Knowledge of HIV prevention biomedical tools among African immigrants in France: the Makasi project

Background

In France, post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) have been available for several years. However, there is still no evidence on the level of knowledge of these HIV prevention tools among immigrants from sub-Saharan Africa living in precarious situations, a population particularly affected by HIV. The aim of this study is to describe the knowledge of these tools in this population and analyse the factors associated with this knowledge.

Methods

The data mobilized are from the Makasi interventional research that was conducted between 2018 and 2020 among immigrants from sub-Saharan Africa in precarious situations in the greater Paris area. Using data collected from 601 participants, we described levels of knowledge of HIV treatment effectiveness, treatment as prevention (TasP), post-exposure prophylaxis (PEP), and pre-exposure prophylaxis (PrEP), by sex with a chi2 test. We investigated factors associated with their knowledge with logistic regressions adjusted for sociodemographic characteristics, living conditions and sexual behaviors (p ≤ 0.2).

Results

The population surveyed was predominantly men (76%), from West Africa (61%) and in a precarious situation: 69% were unemployed, 74% were undocumented, 46% had no health coverage and 13% were homeless. In this population, knowledge of antiretroviral treatments for HIV prevention was heterogeneous: the effectiveness of HIV treatment was well known (84%), but only half of the respondents (46%) were aware of TasP and very few knew about PEP and PrEP: 6% and 5% respectively. Multivariable-adjusted models showed that these tools was better known by educated people, those who had a social network in France, those who have had access to the health system and those who were exposed to sexual risks.

Conclusions

While sub-Saharan African immigrants know the effectiveness of HIV treatment and use certain prevention tools such as HIV testing, they are not aware of PEP and PrEP.

Key messages

Health empowerment and access to health coverage among immigrants in France: the Makasi intervention

Background

The Makasi community-based research project offered an innovative health-related empowerment intervention to immigrants from sub-Saharan Africa living in precarious situations in the greater Paris area, to reduce their social vulnerability and their exposure to HIV. Our objective is to evaluate the impact of the intervention on access to health coverage in this population.

Methods

Participants were recruited based on precariousness criteria in public places in Ile-de-France (squares, railway stations, markets, etc.) by mobile teams of social workers and health mediators. Following a stepped-wedge design, participants were randomised into two groups receiving the intervention sequentially (immediately in one group and 3 months later in the other). We evaluated the impact of the Makasi intervention on access to health coverage among 821 individuals observed at 0, 3, and 6 months, between 2018 and 2021. We implemented random-effects panel models - allowing for unobserved heterogeneity - using a Heckman selection approach to correct for attrition. Finally, we used seemingly unrelated regressions (SUR) to examine the extent to which the effect of the intervention was mediated by health-related empowerment.

Results

Participants - 77% of which were men - had been living in France for 4 years on average. 44% of them had no health coverage at the time of inclusion. Our results provided evidence for a significant impact of the Makasi intervention on participants’ access to health coverage, with an 18 percentage-point increase in the probability of accessing health coverage 6 months after having received the intervention (p < 0.01). The mediation analysis revealed that this effect operated partly through an empowerment process in terms of knowledge of social and health resources.

Conclusions

We showed that a health empowerment intervention provided by social workers and health mediators largely favours access to health rights for immigrants in precarious situations.

Key messages

• A health empowerment intervention improved access to health coverage among immigrants from sub-Saharan Africa living in precarious situations in France.

• Improvement in access to health coverage was found to be partly mediated by reinforcement of participants’ health literacy in terms of social and health resources.

The effect of financial support on depression among young adults during the COVID-19 pandemic

Background

To mitigate the adverse effects of the COVID-19 pandemic on financial resources, governments provided financial support (e.g., emergency aid funds) as well as family via personal assistance. This study aims to assess the moderating effect of financial support from the government or from family on the association between income loss and depression among young adults.

Methods

Two online cross-sectional surveys among young adults (18-29) living in Canada and France were conducted in October-December 2020 (n = 4511) and July-December 2021 (n = 3329). Depressive symptoms were measured using PHQ-9 score+10. Two logistic regression models were performed for each survey with an interaction term between income loss and financial support (government or family modeled separately), controlling for demographics (e.g., country, age, gender, income, living conditions).

