Potential lung cancer screening outcomes using different age and smoking thresholds in the ANRS-CO4 French Hospital Database on HIV cohort

OBJECTIVES

In most lung screening programmes, only subjects ≥ 55 years old and smoking ≥ 30 pack-years are eligible to undergo chest low-dose computed tomography. Whether the same criteria should apply to people living with HIV (PLHIV) is uncertain, given the increased lung cancer risks associated with immunodeficiency and high rates of smoking. We assessed different outcomes obtained from simulating one round of lung cancer screening in PLHIV using different age and smoking thresholds for eligibility.

METHODS

Data from the French Agence Nationale de Recherche sur le SIDA et les Hépatites Virales (ANRS)-CO4 French Hospital Database on HIV (FHDH) cohort of PLHIV and a national representative survey of PLHIV in care in 2011 (the ANRS-VESPA2 [enquête sur les personnes atteintes] study) were used to estimate the maximum proportion of incident lung cancers occurring between 2012 and 2016 that would have potentially been detected by screening in 2011. Secondary outcomes were numbers of eligible subjects in the cohort and numbers of subjects needed to screen (NNS) to detect one lung cancer.

RESULTS

Among 77819 PLHIV in 2011 (median age 46 years; 66% men), 285 subjects subsequently developed lung cancer. Adoption of the US Preventive Services Task Force (USPSTF) recommendations (55-80 years; ≥ 30 pack-years) would have detected 31% of lung cancers at most. Lowering the minimum age to 50 and 45 years would have detected 49% and 60% of cancers, respectively, but would have greatly increased the number of eligible subjects and the NNS to detect one case of lung cancer.

CONCLUSIONS

Use of the USPSTF criteria would have detected only a minority of lung cancers in a large French cohort of PLHIV in 2011. Screening PLHIV at younger ages (45 or 50 years) and/or the use of lower smoking thresholds (20 pack-years) may be beneficial, despite the consequently higher numbers of eligible subjects and NNS to detect one case of lung cancer, and should be evaluated in future studies.

A new strategy for screening infectious diseases amongst migrants: the STRADA study

Background

In France, the prevalence of HIV, HBV and HCV is high amongst migrants and widespread testing is recommended. All legal migrants in France undergo a mandatory medical check-up at the immigration center (OFII). This check-up is an opportunity to offer rapid HIV and hepatitis testing. A screening questionnaire for risk factors (TROD screen) has been developed and could help target the screening offer. The objective of the STRADA study is to evaluate the efficacy of a screening strategy for infectious diseases (Tuberculosis, HIV, HBV and HCV) based on risk-factor questionnaires amongst migrants during the medical check-up.

Methods

STRADA is a prospective, multicenter, observational study with two parts: tuberculosis screening (evaluation of a screening questionnaire) and HIV, HBV and HCV screening. For that part we have created a risk-based questionnaire for those three infections. In the first phase of the study, all migrants eligible are offered a screening, the TROD screen questionnaire. In the second phase, the screening offered on the basis of country of origin will be compared to the screening offered on the basis of the risk factor questionnaire. Finally, a cost-effectiveness study will be performed. During the informed consent process, participants are informed that the study is voluntary and independent from the residence permit.

Preliminary results

A risk-based questionnaire has been created and translated in 10 languages. The screening has been implemented in 20 immigration centers in France. In April 2019, 35,000 participants have answered the TB screen and 8,250 have been screened for at least one of the three virus.

Discussion

This study will determine the acceptability, performance, utility, costs and impact of a targeted optimized screening strategy for migrants in France. The presence of infectious diseases amongst migrants is a major public health issue. STRADA is an innovative initiative that has the potential to improve screening.

Risk of HIV transmission during combined ART initiation for HIV-infected persons with severe immunosuppression

Background

Individuals presenting for care with severe immunosuppression typically have high plasma HIV viral load (pVL) and may transmit HIV before and after initiation of combination antiretroviral therapies (cART).

Patients and methods

Using risk equations and data collected in the IMEA 040 DATA trial on sexual behaviour and pVL level of 84 HIV-infected patients (23 women), we estimated monthly rates of HIV transmission for each virologically unsuppressed participant (pVL >50 copies/mL) who reported sex with HIV-negative or unknown serostatus (HNUS) partners at cART initiation, 24 weeks (W24) and W48 after; rates were considered negligible for other participants.

Results

At cART initiation, median pVL was 5.4 log10 copies/mL. The percentage of virologically unsuppressed patients decreased, from 100% at cART initiation to 27% (95% CI 16%-43%) for heterosexuals and 8% (95% CI 2%-22%) for MSM at W48 (P < 0.001). The percentage of patients reporting sex with HNUS partners increased between cART initiation and W48, from 23% (95% CI 10%-42%) to 42% (95% CI 25%-61%) for heterosexuals (P = 0.042) and from 41% (95% CI 21%-64%) to 73% (95% CI 52%-88%) for MSM (P = 0.004). Median monthly HIV transmission rates were 0.0540 (IQR 0.0339-0.0742) for MSM and 0.0018 (IQR 0.0014-0.0191) for heterosexuals at cART initiation, and were reduced by 95% (95% CI 87%-100%) for heterosexuals and 98% (95% CI 95%-100%) for MSM as early as W24.

