Organisation of testing services, structural barriers and facilitators of routine HIV self-testing during sexually transmitted infection consultations: a qualitative study of patients and providers in Abidjan, Côte d'Ivoire.

BACKGROUND: Consultations for sexually transmitted infection (STI) provide an opportunity to offer HIV testing to both patients and their partners. This study describes the organisation of HIV self-testing (HIVST) distribution during STI consultations in Abidjan (Côte d'Ivoire) and analyse the perceived barriers and facilitators associated with the use and redistribution of HIVST kits by STI patients. MATERIALS AND METHODS: A qualitative study was conducted between March and August 2021 to investigate three services providing HIVST: an antenatal care clinic (ANC), a general health centre that also provided STI consultations, and a dedicated STI clinic. Data were collected through observations of medical consultations with STI patients (N = 98) and interviews with both health professionals involved in HIVST distribution (N = 18) and STI patients who received HIVST kits for their partners (N = 20). RESULTS: In the ANC clinic, HIV testing was routinely offered during the first prenatal visit. HIVST was commonly offered to women who had been diagnosed with an STI for their partner's use (27/29 observations). In the general health centre, two parallel pathways coexisted: before the consultation, a risk assessment tool was used to offer HIV testing to eligible patients and, after the consultation, patients who had been diagnosed with an STI were referred to a care assistant for HIVST. Due to this HIV testing patient flow, few offers of HIV testing and HIVST were made in this setting (3/16). At the dedicated STI clinic, an HIVST video was played in the waiting room. According to the health professionals interviewed, this video helped reduce the time required to offer HIVST after the consultation. Task-shifting was implemented there: patients were referred to a nurse for HIV testing, and HIVST was commonly offered to STI patients for their partners' use (28/53). When an HIVST was offered, it was generally accepted (54/58). Both health professionals and patients perceived HIVST positively despite experiencing a few difficulties with respect to offering HIVST to partners and structural barriers associated with the organisation of services. CONCLUSION: The organisation of patient flow and task-shifting influenced HIV testing and offers of HIVST kits. Proposing HIVST is more systematic when HIV testing is routinely offered to all patients. Successful integration requires improving the organisation of services, including task-shifting.

Multimorbidity in elderly people living with HIV: how do general practitioners manage? / Polypathologie des personnes âgées vivant avec le VIH : quelle gestion en médecine générale ?

INTRODUCTION: The occurrence of multimorbidity concerns more and more people living with HIV (PLWHIV) and its frequency increases with age. General practitioners should occupy a central place in the out-of-hospital follow-up of elderly PLWHIV with multimorbidities. Our study aims to understand the actual position of general practitioners and the barriers they encounter in the management of elderly PLWHIV with multimorbidities. METHODS: This sub-study of the ANRS EP66-SEPTAVIH sancillary tudy, which assesses frailty in PLWHIV aged 70 years and over, is based on in-depth interviews with general practitioners and PLWHIV aged 70 years and over. The data were processed manually. Themes and sub-themes were identified and tabulated before being subjected to a cross-sectional thematic analysis. RESULTS: Based on 30 interviews conducted between April 2020 and June 2021 with 10 general practitioners and 20 PLWHIV aged 70 years and over and with multiple diseases, this study identifies the difficulties that general practitioners encounter in fully participating in the care. The follow-up of these patients is characterized by symbolic partitions between groups of professionals: organizational fragmentation between general practitioners and specialists, fear of encroaching on the role of the other health professionals, and frequent absence of formalization of roles in the coordination of care. CONCLUSIONS: In order to promote optimal follow-up and improve the experience of elderly PLWHIV, it is important that the role of each stakeholder be better defined for better shared follow-up.