Results

In the total sample, half reported depressive symptoms (2020/2021: 53%/46%), and over a third lost income (2020/2021: 10%/12% all income, 38%/22% some income). In 2020, 41% received government financial support (2021: 18%) while family/friends support was constant (12%). In both surveys, among those who received government support, income loss was associated with depression, whether participants lost all income (2020: AOR 1.75 [1.29-2.44]; 2021: AOR 2.17 [1.36-3.44]), or some income (2020: AOR 1.31 [1.17-1.81]; 2021: AOR 1.46 [0.99-2.16]). However, among those who received family support, income loss was no longer significantly associated with depression, whether participants lost all income (2020: AOR 1.37 [0.78-2.40]; 2021: AOR 1.51 [0.88-2.56]), or some income (2020: AOR 1.31 [0.86-1.99]; 2021: AOR 1.10 [0.67-1.81]).

Conclusions

Association between income loss and depression was moderated by receipt of family financial support but not by receipt of government support. Financial support may help to mitigate the negative effects of income loss on young adults mental health during public health crisis.

Key messages

• Financial support may help to minimize risk of depressive symptoms among youth who lost income related to the COVID-19 pandemic.

• Financial support through personal assistance (e.g., family, friends) appears to have a greater impact on youth mental health than COVID-specific government assistance funds.

Analyzing implementation of public health interventions : a need for rigor, and the challenges of stakeholder involvement

OBJECTIVES

This article shows how conceptual models can help to develop and evaluate public health interventions. It also reports on the challenges of getting stakeholders involved.

METHOD

The analysis is based on the reflexive approach applied by the authors during their participation in two public health intervention research (PHIR) projects, in France and in Burkina Faso.

RESULTS

In Paris, PHIR aimed to enable sub-Saharan immigrants to appropriate the existing means of prevention and sexual health care and to strengthen their empowerment in view of preserving their health. Evaluation was carried out using mixed methods. The intervention process theory is based on Ninacs' conceptual model of individual empowerment. The Consolidated Framework For Implementation Research (CFIR) was mobilized a posteriori to analyze the process. PHIR stemmed from collaboration between a research team and two associations. The different stakeholders were involved in the evaluation process, as were, at certain times, persons in highly precarious situations. In Ouagadougou, a community-based dengue vector control intervention was deployed to address an essential but neglected need. As regards evaluation, we opted for a holistic, mixed method approach (effectiveness and process). The contents of the intervention were determined based on tacit knowledge, a community preference survey and solid evidence. The theoretical framework of the intervention consisted in an eco-biological model of vector control. The implementation analysis combined an internal assessment of implementation fidelity with an external CFIR process analysis. All stakeholders were involved in the evaluation process.

DISCUSSION

Analysis confirmed not only the value of process evaluations in PHIR, but also the primordial importance of a rigorous approach. Stakeholder involvement is a major challenge to be addressed early in the planning of RISPs; with this in mind, effective and ethically sound assessment mechanisms need to be drawn up. Interdisciplinary evaluative approaches should be preferred, and the use of justified, relevant, and flexible frameworks is highly recommended.

CONCLUSION

Lessons learned for those wishing to engage in the process evaluation of a public health intervention are hereby presented.

[Practices and Factors Associated with Recent HIV Testing in the General Population, Côte d'Ivoire: Results of the ANRS Study 12323 DOD-CI]

With 2.9% of HIV prevalence in the general population, Côte d'Ivoire is one of the countries most affected by the HIV epidemic in West Africa. In this country, only 63% of people infected with HIV are aware of their status. A cross-sectional phone survey was conducted with a representative sample of 3,867 individuals to describe the practices and factors associated with a recent HIV testing (≤ 1 year) in Côte d'Ivoire. Data relative to the last done HIV test as well as the socio-demographic characteristics, sexual behavior, access to information, perceptions, capacities and autonomy as well as social and geographical environment of the participants were collected. Logistical regression models were used to identify the associated factors with a recent HIV test (≤ 1 year). Lack of information is one of the main barriers to HIV testing (only 60% of individuals know a place to get tested). For men, despite the fact that HIV testing is free of charge, poor economic conditions seem to be a barrier to testing. The social environment, including peer influence, also appears to have an effect on testing among men. For women, testing is associated with their perceptions of HIV exposure. There is a need to rethink the current HIV testing communication in Côte d'Ivoire and to identify economic or social incentives to remove access barriers to HIV testing.

[Enhanced prenatal HIV couple oriented counselling session and couple communication about HIV (ANRS 12127 Prenahtest Trial)]

BACKGROUND

The Prenahtest study investigated the efficacy of a couple-oriented HIV counselling session (COC) in encouraging couple HIV counselling and testing, and improving intra-couple communication about sexual and reproductive health. We report here on the effect of COC on intra-couple communication about HIV.