Conclusions

Risk of onward transmission for severely immunosuppressed individuals is high before and within the first weeks of cART, and persists, at a substantially reduced level, beyond 24 weeks of cART for some individuals. Earlier cART and protecting HIV-negative partners until full viral suppression is achieved could reduce HIV transmission.

Prevalence of and factors associated with depression among people living with HIV in France

OBJECTIVES

Depression is common among people living with HIV (PLWHIV) and is associated with poorer therapeutic outcomes and risky behaviours. We sought to estimate the prevalence of major depressive episode (MDE) across PLWHIV groups, to compare this with its prevalence in the general population and to assess factors associated with it.

METHODS

We used data from the Agence Nationale de Recherche sur le Sida et les Hépatites Virales (ANRS)-Vespa2 study, a national study on a representative sample of PLWHIV conducted in France in 2011. The short form of the depression module of the World Health Organization's Composite International Diagnostic Instrument (CIDI-SF) was used to characterize the occurrence of an MDE during the previous year. MDE prevalence was assessed among the various groups of PLWHIV and compared with that in the general population, accounting for the sociodemographic characteristics of the two populations, using multivariate Poisson regression models. The same method was used to assess associated factors.

RESULTS

MDE prevalence was 28.1% among PLWHIV, ranging from 10.9 to 55.7% across groups. Compared with the general population by sex, regardless of sexual orientation and origin, MDE prevalence was 5.1-fold higher in HIV-infected men who have sex with men [95% confidence interval (CI) 3.9-6.6], 3.1-fold higher in non-sub-Saharan African (SSA) heterosexual men (95% CI 2.2-4.4), 1.6-fold higher in SSA migrant men (95% CI 0.9-2.6), 2.6-fold higher in non-SSA heterosexual women (95% CI 2.1-3.3), and 1.9-fold higher in SSA migrant women (95% CI 1.5-2.5). In the HIV-infected population, MDE was positively related to unemployment, material deprivation, disclosure, experience of discrimination, and untreated hepatitis C, and negatively related to age.

CONCLUSIONS

The prevalence of depression varied across the different groups of PLWHIV, with levels much higher than in the general population. Moreover, there was a strong association with socioeconomic status and HIV experience.

Levels and determinants of breast and cervical cancer screening uptake in HIV-infected women compared with the general population in France

OBJECTIVES

Cancer is a growing concern for HIV-infected people, and screening plays a major role in alleviating the burden it causes. We sought to investigate the levels and determinants of breast cancer screening (BCS) and cervical cancer screening (CCS) in HIV-infected women as compared with the general population.

METHODS

The Agence Nationale de Recherche sur le Sida et les Hépatites Virales (ANRS)-Vespa2 study was conducted in 2011 in a national representative sample of 3022 HIV-infected hospital out-patients in France. The rates and correlates of BCS and CCS among HIV-infected women were compared with those in the general population using multivariate Poisson regression models.

RESULTS

The BCS rate during the 2 years preceding the survey interview was 80.7% among HIV-infected women vs. 89.1% in the general population (P = 0.146). The CCS rate during the preceding 3 years was 88.1% among HIV-infected women vs. 83.1% in the general population (P = 0.021). During the preceding year, the CCS rate among HIV-infected women was 76.5%. The barriers to BCS and CCS were a low educational level [BCS: adjusted prevalence rate ratio 0.88; 95% confidence interval (CI) 0.80-0.97; CCS: adjusted prevalence rate ratio 0.91; 95% CI 0.83-0.99], not having supplementary health insurance (CCS: adjusted prevalence rate ratio 0.92; 95% CI 0.86-0.98), an irregular gynaecological follow-up (BCS: adjusted prevalence rate ratio 0.77; 95% CI 0.64-0.92; CCS: adjusted prevalence rate ratio 0.72; 95% CI 0.64-0.81) and a low CD4 count (BCS: adjusted prevalence rate ratio 0.83; 95% CI 0.71-0.97; CCS: adjusted prevalence rate ratio 0.78; 95% CI 0.63-0.98). The disparities in CCS uptake in terms of age, employment and gynaecological follow-up were less pronounced among HIV-infected women than in the general population.

CONCLUSIONS

BCS and CCS uptake was not lower among HIV-infected women than in the general population, but CCS was suboptimal. Specificities in the profile of barriers to screening emerged.

[Traffic accidentability and risky driving behavior in young people in New Caledonia. Results of study Situation Sociale et Comportements de Santé des Jeunes en Nouvelle-Calédonie]

BACKGROUND

New Caledonia has one of the highest global rates of death from road accidents: 240 deaths per million inhabitants in 2011 with a majority of young people. However, research on driving behaviors has remained rare.

METHODS

A cross-sectional survey based on face-to-face questionnaire with 1400 male and female youth aged 16 to 25 was conducted in 2007. It was used to measure the frequency of accidents and to compute a score of driving behaviors and their associations with socio-demographic characteristics, lifestyles as well as other health behaviors. RESULTS - 

CONCLUSION

A total of 10.6% of boys and 6.5% of girls reported a car accident in the previous twelve months period. Among male participants risky driving behavior was associated with having a degree (ORa=2, 95% CI [1.1-3.8]), sport practices (ORa=3.7, 95% CI [1.9-7.05]), involvement in a fight in the last twelve months (ORa=2.2, 95% CI [1.4-3.4]) and precocity of cannabis use (ORa=1.8, 95% CI [1.2-2.8]). Youth living in couple and those with children presented with higher risk-taking scores. Among female participants, young age at cannabis initiation (ORa=3.1, 95% CI [1.5-6.4]) and at sexual debut (ORa=2.4, 95% CI [1.1-5.1]) were associated with driving risk-taking. Finally, younger age at first alcohol intoxication was associated with risky behavior on the road in both sexes. These results highlighted the multidimensional nature of risk-taking behaviors on the road and showed that they are part of, for boys and girls, a larger pattern of risky behaviors. Such results suggest to include behaviors on the road in a comprehensive approach of prevention.

