Determinants and effects or consequences of internal HIV-related stigma among people living with HIV in Morocco.

BACKGROUND: HIV-related stigma and discrimination constitute a barrier to different intervention programs. Unlike external stigma, internal stigma is not well explored in in the Middle East and North African countries, while grasping this particular form of stigma is essential to limit its effects. The present study aims to measure internal stigma effects and to identify factors associated with this kind of stigma not yet documented among people living with HIV (PLHIV) in Morocco. METHODS: The PLHIV Stigma Index questionnaire (adapted and translated into French and Moroccan Arabic dialect "darija") was used to collect information regarding the stigma and discrimination experienced by PLHIV across 8 cities in Morocco (September-October 2016). A randomly drawn cluster of 10 PLHIV, consisting of 5 men and 5 women, was drawn at each participating medical care center to achieve a nationally representative sample of PLHIV. Fifteen interviewers living with HIV and five supervisors were selected and trained to administer the questionnaire. An internal stigma score (range: 0-7), was calculated based on seven negative feelings/ beliefs. Negative binomial regression was used to identify characteristics associated with the internal stigma score. RESULTS: Among 626 PLHIV, internal stigma was reported by 88.2%. The median [IQR] internal stigma score was 4 [2-5]. Regarding internal stigma, 51% avoided going to the local clinic when needed and 44% chose not to attend social gatherings. Belonging to at least one key population (aIRR [95%CI] = 1.15 [1.03; 1.28]), experiencing discriminatory reactions from family following HIV status disclosure (1.28 [1.11; 1.49]), avoiding HIV services for fear of stigmatization by staff (1.16 [1.05; 1.28]) and being denied health services because of HIV status (1.16 [1.03;1.32]), are among the factors significantly associated with an increase of the internal stigma score. CONCLUSIONS: Internal stigma is high among Moroccan PLHIV and significantly impacting their life decisions and their healthcare access. Multi-level interventions are needed to address internal stigma experienced by PLHIV in Morocco.

[Mental health professionals' representations of their practices in Rabat, Morocco]. / La représentation des professionnels de santé mentale sur leurs pratiques a Rabat, Maroc.

INTRODUCTION: The main challenges faced by the mental health system in Morocco are insufficient quality of care and limited human resources. Training of mental health providers therefore constitutes a way of improving quality of care. METHODS: We conducted 22 semi-structured interviews with mental health practitioners, mental health senior managers and psychiatry teachers in order to identify training needs. RESULTS: The main findings were the lack of communication, collaboration and updated knowledge especially concerning diagnosis, psychotropic drug prescriptions and addiction medicine. We also identified specific training needs for mental health specialists, such as geriatric psychiatry and paediatric psychiatry. DISCUSSION: Consequently, better training in these areas would contribute to the success of managed care strategies in primary healthcare facilities.

Feasibility and acceptability of a new integrated approach to control cystic echinococcosis in Morocco: Vaccination of sheep and anthelmintic treatment of dogs.

Cystic echinococcosis (CE) or hydatidosis is a common parasitic disease worldwide, especially in poor and developing countries. In Morocco, CE is a major zoonosis, despite the implementation of a national control program since 2007. Therefore, in 2016, a field trial that associates the EG95 vaccine (lambs) and anthelmintic treatment (dogs) was started in the Mid Atlas, the most endemic region in Morocco, with preliminary positive results. Here, a qualitative approach was used to analyze the feasibility and social acceptability of this strategy. Fifteen focus group discussions were separately conducted with breeders and with their wives, and forty-two individual interviews were performed with private-sector veterinarians and officers from structures responsible for the CE control program. Recordings were transcribed and analyzed with the R software, using the RQDA package. This qualitative research was validated using the credibility, transferability, dependability and confirmability criteria. This study showed that the professionals' views on sheep vaccination and anthelmintic treatment were divided between acceptability and concerns. Conversely, breeders and their wives highlighted the issue of the costs of procedures the utility of which was not immediately clear to them. All participants proposed solutions to improve this strategy, and also stressed the lack of education on CE. By bringing together the views of the communities and the professionals, this study traced the main lines (targeting the different aspects of CE and taking into account the local socio-cultural beliefs) that must be taken into account to ensure the short- and long-term CE control in Morocco.

Stakeholder analysis to improve the national control program of cystic echinococcosis in Morocco.

Cystic echinococcosis (CE) is a major zoonosis in Morocco. Despite a national hydatidosis control programme (NHCP) established in 2005, CE burden is still high nationwide. The aim of this study was to carry out an NHCP stakeholders' analysis to identify weak points and propose improvement strategies. In total, 164 semi-structured interviews were carried out with national and local stakeholder representatives, and one stakeholders' workshop was organized. Classical categories of stakeholder analysis (i.e. involvement, interest, importance, influence, priority, and power) were semi-quantified. Based on these categories, an analytical framework was proposed, by selecting elements from the stakeholder analysis, to structure the assessment around three criteria: measure appropriation, political agency, and socio-technical agency. Besides specific weak points of the NHCP, the analysis highlighted the complexity of implementing a zoonotic disease control programme due to the involvement of many different stakeholders. Finally, this study provides a simplified stakeholder analysis method that could be used to assess other health programmes targeting zoonotic diseases, in Morocco and in similar countries.