Introduction: La polypathologie est une problématique de santé qui concerne de plus en plus de personnes vivant avec le VIH (PVVIH) et dont la fréquence augmente avec l'âge. Le recul actuel de l'hospitalo-centrisme devrait amener le médecin généraliste à occuper une place centrale dans le suivi extra-hospitalier des PVVIH âgées et polypathologiques. Notre étude cherche à comprendre la place qu'occupent réellement les médecins généralistes et les barrières qu'ils rencontrent dans la prise en charge des PVVIH âgées et polypathologiques. Méthodes: Nous présentons ici les résultats d'une étude ancillaire d'une précédente recherche (ANRS EP66-SEPTAVIH) qui évalue la fragilité chez les PVVIH âgées de 70 ans et plus. Elle repose sur des entretiens approfondis réalisés auprès de médecins généralistes et de PVVIH âgées de 70 ans et plus. Les données ont fait l'objet d'un traitement manuel et les thèmes et sous-thèmes identifiés ont été classés dans un tableau sous forme de grilles d'être soumis à une analyse thématique transversale. Résultats: À partir de 30 entretiens réalisés d'avril 2020 à juin 2021 auprès de 10 médecins généralistes et 20 PVVIH âgées de 70 ans et plus et polypathologiques, cette étude identifie les difficultés que les médecins généralistes rencontrent pour intervenir pleinement dans la prise en charge de ces patients. Leur suivi est caractérisé par des cloisonnements symboliques entre groupes de professionnels : morcellement organisationnel entre médecins généralistes et spécialistes, peur d'empiéter sur le rôle de l'autre professionnel de santé et absence fréquente de formalisation des rôles dans la coordination des soins. Conclusions: Afin de favoriser un suivi optimal et d'améliorer le vécu des PVVIH âgées, il est important que le rôle de chaque intervenant soit mieux défini pour un meilleur suivi partagé.

Is Madagascar at the edge of a generalised HIV epidemic? Situational analysis.

OBJECTIVES: To describe the epidemiological situation of the HIV/AIDS epidemic and to identify the main drivers for vulnerability in Madagascar. DESIGN: Literature review, qualitative research and situational analysis. DATA SOURCES: Search of electronic bibliographic databases, national repositories of documentation from 1998 to 2018. Search keywords included Madagascar, HIV, sexually transmitted infections, men who have sex with men (MSM), sex workers (SWs), transactional sex (TS), injecting drug users (IDUs), vulnerability and sexual behaviour. Qualitative sources were interviews and focus group discussions. REVIEW METHODS: Studies focused on HIV and/or vulnerability of HIV in Madagascar in general, and key populations (KPs) and HIV/AIDS response were taken into account. National reports from key HIV response actors were included. RESULTS: Madagascar is characterised by a low HIV/AIDS epidemic profile in the general population (GP) (0.3%) combined with a high prevalence of HIV among KPs (SWs, MSM and IDUs).An increase in HIV prevalence among KP has been observed during recent years. Hospital-based data suggest an increase in HIV prevalence among the GP. The vulnerability traits are inconsistent use of condoms, multipartner relationships and other contextual factors like widespread TS and gender inequality. A high prevalence/incidence of sexually transmitted infections could indicate a high vulnerability to HIV/AIDS. However, there are no reports of HIV prevalence of >1% in antenatal consultation. CONCLUSION: There is not enough evidence to make a conclusion about the HIV epidemiological situation in Madagascar due to the scarcity of the epidemiological data. However, Madagascar may be closer to a turning point towards a high-prevalence epidemic with severe consequences, particularly when taking into account its socioeconomical fragility and underlying vulnerabilities. More precise epidemiological data and improved HIV/AIDS diagnosis and case management should be a public health priority.

Family, social and cultural determinants of long-lasting insecticidal net (LLIN) use in Madagascar: secondary analysis of three qualitative studies focused on children aged 5-15 years.