Women living with HIV still lack highly effective contraception: results from the ANRS VESPA2 study, France, 2011

OBJECTIVES

Advances in antiretroviral treatment (ART) have led to improvements in reproductive health for women living with HIV. This paper aims to investigate the pattern of contraceptive use among women living with HIV in France.

STUDY DESIGN

Data were drawn from the ANRS VESPA2 study, which included a representative sample of HIV-positive people. Contraception methods were documented, including condoms, highly effective contraception methods (HEC) and traditional methods. We measured the frequency of not using any modern contraception (neither condoms nor HEC) and of HEC use and studied their correlates (i.e., geographic origin, age, parity, partnership status, education level, material deprivation, employment status, health insurance, visits to a gynecologist, being on ART, cardiovascular risk) among women at risk of an unintended pregnancy.

RESULTS

Of the 662 women of reproductive age, 327 were in need of contraception. Overall, 20.5% used HEC, 58.8% used condoms and 20.7% used traditional or no methods, with no difference according to geographic origin [sub-Saharan African (SSA) women vs. French and other migrant women]. Among SSA women, being <30years old [odds ratio (OR) 16.39, 95% confidence interval (95%CI) 2.77-97.01], having had at least one child (OR 3.75, 95%CI 1.75-8.04) and being employed (OR 2.36, 95%CI 0.99-5.61) were associated with HEC use; among French and other migrant women, HEC use was associated with being in a stable partnership (OR 4.5, 95%CI 1.2-17.2) and material deprivation (OR 3.3 95%CI 1.4-9.8). Gynecologist visits, health insurance status and cardiovascular risk were not associated with HEC use.

CONCLUSIONS

Condoms remained the predominant contraceptive method despite the absence of restrictions on hormonal contraception and intrauterine device use for HIV-positive women. The recent recommendations about dual method protection should be actively promoted, targeting HIV-positive women, HIV specialists and gynecologists to overcome the barriers to effective contraception.

IMPLICATIONS

The information provided in this study constitutes a major contribution to comprehensively inform the scientific community on contraception practices among women living with HIV in France in the early 2010s. Our results show that the therapeutic advances since the late 1990s and the removal of restrictions on hormonal contraception use have not led to the expected shift in contraception patterns. There is an urgent need to promote dual method protection, as condom use may decrease in the future in the context of the preventive effect of ART.

Trajectoire socio-économique et consommation d’alcool au début de l’âge adulte : résultats de la cohorte française TEMPO

Contexte

Les liens entre trajectoire socio-économique et consommation d’alcool ont été peu étudiés, particulièrement chez des personnes jeunes.

Objectifs

L’objectif de cette étude était d’identifier l’association entre trajectoire socio-économique et consommation d’alcool au début de l’âge adulte en tenant compte d’autres facteurs associés à la consommation d’alcool.

Matériel et méthodes

Les données proviennent de la cohorte TEMPO (www.tempo.inserm.fr) - une étude de cohorte prospective de 1103 personnes âgées de 22 à 35 ans en 2009 dont un des parents participe à la cohorte GAZEL (www.gazel.inserm.fr). La consommation d’alcool (abstinence, consommation faible ou intermédiaire, abus) a été mesurée en 2009 par l’AUDIT (OMS). La trajectoire socio-économique depuis l’enfance jusqu’à l’âge adulte a été mesurée par :

Dans l’échantillon, 4 groupes de trajectoire socio-économique ont été identifiés : trajectoires favorable, ascendante, descendante, défavorable. Les données ont été analysées par des modèles de régression logistique ajustés sur le sexe, l’âge, la situation maritale, l’emploi, le soutien social, la maternité, l’existence de maladies chroniques, les difficultés psychologiques et la consommation d’alcool des parents.

Résultats

La trajectoire socio-économique des personnes était associée à leur consommation d’alcool, et particulièrement à l’abstinence : par rapport aux personnes qui avaient une trajectoire socio-économique favorable : ORs multivariés (trajectoire socio-économique ascendante : OR = 1,89, 95 % IC 1,05–3,40), (trajectoire descendante : OR = 2,10, 95 % IC 1,00–4,44), (trajectoire défavorable : OR = 3,01, 95 % IC 1,38–6,56).

Conclusion

La trajectoire socio-économique est associée à la non-consommation d’alcool au début de l’âge adulte, indépendamment d’autres facteurs.

