circumstances of late HIV diagnosis, meaning of an HIV-positive diagnosis and perceptions of risk among HIV-positive people from a variety of cultural and ethnic backgrounds in Sydney. The focus was on commonalities across cultures and ethnicities. Data were collected through semi-structured in-depth interviews with clients of the Multicultural HIV/AIDS and Hepatitis C Service and a sexual health clinic. Regular HIV tests were the exception in this group. Testing was usually motivated by a serious health crisis. Participants interpreted their diagnosis in the context of their knowledge and experiences with HIV/AIDS in their country of birth and the perceptions of HIV/AIDS in their ethnic communities in Australia. Many were not aware of the relationship between HIV and AIDS. Risk was perceived in terms of 'risk group' membership not in terms of practices and behaviours. Late diagnosis cannot be explained solely by association with country of birth, race or ethnicity. Rather, it is located within complex sets of social and cultural relations: the values attributed to HIV/AIDS and those infected and the social and cultural relations of ethnic communities in Australia and the dominant culture. These are enacted in healthcare seeking behaviour, perceptions of people with HIV and perceptions of being 'at risk'.

Caractéristiques des patients nouvellement pris en charge pour une infection VIH dans un CHU parisien en 2002–2003

OBJECTIVES

The authors had for aim to assess incident HIV+ patients in Saint-Antoine hospital, Paris in 2002-2003 (transfers excluded).

METHODS

Sociodemographic, clinical, and virological data were collected to compare French and sub-Saharan patients.

RESULTS

Three hundred new HIV+ patients were identified: mean age 36.2 year; ratio M/W 65/35; origin: Caucasian 43%, African 44%, Maghrebian 8%, Asian 3%; nationality: French 45%, sub-Saharan African 44%; illegal aliens 65%; employed 51%; transmission: heterosexual 54%, homosexual 39%, intravenous drug user (IVDU) 2%; circumstances for diagnosis: HIV exposure 34%, primary infection 9%, symptoms/AIDS 23%, pregnancy 6%, other 28%; CDC stage: A 77%, B 9%, C 14%; mean T-CD4+ 374/mm3, median HIV-RNA 30780 cp/mL; co-infection HBV 7.3% HCV 5%.

OUTCOME

88% still followed up in Saint-Antoine, 2% transferred, 9% lost to follow-up, 1% dead. A significant difference was shown: 1) between French (N = 123) and African (N = 46) men for heterosexual transmission (10 vs 91%), working status (85 vs 28%), T-CD4+ (354 vs 251/mm3), outcome (lost to follow-up 5 vs 24%) [P < 0.01]; 2) between French (N=13) and African (N = 85) women for age (41 vs 32 years), working status (38 vs 10%), stage A (54 vs 81%) [P < 0.05]; 3) between African patients according to sex (46M/85W) for age (39 vs 32 years), working status (28 vs 10%; P = 0.01), outcome (lost to follow-up 24 vs 6%) [P < 0.01].

CONCLUSION

This study highlights the persistence of HIV in native homosexual French men and the increasing prevalence in African migrant with precarious social status.