METHODS

Within this 4-country trial (India, Georgia, Dominican Republic and Cameroon), 484 to 491 pregnant women per site were recruited and individually randomized to receive either the COC intervention, enhanced counselling with role playing, or standard post-test HIV counselling. Women were interviewed at recruitment, before HIV testing (T0), and 2 to 8 weeks after post-test HIV counselling (T1). Four dichotomous variables documented intra-couple communication about HIV at T1: 1) discussion about HIV, 2) discussion about condom use, 3) suggesting HIV testing and 4) suggesting couple HIV counselling to the partner. An intra-couple HIV communication index was created: low degree of communication ("yes" response to zero or one of the four variables), intermediate degree of communication ("yes" to two or three variables) or high degree of communication ("yes" to the four variables). To estimate the impact of COC on the intra-couple HIV communication index, multivariable logistic regressions were conducted.

RESULTS

One thousand six hundred and seven women were included in the analysis of whom 54 (3.4%) were HIV-infected (49 in Cameroon). In the four countries, the counselling group was associated with intra-couple HIV communication (P≤0.03): women allocated to the COC group were significantly more likely to report high or intermediate degrees of intra-couple communication about HIV (versus low degree of communication) than women allocated to standard counselling.

CONCLUSION

COC improved short-term communication about HIV within couples in different sociocultural contexts, a positive finding for a couple approach to HIV prevention.

Impaired fertility in HIV-1-infected pregnant women: a clinic-based survey in Abidjan, Côte d'Ivoire, 1997

OBJECTIVE

Differences in fertility among HIV-1-positive and HIV-negative women tested in prenatal clinics were suspected by routine data collection in Abidjan, Côte d'Ivoire. This study was conducted on detailed fertility patterns among women at the same antenatal care centres, in order to assess these differences.

METHOD

The survey was carried out on 1201 consecutive women who agreed to be tested for HIV. Data collected included a detailed account of pregnancies, the time interval between the last two pregnancies, and the health status at the time of the survey. Blood samples were tested for HIV and syphilis with informed consent.

RESULTS

Despite an earlier exposure to pregnancy risk, HIV-1-infected women aged 25 years and above, had, on the average, fewer pregnancies than uninfected women. An analysis of the interval between the last two pregnancies among multigravidae showed that, all things being equal, being HIV-1 positive decreased the risk of being pregnant by 17% (Cox regression, hazard ratio = 0.83, 95% confidence interval (CI): 0.69-0.99). This shift in the occurrence of the last pregnancy was more profound among HIV-1-positive women already at the symptomatic or AIDS stage, than among asymptomatic women.

CONCLUSION

These data confirm that women infected by HIV-1 would become pregnant less often than uninfected women, for an equal exposure to the risk of pregnancy. Therefore HIV-1-positive women could be under-represented at antenatal centres. Programmes involving such settings both for epidemiological surveillance and the reduction of mother-to-child transmission should take this observation into account.

Impact of chloroquine resistance on malaria mortality

Over 12 years, from 1984 to 1995, we conducted a prospective study of overall and malaria specific mortality among three rural populations in the Sahel, savanna and forest areas of Senegal. The emergence of chloroquine resistance has been associated with a dramatic increase in malaria mortality in each of the studied populations. After the emergence of chloroquine resistance, the risk of malaria death among children 0-9 years old in the three populations was multiplied by 2.1, 2.5 and 5.5, respectively. This is the first study to document malaria mortality at the community level in Africa before and after the emergence of chloroquine resistance. Findings suggest that the spread of chloroquine resistance has had a dramatic impact on the level of malaria mortality in most epidemiological contexts in tropical Africa.

HIV-1 infection and reproductive history: a retrospective study among pregnant women, Abidjan, Côte d'Ivoire, 1995-1996. Ditrame Project