BACKGROUND: Although it is accepted that long-lasting insecticidal net (LLIN) use is an effective means to prevent malaria, children aged 5 to 15 years do not appear to be sufficiently protected in Madagascar; the malaria prevalence is highest in this age group. The purpose of this research is to summarize recent qualitative studies describing LLIN use among the Malagasy people with a focus on children aged 5-15 years. METHODS: Qualitative data from three studies on malaria conducted between 2012 and 2016 in 10 districts of Madagascar were analysed. These studies cover all malaria epidemiological profiles and 10 of the 18 existing ethnic groups in Madagascar. A thematic analysis was conducted on the collected data from semi-structured interviews, direct observation data, and informal interviews. RESULTS: A total of 192 semi-structured interviews were conducted. LLINs are generally perceived positively because they protect the health and well-being of users. However, regional representations of mosquito nets may contribute to LLIN lower use by children over 5 years of age including the association between married status and LLIN use, which leads to the refusal of unmarried young men to sleep under LLINs; the custom of covering the dead with a mosquito net, which leads to fear of LLIN use; and taboos governing sleeping spaces for siblings of opposite sexes, which leads to LLIN shortages in households. Children under 5 years of age are known to be the most vulnerable age group for acquiring malaria and, therefore, are prioritized for LLIN use when there are limited supplies in households. In contrast, children over 5 years of age, who are perceived to be at less risk for malaria, often sleep without LLINs. CONCLUSIONS: Perceptions, social practices and regional beliefs regarding LLINs and vulnerability to malaria contribute to the nonuse of LLINs among children over 5 years of age in Madagascar. Modifying LLIN policies to account for these factors may increase LLIN use in this age group and reduce disease burden.

Factors influencing maternal healthcare seeking in a highland region of Madagascar: a mixed methods analysis.

BACKGROUND: In Madagascar, maternal mortality remains stable and high (426 deaths per 100,000 live births). This situation is mainly due to a delay or lack of use of maternal healthcare services. Problems related to maternal healthcare services are well documented in Madagascar, but little information related to maternal healthcare seeking is known. Thus, this paper aims to identify and analyze the factors that influence the utilization of maternal services, specifically, the use of antenatal care (ANC) during pregnancy and the use of skilled birth attendants (SBAs) at delivery. METHOD: We used quantitative and qualitative approaches in the study. Two communes of the Vakinankaratra region, which are located in the highlands, were the settings. Data collection occurred from October 2016 to July 2017. A total of 245 pregnant women were included and followed up in the quantitative survey, and among them, 35 participated in in-depth interviews(IDIs). Logistic regressions were applied to explore the influencing factors of antenatal and delivery healthcare seeking practices through thematic qualitative analysis. RESULTS: Among the 245 women surveyed, 13.9% did not attend any ANC visits. School level, occupation and gravidity positively influenced the likelihood of attending one or more ANC visits. The additional use of traditional caregivers remained predominant and was perceived as potentially complementary to medical care. Nine in ten (91%) women expressed a preference for delivery at healthcare facilities (HFs), but 61% of births were assisted by a skilled birth attendant (SBA).The school level; the frequency of ANCs; the origin region; and the preference between modern or traditional care influenced the use of SBAs at delivery. A lack of preparation (financial and logistics problems) and women's low involvement in decision making at delivery were the main barriers to giving birth at HFs. CONCLUSION: The use of maternal healthcare services is starting to gain ground, although many women and their relatives still use traditional caregivers at the same time. Relatives play a crucial role in maternal healthcare seeking. It would be necessary to target women's relatives for awareness-raising messages about ANC and childbirth in healthcare facilities and to support and formalize collaborations between traditional healers and biomedical caregivers.

Implementation of HPV-based screening in Burkina Faso: lessons learned from the PARACAO hybrid-effectiveness study.

BACKGROUND: Cervical cancer screening in sub-Saharan countries relies on primary visual inspection with acetic acid (VIA). Primary human papillomavirus (HPV)-based screening is considered a promising alternative. However, the implementation and real-life effectiveness of this strategy at the primary-care level in limited-resource contexts remain under explored. In Ouagadougou, Burkina Faso, free HPV-based screening was implemented in 2019 in two primary healthcare centers. We carried out a process and effectiveness evaluation of this intervention. METHODS: Effectiveness outcomes and implementation indicators were assessed through a cohort study of screened women, observations in participating centers, individual interviews with women and healthcare providers and monitoring reports. Effectiveness outcomes were screening completeness and women's satisfaction. Logistic regression models and concurrent qualitative analysis explored how implementation variability, acceptability by women and the context affected effectiveness outcomes. RESULTS: After a 3-month implementation period, of the 350 women included in the cohort, 94% completed the screening, although only 26% had their screening completed in a single visit as planned in the protocol. The proportion of highly satisfied women was higher after result disclosure (95%) than after sampling (65%). A good understanding of the screening results and recommendations increased screening completeness and women's satisfaction, while time to result disclosure decreased satisfaction. Adaptations were made to fit healthcare workers' workload. CONCLUSION: Free HPV-based screening was successfully integrated within primary care in Ouagadougou, Burkina Faso, leading to a high level of screening completeness despite the frequent use of multiple visits. Future implementation in primary healthcare centers needs to improve counseling and reduce wait times at the various steps of the screening sequence.