Socio-economic conditions, health status and employment among persons living with HIV/AIDS in France in 2001

To investigate employment levels and identify barriers to work among persons living with HIV/AIDS in France in 2001, we conducted a cross-sectional study among HIV-infected patients seen in the hospital outpatient clinics of the two French regions most affected: Ile-de-France (IDF) and Provence-Alpes-Côte-d'Azur (PACA). Of the 840 outpatients included in the study, 58.8% in IDF and 46.8% in PACA were currently employed, and 28.1 and 47.8%, respectively, were receiving disability benefits. Among unemployed patients, 32.1% in IDF and 29.6% in PACA reported that they planned to (re)enter the workforce. Current and planned employment status were associated with characteristics indicative of the patients' social and demographic situation before the HIV diagnosis (region of residence, educational level, HIV transmission group, age, nationality) and with their health status at the interview (HIV progression, HCV co-infection). Receiving disability benefits was negatively associated with plans to return to work. HIV-related discrimination at work was reported by 11.9% of the patients in IDF and 9.2% in PACA, and was not associated with occupational status. Thus, social interventions should seek to prevent patients, particularly the most socially vulnerable, from leaving their jobs at acute stages of their illness and should promote (re)entry into the workforce among unemployed patients.

Prevalence of educational inequalities in obesity between 1970 and 2003 in France

This paper examines trends in obesity rates and education-related absolute and relative inequalities in obesity over the last 40 years in France. Data are drawn from the French Decennial Health Surveys of 1970, 1980, 1991 and 2003. The difference in obesity rates between the least- and most-educated, the Slope Index of Inequality, is used to estimate absolute inequalities in obesity. The ratio of the corresponding rates, the Relative Index of Inequality, reveals the relative inequalities in obesity. Obesity rates were similar in men and women, but educational inequalities were greater in women. Obesity rates were similar over the first three surveys but increased for all in the 2003 survey. This increase was accompanied by increases in absolute inequalities in men (P = 0.04) from a Slope Index of Inequality of 4.80% (95% confidence interval [CI] = 2.27, 7.32) to 8.64% (95% CI = 5.97, 11.32) and women (P = 0.004) from 8.90% (95% CI = 6.18, 11.63) to 14.57% (95% CI = 11.83, 17.32). Relative inequalities in obesity remained stable over the 40 years. Recent increase in obesity rates in France is accompanied by increases in absolute education-related inequalities, while relative inequalities have remained stable; this suggests that obesity rates have increased at a much faster rate in the low-education groups.

Disease severity, self-reported experience of workplace discrimination and employment loss during the course of chronic HIV disease: differences according to gender and education

OBJECTIVES

Evidence for the existence of a harmful effect of chronic disease on employment status has been provided. Although this effect of chronic illness on employment has been reported to be higher among the groups with the lowest position on the labour market, the mechanisms of such inequalities are poorly understood. The present study aimed at investigating social inequalities in the chances of maintaining employment during the course of HIV infection and at examining the correlates of such inequalities.

METHODS

The authors used data from a national representative sample of people living with HIV in France (ANRS-EN12-VESPA survey). Retrospective information on social trajectory and disease characteristics from the time of HIV diagnosis was available. The risk of employment loss associated with indicators of disease severity and HIV-related workplace discrimination was computed over time since HIV diagnosis according to sociodemographic and occupational factors, using Cox proportional hazards models.

RESULTS

Among the 478 working-age participants diagnosed as being HIV-infected in the era of multitherapies and employed at the time of HIV diagnosis, 149 experienced employment loss. After adjusting for sociodemographic and occupational factors, disease severity and self-reported HIV-related discrimination at work were significantly associated with the risk of employment loss in a socially-differentiated manner: advancement in HIV disease was associated with an increased risk of employment loss among women (HR 4.45, 95% CI 2.10 to 9.43) but not among men; self-reported experience of HIV-related discrimination at work was associated with an increased risk of employment loss among individuals with a primary/secondary educational level (HR 8.85, 95% CI 3.68 to 21.30) but not among those more educated.

CONCLUSIONS

Chronic HIV disease affects the chances of maintaining employment in a socially-differentiated manner, resulting in increasing inequalities regarding workforce participation. Disease severity and workplace HIV-related discrimination, particularly affecting the employment status of the most socioeconomically disadvantaged, may play a major role.

Management of HIV-related stigma and adherence to HAART: Evidence from a large representative sample of outpatients attending French hospitals (ANRS-EN12-VESPA 2003)

This study investigated patterns of HIV disclosure to significant others (parents, siblings, children, other relatives, friends and colleagues) and describe them in terms of socio-demographic background and other characteristics, including experiences of AIDS-related discrimination. It also assessed the relationship between disclosure patterns and adherence to HAART. We used a cross-sectional survey conducted among a national representative sample of 2,932 HIV-infected people recruited in French hospitals. HIV disclosure patterns were both selective and cumulative: disclosure was more frequent for friends and siblings, while concealment prevailed concerning children, other relatives, and colleagues; but patients who disclosed their seropositivity to one significant other were also more likely to disclose it to other significant others. Patients reporting experiences of discrimination from sexual partners were less likely to be highly adherent, and we also found a significant relationship between uncontrolled disclosure and non-adherence. Patients who have opted for concealment probably consider non-adherence and uncontrolled disclosure as competing risks, but among them a significant minority loses on both counts. Counselling provided to HIV-infected people should not separate the adherence and disclosure issues, and adherence interventions should seek to help patients to manage concurrently disclosure/concealment of their seropositivity and its consequences.

[Can we stop the hepatitis C virus transmission in drug users?]