The aim of this paper is to determine the differences of fertility between HIV-1 infected and uninfected women in Abidjan, Côte d'Ivoire, using data available in an observational study conducted in 1995 and 1996 in 2 antenatal care centres in the district of Yopougon, Abidjan, within an intervention programme to reduce mother-to-child HIV-1 transmission (DITRAME project, ANRS 049). Fertility indicators have been constructed from retrospective data on pregnancies and births, and univariate and multivariate analyses have been performed on these indicators and stratified by age groups to compare HIV-1 positive and HIV-negative populations. The main outcome measures were the number of pregnancies, the number of miscarriages, the risk of miscarriage and the proportion of primigravida. Four thousand, three hundred and ninety-six women agreed to HIV testing: 12.1% were found to be HIV-1 infected. HIV-1 positive women had significantly fewer pregnancies than HIV-negatives in age-groups 25-29 (P = 0.05) and 30-34 (P = 0.008). The risk of having had at least one abortion or stillbirth was significantly higher for HIV-1 infected women than for HIV-negatives (OR = 1.28, 95% CI: 1.02-1.60), when controlling for social and demographic factors. This study suggests that HIV-1 infection has deleterious consequences on female fertility, with lower fertility rates and more frequent adverse pregnancy outcomes. Family planning and antenatal care services should consider antenatal HIV counselling and testing in women in areas of high HIV prevalence.

Role of immunizations in the recent decline in childhood mortality and the changes in the female/male mortality ratio in rural Senegal

In early 1987, immunizations were introduced to an isolated area of eastern Senegal where there had previously been no regular immunizations. Since immunizations were the only change introduced in the area during this period, this allowed the authors to study the impact of immunizations of mortality in different age groups and the possible interaction with sex differences in mortality. They compared mortality rates for the 6 years before and the 6 years after the introduction of immunization. Neonatal mortality declined 31% (95% confidence interval (CI) 17 to 43); between 1 and 8 months of age, the reduction was 20% (95% CI -2 to 37); and between 9 and 59 months of age, mortality declined 48% (95% CI 39 to 56). Excluding acute measles deaths, the reduction was 16% (95% CI -8 to 35) between 1 and 8 months of age and 32% (95% CI 20 to 43) between 9 and 59 months of age. The decline was stronger in villages that maintained high coverage after the initial national campaign, whereas mortality increased again in the villages where the coverage declined. Since the reduction in mortality was most marked after 9 months of age, measles immunization is likely to have been the most important vaccination. Both female and male mortality declined but not equally quickly. The reduction in mortality in the neonatal period was significantly greater in males than in females, resulting in an increase in the female/male mortality ratio from 0.64 (95% CI 0.50 to 0.83) to 0.96 (95% CI 0.71 to 1.30), p = 0.04. After 9 months of age, the reduction in mortality was somewhat greater in females than in males, resulting in a decrease in the female/male mortality ratio from 1.04 (95% CI 0.85 to 1.28) to 0.79 (95% CI 0.62 to 1.02), p = 0.10.

Lower mortality for female-female twins than male-male and male-female twins in rural Senegal

Twins have been registered prospectively for 12-22 years in 42 small villages in the Bandafassi area of Eastern Senegal. We studied 98 pairs of twins to test whether twins in opposite-sex pairs have higher postneonatal mortality than same-sex twins. Neonatal mortality for twins was 41.3%; mortality for infants and for children under age 5 years was 53.0% and 66.8%, respectively. Neonatal mortality was identical for same-sex and opposite-sex twin pairs, but much higher for boys than girls [relative risk = 1.8; 95% confidence interval (CI) = 1.2-2.6]. There was clustering of double neonatal deaths for all types of twins. In the postneonatal period, female-female twins had lower mortality than other twin types. Twins had higher post-neonatal mortality as long as the co-twin was alive [mortality rate ratio (MR) = 2.6; 95% CI = 1.0-6.7]. Girls had excess mortality when the co-twin was of the opposite sex (MR = 4.3; 95% CI = 1.2-15.3), whereas there was no difference for boys. In conclusion, contact with a co-twin of the opposite sex increased child mortality for female twins. Our data are not sufficient to determine whether this difference is specific for girls or applies to boys as well.

Barriers to universal child immunization in rural Senegal 5 years after the accelerated Expanded Programme on Immunization

Although the Expanded Programme on Immunization (EPI) has been a worldwide success, weak points remain, particularly in Africa. In Senegal, for example, immunization coverage was low in 1990 (60%), in part because of poor results in rural areas. In order to identify obstacles to EPI in such areas, we carried out an immunization survey in Bandafassi, a rural area of Senegal, where 6078 inhabitants lived in 23 small villages. Only 41% of children aged 1-10 years were completely vaccinated in February 1992, with considerable variations in coverage from one village to another, according to their geographical location: 71% of children were completely vaccinated in villages less than 10 km from the health centre, whereas in remote villages only 10% of children had been completely vaccinated. There was no variation according to ethnic group. From 1987 to 1992, the gap in immunization coverage between the remote villages and those located close to the health centre has steadily increased. There is a need to improve the performance of the mobile teams in the remote villages and to increase awareness about the importance of immunization.