Describing, analysing and understanding the effects of the introduction of HIV self-testing in West Africa through the ATLAS programme in Côte d'Ivoire, Mali and Senegal.

BACKGROUND: The ATLAS programme aims to promote and implement HIV self-testing (HIVST) in three West African countries: Côte d'Ivoire, Mali, and Senegal. During 2019-2021, in close collaboration with the national AIDS implementing partners and communities, ATLAS plans to distribute 500,000 HIVST kits through eight delivery channels, combining facility-based, community-based strategies, primary and secondary distribution of HIVST. Considering the characteristics of West African HIV epidemics, the targets of the ATLAS programme are hard-to-reach populations: key populations (female sex workers, men who have sex with men, and drug users), their clients or sexual partners, partners of people living with HIV and patients diagnosed with sexually transmitted infections and their partners. The ATLAS programme includes research support implementation to generate evidence for HIVST scale-up in West Africa. The main objective is to describe, analyse and understand the social, health, epidemiological effects and cost-effectiveness of HIVST introduction in Côte d'Ivoire, Mali and Senegal to improve the overall HIV testing strategy (accessibility, efficacy, ethics). METHODS: ATLAS research is organised into five multidisciplinary workpackages (WPs): Key Populations WP: qualitative surveys (individual in-depth interviews, focus group discussions) conducted with key actors, key populations, and HIVST users. Index testing WP: ethnographic observation of three HIV care services introducing HIVST for partner testing. Coupons survey WP: an anonymous telephone survey of HIVST users. Cost study WP: incremental economic cost analysis of each delivery model using a top-down costing with programmatic data, complemented by a bottom-up costing of a representative sample of HIVST distribution sites, and a time-motion study for health professionals providing HIVST. Modelling WP: Adaptation, parameterisation and calibration of a dynamic compartmental model that considers the varied populations targeted by the ATLAS programme and the different testing modalities and strategies. DISCUSSION: ATLAS is the first comprehensive study on HIV self-testing in West Africa. The ATLAS programme focuses particularly on the secondary distribution of HIVST. This protocol was approved by three national ethic committees and the WHO's Ethical Research Committee.

Acceptability of HPV screening among HIV-infected women attending an HIV-dedicated clinic in Abidjan, Côte d'Ivoire.

BACKGROUND: Cervical cancer incidence is high among women living with HIV due to high-risk HPV persistence in the cervix. In low-income countries, cervical cancer screening is based on visual inspection with acetic acid. Implementing human papilloma virus (HPV) screening through self-sampling could increase women's participation and screening performance. Our study aims to assess the preintervention acceptability of HPV screening among HIV-infected women in Abidjan, Côte d'Ivoire. METHODS: Applying the Health Belief Model theoretical framework, we collected qualitative data through in-depth interviews with 21 HIV-infected women treated in an HIV-dedicated clinic. Maximum variation sampling was used to achieve a diverse sample of women in terms of level of health literacy. Interviews were recorded and transcribed with the participants' consent. Data analysis was performed using NVivo 12. RESULTS: Screening acceptability relies on cervical cancer representations among women. Barriers were the fear of diagnosis and the associated stigma disregard for HIV-associated health conditions, poor knowledge of screening and insufficient resources for treatment. Fees removal, higher levels of knowledge about cervical cancer and of the role of HIV status in cancer were found to facilitate screening. Healthcare providers are obstacle removers by their trusting relationship with women and help navigating through the healthcare system. Self-confidence in self-sampling is low. CONCLUSIONS: Free access to cervical screening, communication strategies increasing cervical cancer knowledge and healthcare provider involvement will foster HPV screening. Knowledge gathered through this research is crucial for designing adequate HPV-based screening interventions for women living with HIV in this setting.