Despite the effectiveness of drug treatment and harm reduction programmes aimed at reducing illegal drug use, especially heroin use, situations at risk of transmitting HCV infection are still very frequent. Among routes of drug administration, injection appears as the most dangerous mean regarding the spread of HCV infection among drug users. This practice frequently occurs within a context of a group sharing climate (equipment, substance, housing, etc.) and mutual support. Risk of unsafe behaviour is increased at the time of their first injection or during the first steps of their experience as newly injectors. Public health interventions should target a reduction in the number of injections by modifying the pharmacological format of sublingual buprenorphine, by defining the cessation of injection as one of the main objectives of drug users care programs, by designing and implementing interventions and iniatives that target recreational multiple drug users at risk of initiating drug injection.

Vulnerability, unsafe sex and non-adherence to HAART: Evidence from a large sample of French HIV/AIDS outpatients

Current socio-behavioural research in HIV-infected people has tried to identify patients with "high-risk" profiles, i.e. who simultaneously exhibit non-adherence to highly active anti-retroviral therapy (HAART) and unsafe sex with serodiscordant partners. We challenged this approach by investigating the correlates of both behaviours, for homosexual men, heterosexual men and heterosexual women separately, among a representative sample of 4963 HIV-infected people in France. Variables introduced in the analysis dealt with patients' background and daily life, with a focus on situations of economic, social and personal vulnerability. Overall, 2932 patients agreed to participate, and 1809 were both receiving HAART and sexually active. Among heterosexual women, non-adherence and unsafe sex appeared as joint outcomes of similar situations of vulnerability. Among heterosexual men, these behaviours were weakly correlated and shared some predictors related to situations of vulnerability. Among homosexual men, non-adherence and unsafe sex were not correlated and had distinct determinants. Situations of vulnerability, the context and the motives of unsafe sex, as well as factors associated with non-adherence and unsafe sex varied greatly with gender and sexual preference. Theoretical models used for designing behavioural interventions should take into account this diversity.

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.

[Epidemiology and social determinants of health inequalities]

BACKGROUND

The general approach of social epidemiology is based on the observation of a strong social stratification of health outcomes within populations: a similar stratification of factors associated with health must therefore also exist according to social status. To explain social differences in health, the natural approach for epidemiologists is to consider an imbalanced distribution of established risk factors according to the social position of individuals. As this approach has largely failed, two main other research areas were recently explored: (i) identification of "new" social risk factors; (ii) research of possible mechanisms of social differences in health.

METHODS AND RESULTS

Identification of social risk factors: early events and life course, occupational factors, social relationships (social networks and support, discrimination, neighborhood characteristics), health care. Research of possible mechanisms of social differences in health in the context of specific theoretical frameworks: the materialist model, the psychosocial model and the eco-social model integrating the interaction between individuals'characteristics and their environment.

COMPLEX METHODOLOGICAL PROBLEMS

definition and measurement of variables characterizing the social situation of individuals; quantification of social inequalities at population level. Observational methods must often rely on very long-lasting cohorts, and imply statistical methods that account for longitudinal data or are able to manage simultaneously individual and contextual data.

Psychological stress among hospital doctors caring for HIV patients in the late nineties

To assess stress and satisfaction related to HIV medical work and its impact on psychological wellbeing, a cross-sectional study was undertaken among the population of doctors caring for HIV/AIDS patients in French hospitals. They were sent a questionnaire on demographic and professional characteristics along with three additional scales: the Consultants Mental Health Questionnaire with three components - stress, satisfaction and responses to job stress; the Maslach Burnout Inventory; and the GHQ-12 (General Health Questionnaire). A total of 670 physicians responded anonymously (65.4% participation). For 45% of respondents, HIV/AIDS represented less than 25% of their activity. Three dimensions were extracted by multivariate analysis from the stress scale (overload, social relationships at work, patients/family distress) and four dimensions from the satisfaction scale (work content, patients/family, peer recognition, work environment). Length of time working in HIV/AIDS, and proportion of clinical work in HIV/AIDS were not related to either stress or satisfaction. Only participation in NGOs increased the level of stress. Stress was not related to time spent in clinical work, neither to HIV work. Satisfaction derived from work decreases with time in direct contact with patients and is mainly related to the position in hospital. Eleven per cent sought help from professionals for psychological problems. Stress derived from patients suffering was not related to any psychological outcomes. Work overload and stress derived from social relationships at work are the main predictors of psychological distress, emotional exhaustion and depersonalization, while the moderator effect of satisfaction is weak. In the late nineties, the amount of HIV work did not appear as a specific feature of hospital medical work.

Unsafe injecting practices among attendees of syringe exchange programmes in France

AIMS

To describe syringe exchange programme attendees and their injection practices.

DESIGN

Cross-sectional study (one week in 1998). Data were collected through a standardized questionnaire.

SETTING

60/74 syringe exchange programmes (SEPs) in France.

PARTICIPANTS

Clients requesting syringes in 60 SEPs.

MEASUREMENTS

Self-reports of drug use, injecting behaviour, sexual behaviour, serological status (HIV, HBV, HCV). Prevalence of unsafe injecting practices in the previous month such as: syringe sharing; and sharing other injection paraphernalia.

FINDINGS

1004 questionnaires were collected (response rate: 50%). The mean age of respondents was 30 years, and 70% were males. Among individuals tested, HIV reported prevalence was 19.2%, HCV 58.4% and HBV 20.8%. The mean duration of drug use was 11 years. Eighty-five percent were polydrug users and buprenorphine high-dosage was the substance most used (73%). In the previous month, 45% of the participants had re-used a syringe, 93% injected at least daily (mean 3.6 injections per day), 18% shared a syringe and 71% shared injection paraphernalia. In multivariate analyses, unsafe injecting practices were associated with heroin and cocaine use and with living in a couple. The cluster analysis identified five categories of IDUs: users of buprenorphine-HD (45% of the responders), morphine-sulphate (17%), benzodiazepines and other legal drugs (13%), methadone associated with other legal drugs (13%) and crack-cocaine (13%). The buprenorphine-HD group had better social status and safer injection practices.