The socio-economic burden of cystic echinococcosis in Morocco: A combination of estimation method.

Cystic echinococcosis (CE) is a major zoonosis in Morocco despite the launch of a national control programme in 2005. As its economic consequences have not been studied yet in Morocco, this study estimated CE impact in terms of monetary losses, disability-adjusted life years (DALY), and DALY for zoonotic diseases (zDALY) in the entire country and in specific regions for the 2011 to 2014 period. The direct monetary losses were related to organ seizure from infected animal in slaughterhouses, and to healthcare expenses as well as lost wages for infected humans. Animal production losses concerned milk yield, fertility, carcass weight, and wool production. Losses due to human infection were also composed of disability and productivity losses at work. Monte Carlo simulations were used to estimate monetary losses and zDALY values. Nationwide, the estimated DALY was 0.5 years per 100,000 persons per year, and the zDALY was 55 years per 100,000 persons per year. Total yearly losses were estimated at 73 million USD (54-92 million USD). However, losses differed significantly among regions. Most of the economic losses consisted of unperceived consequences, i.e. decreased animal production and reduced productivity of asymptomatic individuals. Future studies should determine the socioeconomic and epidemiological factors underlying the differences in economic losses among regions to develop better adapted control programmes.

"The mosquitoes that destroy your face". Social impact of Cutaneous Leishmaniasis in South-eastern Morocco, A qualitative study.

OBJECTIVE: To document the psychosocial burden of Cutaneous Leishmaniasis (CL) in rural communities in Southeastern Morocco. METHOD: Between March and April 2015, we conducted qualitative research in communities exposed to Leishmania major or L. tropica in Errachidia and Tinghir provinces. Twenty-eight focus groups discussions (FGDs) were realized, with a stratification by gender and tradition of medicine (users of folk versus professional medicine). Data were analyzed using content analysis. RESULTS: This rural population most exposed to CL in Morocco lacks access to health care in general and clearly points out there are other major public health issues that need to be resolved. Nonetheless, respondents consider the impact of CL lesions and scars as important and similar to that of burn scar tissue. Young women with CL scars in the face are stigmatized and will often be rejected for marriage in these communities. People usually try a long list of folk remedies on the active lesions, but none was felt adequate. There was a clear demand for better treatment as well as for treatment of the scars. CONCLUSIONS: The psycho-social impact of CL due to L.major and L.tropica is substantial, especially for young single women with facial scars. These generate social and self-stigma and diminish their marriage prospects. CL is well known, but not considered as a major health priority by these poor rural communities in South-eastern Morocco where gender discrimination is still an issue and access to basic health care is as neglected as CL. Early CL diagnosis and new treatment options with better skin outcomes are urgently needed.

Psychosocial impact of scars due to cutaneous leishmaniasis on high school students in Errachidia province, Morocco.

BACKGROUND: In Morocco, cutaneous leishmaniasis (CL) is usually known to be a slowly healing localized skin disease, but in some cases, it can lead to mutilating scars. The outbreak of CL due to Leishmania major in the Errachidia province in southeastern Morocco between 2008 and 2010 left many adolescents with permanent scar tissue on the face or other exposed body parts. We studied the psychosocial impact of CL on these young people. METHODS: In 2015 we conducted a cross-sectional survey among high-school students living in boarding schools in two CL-endemic areas of Errachidia: Rissani and Tinejdad. A self-administered questionnaire elicited responses about general knowledge of CL and related scars. An open-ended question focused on the possible psychosocial effects associated with these scars. The quantitative data were analyzed with Epi Info™ and the text data with NVivo software. RESULTS: Almost 20% of 448 respondents reported they had experienced a CL lesion and 87% said it could possibly or definitely lead to psychological consequences. The text analysis showed that girls more often than boys expanded on the negative psychological effects of CL. The students considered CL as "dangerous", "serious", and "deathly", and said it sometimes led to extreme suicidal ideations. CONCLUSIONS: The burden of CL in this age group is not negligible. The indelible CL scars lead to self-stigma and social stigma, and the emergence of negative psychological effects in this age group. While some students accepted their CL scars and related suffering as their "destiny", others were eagerly demanding protective measures against CL and treatment for the scars.

Intersectoral collaboration between the medical and veterinary professions in low-resource societies: The role of research and training institutions.

BACKGROUND: Neglected zoonoses continue to significantly affect human health in low-resource countries. A symposium was organised in Antwerp, Belgium, on 5 November 2010 to evaluate how intersectoral collaboration among educational and research institutions could improve the situation. RESULTS: Brucellosis and echinococcosis were presented as models for intersectoral collaboration. Low-resource societies face evident knowledge gaps on disease distribution, transmission within and across species and impact on human and animal health, precluding the development of integrated control strategies. RECOMMENDATIONS: While veterinarians have been the main driver of the One Health initiative, the medical profession does not seem to be fully aware of how veterinary science can contribute to human public health. It was postulated that transdisciplinarity could help fill knowledge gaps and that encouraging such transdisciplinarity should start with undergraduate students. Furthermore, intersectoral collaboration on zoonoses should not ignore the social sciences (e.g. assessment of indigenous knowledge and perception; participatory surveillance), which can contribute to a better understanding of the transmission of diseases and improve communities' participation in disease control activities.