Frequency, risk factors, and complications of induced abortion in ten districts of Madagascar: results from a cross-sectional household survey.

BACKGROUND: Madagascar has restrictive abortion laws with no explicit exception to preserve the woman's life. This study aimed to estimate the incidence of abortion in the country and examine the methods, consequences, and risk factors of these abortions. METHODS: We interviewed 3179 women between September 2015 and April 2016. Women were selected from rural and urban areas of ten districts via a multistage, stratified cluster sampling survey and asked about any induced abortions within the previous 10 years. Analyses used survey weighted estimation procedures. Quasi-Poisson regression was used to estimate the incidence rate of abortions. Logistic regression models with random effects to account for the clustered sampling design were used to estimate the risk of abortion complications by abortion method, provider, and month of pregnancy, and to describe risk factors of induced abortion. RESULTS: For 2005-2016, we estimated an incidence rate of 18.2 abortions (95% CI 14.4-23.0) per 1000 person-years among sexually active women (aged 18-49 at the time of interview). Applying a multiplier of two as used by the World Health Organization for abortion surveys suggests a true rate of 36.4 per 1000 person-year of exposure. The majority of abortions involved invasive methods such as manual or sharp curettage or insertion of objects into the genital tract. Signs of potential infection followed 29.1% (21.8-37.7%) of abortions. However, the odds of potential infection and of seeking care after abortion did not differ significantly between women who used misoprostol alone and those who used other methods. The odds of experiencing abortion were significantly higher among women who had ever used contraceptive methods compared to those who had not. However, the proportion of women with a history of abortion was significantly lower in rural districts where contraception was available from community health workers than where it was not. CONCLUSIONS: Incidence estimates from Madagascar are lower than those from other African settings, but similar to continent-wide estimates when accounting for underreporting. The finding that the majority of abortions involved invasive procedures suggests a need for strengthening information, education and communications programs on preventing or managing unintended pregnancies.

Appréciation des interventions de lutte contre la malnutrition maternelle par la population à Madagascar.

INTRODUCTION: Madagascar has adopted strategies to fight against maternal malnutrition, but the evaluation of their implementation is not effective.Purpose of research: The present study aims to describe beneficiary appreciation of interventions to fight maternal malnutrition and to identify their expectations. METHOD: A qualitative study was conducted in the Amoron’i Mania region, Madagascar. The study included mothers of children under 5, pregnant women, and other family members and community members (fathers, grandmothers, matrons and community workers). Six focus groups and 16 individual interviews were conducted to collect the data. The thematic analysis was used. RESULTS: Food supplementation, improved production of agriculture and livestock, and nutrition education, operated by NGOs, are the best-known interventions. The health centers were not mentioned as interveners and their interventions were ignored. The effectiveness of the intervention is generally judged on the benefits perceived by the beneficiaries. Interveners working on a project basis were assessed as unsustainable. Two main problems were mentioned: first, the insufficiency of agricultural production resulting in the inaccessibility of the ingredients required for the nutrition education, and second the low coverage of the interventions. The improvement of agricultural production is the main suggestion mentioned to fight against maternal undernutrition. CONCLUSIONS: Beneficiaries thought that existing interventions in the region are insufficient to address the problem of malnutrition among mothers.

Nationwide evaluation of malaria infections, morbidity, mortality, and coverage of malaria control interventions in Madagascar.