CONCLUSIONS

In France, despite an increase in the accessibility to syringes and substitution treatments, unsafe injecting practices persist among SEP attenders. Interventions should stress the importance of using sterile material for each injection, even with a steady sex partner.

Advances in HIV treatment and prevention: should treatment optimism lead to prevention pessimism?

Advances in HIV treatment have changed the natural history of HIV disease and improved the life of infected people. But, paradoxically, the transformation of a lethal disease into a chronic condition has lead many people to pessimism regarding the future of HIV prevention. Post-exposure prophylaxis and prophylaxis of vertical transmission have added new tools, although they do not change the main features of HIV prevention which still relies on safer drug use and safer sex. The role assigned to HIV testing started to change in some countries where it had not been encouraged; however the impact of these changes appears still very limited, except for prevention of vertical transmission. Recent developments should be placed in the whole historical perspective of HIV infection: after the early period of dramatic favourable changes (around 1990), positive changes in attitudes and behaviour have slowed down or even stabilized. Proofs of 'relapse' are, however, still tenuous. The impact of therapeutic changes is combined with the normalization process of HIV infection issues. In the general population, HIV infection seems a more remote personal and social concern and the perception of risk has decreased. The changes in the social context of prevention are more diverse. On one hand, some social norms renewed during the HIV era may have long-lasting effects. The acknowledgement of social and human rights of homosexuals and drug users, stimulated by the AIDS movement, has entered a long-term process and may continue to support preventive behaviours. On the other hand, the exceptionalist alliance which supported and stimulated the HIV policies is weakening. This process might be accelerated by improved therapeutic perspectives. The main challenge is the success of the integration of HIV prevention in broader public health policies (including prevention of STI transmission, family planning, health promotion, etc.) without losing advances in prevention strategies gained in the HIV/AIDS era.

Lack of legal income is strongly associated with an increased risk of AIDS and death in HIV-infected injecting drug users

The aim of the study was to analyze the impact of soci-economic status in addition to other risk factors in the progression of HIV disease in a cohort of injecting drug users (IDUs) with a mean follow-up of two years. Between 1989 and 1992, 124 HIV-infected IDUs were recruited in a primary care outpatient clinic providing free consultations and free access to therapy. The main outcome measures were death and AIDs-defining events. The proportion of current daily injectors at entry in the study and at the end of follow-up was 67.7% and 57.2%, respectively. The proportion of individuals on maintenance opioid therapy at entry in the study and at the end of follow-up was 0 and 12.1%, respectively. CD4 cell counts below 200 x 10(6)/L at baseline, positive p24 antigenemia at baseline, the lack of legal income and occasional drug use at entry were risk factors for clinical progression and death. When adjusted in a multivariate analysis, the absence of legal income remained associated with death and occurrence of an AIDS-defining event with a relative risk of 5.2 (1.5-18.1) (p = 0.004). Lack of legal income is a strong risk factor for progression of HIV disease in IDUs, that is independent of CD4 cell count and p24 antigenemia.

Prevalence of overweight and weight gain in relation to night work in a nurses' cohort

OBJECTIVE

To investigate the relation between exposure to night work and prevalence of overweight and weight gain.

DESIGN

Longitudinal observational study.

SUBJECTS

469 nurses (age: 21-58 y).

MEASUREMENTS

Body Mass Index, exposure to night work, age, parity, smoking and sports activities in 1980, 1985 and 1990.

RESULTS

Prevalence of overweight was associated with exposure to night work in 1980 and weight gains (especially those exceeding 7 kg) were more frequent among nurses on night work than on daytime work between 1985 and 1990.

CONCLUSION

Exposure to night work can lead to weight gain and overweight.

[Evaluation of a new AIDS communication and prevention model. Analysis of reactions to the program "3000 scenarios against a virus"]

In June 1994, 31 films on AIDS prevention have been broadcasted on the French television networks. Because of their cinematographic construction, the diversity of the situations, and the presentation of prevention as a relation, these films represent a new model for AIDS information campaigns. This campaign has been evaluated through both qualitative and quantitative approaches. A telephone survey was conducted on a representative sample of 1000 persons who had seen at least three films, that is 30% of the general population. The formal characteristics of the campaign induced particular interest while the content of the films induced emotion and lead to a personal implication. This new kind of communication lead to discussions, but these were mostly restricted to prevention in general and to people with AIDS. Personal and social experience characteristics, in particular the ability to talk about sexuality, seem to be determinant to explain the observed reactions. In contrast, the impact of the campaign is not different according to the age of the respondent and to sexual activity. These results show that it may be of some interest to define communication tools on AIDS that would take into account people's attitudes toward sexuality and their ability to talk about it.

Psychotropic drug use and shift work among French nurses (1980-1990)

Use of minor tranquilizers and hypnotics and the association with shift work was examined in a sample of French nurses interviewed in 1980, 1985 and 1990. Permanent night schedule was related to a higher use of hypnotics/tranquillizers, the relation begin significant in 1990. At each follow-up date, the use of drugs increased with sleep disorders, symptoms of psychological disorders reported by the nurses themselves, an impaired health and fatigue. Age was linked to the use of hypnotics/tranquillizers; the older the nurses were, the more likely they were to take the drugs. Using a logistic analysis, the following variables were significant: time schedules, self-assessment of health, fatigue, age and marital status. Time schedules involving night work, especially permanent night schedule, were related to a higher proportion of drug use. These findings confirmed the general patterns of psychotropic drug use (age, sleep disorders, physical health and martial status) among women and emphasized the relation between time schedules involving night work and the use of hypnotics/tranquillizers.

Back pain and associated factors in French nurses

The aim of this study was to assess, in a prospective cohort of nurses, the risk factors associated with six back pain indicators: back pain (BP), chronic or recurring BP (occurring often or lasting for more than 3 months), cervical (CP), dorsal (DP) and lumbar (LP) pain and medical treatment for BP. In 1980, a sample of 469 nurses was randomly selected from six public sector hospitals. They were followed up and interviewed in 1980, 1985 and 1990. BP indicators were assessed on the basis of the nurses' self-reports during the 12 months before questionnaire administration in 1990. The data collected were subjected to cross-sectional analysis in 1990, to study the associations between the six BP indicators and the risk factors. In a longitudinal analysis, the 1990 BP indicators were analysed in relation to the risk factors present in 1985 among the 210 nurses who were still working in hospitals in 1990 and had not suffered from musculoskeletal disorders (MSDs) between 1980 and 1985. Of the 310 nurses still working in hospitals in 1990, 57.9% had suffered from BP within the previous 12 months, 23.6% of them from CP, 23.0% from DP and 41.1% from LP, 40.5% had suffered from chronic or recurring BP, 31.1% had undergone treatment and 7.4% had taken sick leave for BP. In 1990, BP accounted for 35.8% of the total number of days of sick leave.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of shift work on sleep among French nurses. A longitudinal study

In industrialized countries, the proportion of shift workers is currently estimated to be approximately 20% of the working population. The problem of sleep may be one of the major consequences of shift work. To study the relation between shift work and sleep quality in a female population, 469 nurses at 6 public hospitals in various French regions were interviewed about their working conditions and health in 1980. They were followed up and interviewed again in 1985 and 1990. First, the results showed that nurses had more sleep disorders on alternating schedule including night work at the beginning of the study in 1980, and there was no more association between shift work and sleep quality after 1980. Second, sleep disorders predicted transfer from shift work to day work between 1980 and 1985 and sleep disorders decreased strongly after such transfer. The absence of relation between time schedules and sleep in 1985 and 1990 can be explained by the fact that the follow-up sample was selected, ie, the nurses who continued to work on shift work were able to adapt to it.

Images of AIDS among teenagers and young adults

This study analyzed images of AIDS and HIV-1 seropositivity among young people. The method employed is content analysis of 307 screen plays written by participants aged 15-25 as part of a competition organized by Médecins du Monde, APS, CRIPS. The participants were instructed to write a screen play for a 13-minute film on the theme of "Living in the city with HIV". In most stories, the seropositive hero was a young male or female heterosexual. Only a few scenarios involved drug abusers or homosexuals. Despite the absence of evidence of stigmatizating attitudes, HIV infection is often seen as a punitive consequence of a promiscuous sexual lifestyle. The announcement of seropositivity is perceived as a violent break with everyday life associated with introspection, and rejection of close friends and family. To cope with such a dramatic situation, the subject has to undergo a violent crisis. Life as portrayed in the scenarios is similar to life for people with HIV as it appears in personal testimonies. The majority of storylines concerning young heterosexuals show that participants understood that anybody can be affected by AIDS. There was no division into risk groups and the tolerant positions adopted demonstrate the impact of the associative movement and of information campaigns in France. However, the recurrence of the notion of 'illness as punishment' indicates that much work remains if AIDS is to be dissociated from moral connotations.

Hospital care for drug users with AIDS or HIV infection in France

Health care workers in three AIDS hospital units in the Paris region were interviewed to analyse the issues related to the care of addicted HIV patients in the light of principles and practices regarding drug abuse treatment in France. Health care workers report a large variety of disruptive incidents involving some addicted in-patients. To deal with these difficulties, physicians advocate the separation of drug abuse treatment and HIV disease treatment. However, practices differ between the three settings regarding the management of patients. In two units, a contract is made with the patient covering general and specific rules of hospital stay and sanctions should the contract be broken. In the third unit, the use of such a contract is considered to be a continuation of drug abusers' stigmatization and an obstacle to the adoption of the 'sick role' by the addicted patient.

Methodological issues for the assessment of clusters of adverse pregnancy outcomes in the workplace: the case of video display terminal users

In this paper, we review the consecutive methodological steps to follow when assessing clusters of adverse pregnancy outcomes (APO) in the workplace and the decisions to be taken at each step. The example of clusters of APO reported in VDT users in 1979 to 1982 is taken to illustrate each point. It appears that the number of "expected-unexpected" clusters of APO in VDT users has been largely overestimated as compared to observations and that this might be due to inadequate choices in the models used.