BACKGROUND: In the last decade, an important scale-up was observed in malaria control interventions. Madagascar entered the process for pre-elimination in 2007. Policy making needs operational indicators, but also indicators about effectiveness and impact of malaria control interventions (MCI). This study is aimed at providing data about malaria infection, morbidity, and mortality, and MCI in Madagascar. METHODS: Two nationwide surveys were simultaneously conducted in 2012-2013 in Madagascar: a study about non-complicated clinical malaria cases in 31 sentinel health facilities, and a cross-sectional survey (CSS) in 62 sites. The CSS encompassed interviews, collection of biological samples and verbal autopsies (VA). Data from CSS were weighted for age, sex, malaria transmission pattern, and population density. VA data were processed with InterVA-4 software. RESULTS: CSS included 15,746 individuals of all ages. Parasite rate (PR) as measured by rapid diagnostic tests was 3.1%, and was significantly higher in five to 19 year olds, in males, poorer socio-economic status (SES) quintiles and rural areas. Long-lasting insecticidal nets (LLIN) use was 41.7% and was significantly lower in five to 19 year olds, males and wealthier SES quintiles. Proportion of persons covered by indoor residual spraying (IRS) was 66.8% in targeted zones. Proportion of persons using other insecticides than IRS was 22.8%. Coverage of intermittent preventive treatment during pregnancy was 21.5%. Exposure to information, education and communication messages about malaria was significantly higher in wealthier SES for all media but information meetings. The proportion of fever case managements considered as appropriate with regard to malaria was 15.8%. Malaria was attributed as the cause of death in 14.0% of 86 VA, and 50% of these deaths involved persons above the age of five years. The clinical case study included 818 cases of which people above the age of five accounted for 79.7%. In targeted zones, coverage of LLIN and IRS were lower in clinical cases than in general population. CONCLUSIONS: This study provides valuable data for the evaluation of effectiveness and factors affecting MCI. MCI and evaluation surveys should consider the whole population and not only focus on under-fives and pregnant women in pre-elimination or elimination strategies.

[Representations and disease experience of hepatitis B by Sub-Saharan patients in Ivory Coast and France]. / Représentations et vécu de l'hépatite B de patients subsahariens en Côte d'Ivoire et en France.

OBJECTIVE: Hepatitis B, a major public health problem in Africa and among Sub-Saharan populations living in France, remains poorly characterized and insufficiently managed. Two social sciences studies in Abidjan (Côte d'Ivoire) and Île-de-France investigated representations of hepatitis B and attitudes towards medical care among chronic hepatitis B carriers. Comparison of the two studies raises the question of the role of different settings of access to care in the relationship towards disease and medical care. METHODS: In Abidjan, the study was conducted with 14 patients at the University Hospital and the blood donor monitoring medical centre (Centre médical de suivi des donneurs de sang). In Île-de-France, it was conducted among 33 chronic carriers in two hospital departments. The method was qualitative, using semi-structured interviews and consultation observations. RESULTS: The comparison showed similarities and differences. Similarities exclusively concerned representations of hepatitis B, ignorance of the disease, and the negatively-charged association with HIV, linked in particular to the lack of collective mobilization on issues relating to hepatitis B in Africa and France. Differences concerned patients' attitudes towards medical follow-up and screening of close relatives, which are determined by the radically different funding conditions between the two sites. Given the lack of universal health insurance in Ivory Coast, patients with chronic hepatitis B experience difficulties of access to medical care. CONCLUSION: These studies emphasize the need for awareness campaigns on hepatitis B and information about conditions of management of chronic hepatitis B carriers in Sub-Saharan Africa.

[Chronic hepatitis B and HIV care: the key role of the doctor-patient relationship]. / Prise en charge du VIH et de l'hépatite B chronique chez les migrants subsahariens en France : le rôle-clé de la relation médecin-patient.

In France, populations from sub-Saharan Africa represent a large proportion of the persons living with chronic hepatitis B or HIV. The objective of this study was to analyse the characteristics of the doctor-patient relationships in these diseases, when the patient is a sub-Saharan migrant, according to the doctor's objectives, the patient's expectations, and the context of care for these in diseases. A qualitative study by semi-structured interviews and by observations of medical consultations was conducted in four hospitals in Ile-de-France. Seventy-three patients from Sub-Saharan Africa living with chronic hepatitis B or HIV, and 13 doctors were interviewed. The study emphasizes the central role of the doctor-patient relationship in meeting the patient's expectations in relation to management. The characteristics of this relationship are different for these two diseases. For hepatitis B, a mismatch was observed between the doctor's objectives, centered on medical care, and the patient's expectations (information about the disease and treatment, support in everyday life with the infection and administrative procedures) in a context of misunderstanding and negative perception of hepatitis B. For HIV, the doctor's objectives and the patient's expectations were more closely matched because personal, social, and administrative difficulties are integrated into care. Management of sexual problems and legal obstacles to family entry and settlement remain uncertain. Similar studies in populations born in France would be necessary to complete these results.