Differential mortality: some comparisons between England and Wales, Finland and France, based on inequality measures

Inequalities in mortality between social classes or socioeconomic groups were compared in three European countries, using similar sources of data from large national cohort studies. People registered at a census in 1971 (1975 for France) or a sample of them, were followed until 1980 or 1981. The Gini coefficient, a measure widely used in economics, allowed the comparison of various situations involving different numbers and group sizes. It was applied to age groups 35-44, and 45-54 for men only. According to this measure, inequalities were of the same order in England and Wales and Finland, and greater in France. Differences between the three countries concerning the principal causes of death leading to inequalities were cardiovascular diseases in England and Wales, accidents and cardiovascular diseases in Finland, and cancer and cirrhosis in France.

Correspondence analysis and logistic modelling: complementary use in the analysis of a health survey among nurses

Logistic or other modelling approaches are often appropriate for studying epidemiological data. However, health surveys may be more complex. With numerous variables, there is a need for exploratory analysis. Parsimonious description of the data is also a useful complement to modelling. Correspondence analysis may be useful in such exploratory phases. An example of the complementary use of the two approaches is presented in the context of a health survey among nurses, which focused on the relationship between shift and night work, and declared health problems.

[Submitting to disease, controlling disease, industrialization and medical technology: the case of tuberculosis]

This article presents an overview of the research work undertaken in France and Algeria on tuberculosis and the application of tuberculosis treatments. Tuberculosis is one of the best medical pointers to social inequality. The disease is seen here as typical of the links between industrialization and health, with regard to the evolution of the epidemiological model and the influence of innovational+ treatments, based on chemotherapy, on the organization of care for tubercular patients, together with the socio-economic and cultural changes that have affected both French and Algerian society during the twentieth century. The first part of the article shows how the epidemiology of tuberculosis tends to vary in accordance with the dynamic evolution of social relationships as industrialization occurs in each country, and how world-wide epidemiological trends are one of the best medical pointers to the North-South divide. The second part of the article is given over to a study of the way in which the application of tuberculosis treatments in both France and Algeria is a function of the organization of the health system in each country, of the status and power of the medical profession within society, and of the impact of technical innovations on the changing forms of care for tubercular patients in both countries. In France, it can be seen that the structure of the system set up to combat tuberculosis in the inter-war years has tended to remain unchanged, despite the opportunities for re-organization of tuberculosis treatment and for making therapy less onerous which have arisen as the incidence of the disease has dropped and antibiotics have been introduced. This resistance to change seems due primarily to the difficulty of achieving redeployment of medical staff, and the inertia caused by the rigid structure of tuberculosis care within the French socio-medical system.(ABSTRACT TRUNCATED AT 250 WORDS)

[Social inequality in deaths in Great Britain and in France]

In this paper data are compared on differential mortality for working men in the United Kingdom and France, for the years 1970-1972 (U.K.) and 1966-1971 (F). Differential mortality in the United Kingdom is described in 'occupational mortality' published by O.P.C.S.; mortality according to 'Catégories socio-professionnelles' has been studied for a large cohort by INSEE (National Institute of Statistics and Economic Studies). The comparison between those two sets of data leads to the following conclusions: social differences in death rates seem to be larger in France than in United Kingdom. the main causes of death responsible for these inequalities differ in the two countries: respiratory diseases are the main cause in U.K.; in France, accidents and alcohol-related death lead to the largest inequalities. We discuss the difficulties of comparison between countries: some of the apparent differences may relate to the fact that, in France, mortality data concerns a cohort followed since 1954, while British data comes from a transversal survey. Another point of difference is the fact that foreigners are not included in the French study. In every country where data exist on the subject, inequalities in health are found. The reasons why these inequalities exist, and what should be done to reduce them, is a matter for discussion. The purpose of this paper is to contribute to the debate, by throwing light on some aspects of the observed differences.

[Emergence and development of the tuberculosis control system in France between 1900 and 1940]

In industrialised countries the treatment of tuberculosis was one of the first public health services to appear at the beginning of the 20th century. This initiative represented a departure from the usual measures set up by public health specialists for improving living and environmental conditions, as new knowledge about the process of infection meant that action could be taken on the population directly. The processes which served to stratify and differentiate living standards characteristic of this period of industrialisation are reflected in the epidemiology of tuberculosis: the hierarchy of mortality rates runs parallel to that of the social groups. Many authors now question the role of the health service in the regression of infectious diseases, which they attribute more to changes in lifestyle. This text attempts to analyse the context and the objectives which surrounded the establishment of the service to combat tuberculosis in France, with reference to the various theories which seek to explain the emergence of social services in health or in education. Hence three theses are examined with reference to the actual history of the tuberculosis service. In this service an instrument of the ruling class, owners of the means of production, who thereby assure the reproduction of the workforce at a time when industrialisation demands an increase in the workforce, and when additional reserves of manual labour are being exhausted? Was the use of techniques arising out of new knowledge accompanied by an extension of the power of doctors into areas which had hitherto been outside their field of intervention? Did medical activity lead to new norms being introduced into everyday life in the name of scientific values? An interpretation in terms of social control is put forward to explain both the public health movement, compulsory education and urbanisation. Is this helpful in understanding how the organisation of the struggle against tuberculosis came about? This research is based on the systematic analysis of documents and journals on tuberculosis published in France during the period under study. Support is found for elements of all the these examined without any one being able to account for all aspects of the establishment of this service. The service represents the meeting point of a number of different forces: economic forces; political forces, as witnessed in the debate between the social and technical approach before the first World War; and professional forces, given the transformation of medical practice with the introduction of public health services and national insurance.