Obstacles to routine immunization in Madagascar: Structural, relational and cultural constraints.

This article proposes an overview of anthropological studies concerning childhood immunization in Madagascar, where vaccine coverage still remains low. The COVID-19 epidemic has heightened the reticence of populations to be vaccinated in the public health centres of this country. It appears necessary to study the factors which may impact immunization practices and its representations. The principal results of these studies describe immunization from the perspective of parents of children under five years of age. The role that they attribute to a vaccine is essentially that of reinforcing the health of children against illness. There is a misunderstanding of combination vaccines, one vaccine generally being associated with one disease. The findings also show a complex relationship with immunization, injections and the health passport. Finally, uptake of immunization or not is motivated by the structural and local context such as the perceived frailness of the newborn baby, the practice of post-partum confinement, or the lack of knowledge about the vaccine. Lack of understanding of immunization and mistrust of it are signs of a fragile health system. An in-depth analysis of immunization and the impact of COVID-19 on its perception will provide a clearer view of the fragility of the immunization programmes implemented in Madagascar.

Assessing the Acceptability of Home-Based HPV Self-Sampling: A Qualitative Study on Cervical Cancer Screening Conducted in Reunion Island Prior to the RESISTE Trial.

Cervical cancer incidence and mortality rates are 2 to 3 times higher in the overseas department of Reunion compared with mainland France. RESISTE's cluster-randomized controlled trial aims to test the effectiveness of home-based self-sampling (HBSS) through a high-risk oncogenic papillomavirus test sent out by post to women who have not been screened in the past 3 years, despite having been invited to do so through a reminder letter. Prior to the trial, qualitative research was carried out to understand screening barriers and assess anticipated acceptability. Semi-structured interviews were conducted with 35 women and 20 healthcare providers. Providers consider HBSS a viable method in reaching women who tend not to visit a doctor regularly, or who are reluctant to undergo a smear pap, as well as those who are geographically isolated. They considered, however, that women would require support, and that outreach was necessary to ensure more socially isolated women participate. The majority of the women surveyed were in favour of HBSS. However, two-thirds voiced concerns regarding the test's efficiency and their ability to perform the test correctly, without harming themselves. Based on these findings, recommendations were formulated to reassure women on usage and quality, and to help reach socially isolated women.

Combined incentive actions, focusing on primary care professionals, to improve cervical cancer screening in women living in socioeconomically disadvantaged geographical areas: a study protocol of a hybrid cluster randomised effectiveness and implementation trial- RESISTE.

INTRODUCTION: Cervical cancer (CC) causes thousands of deaths each year. Nearly 100% of cases are caused by oncogenic strains of human papillomavirus (HPV). In most industrialised countries, CC screening (CCS) is based on the detection of HPV infections. For many reasons including lower adherence to CCS, underserved women are more likely to develop CC, and die from it. We aim to demonstrate that the use of incentives could improve screening rates among this population. METHODS AND ANALYSIS: Our cluster randomised, controlled trial will include 10 000 women aged 30-65 years eligible for CCS, living in deprived areas in four French departments, two mainlands and two overseas, and who did not perform physician-based HPV testing within the framework of the nationally organised screening programme. HPV self-sampling kit (HPVss) will be mailed to them. Two interventions are combined in a factorial analysis design ending in four arms: the possibility to receive or not a financial incentive of €20 and to send back the self-sampling by mail or to give it to a health professional, family doctor, gynaecologist, midwife or pharmacist. The main outcome is the proportion of women returning the HPVss, or doing a physician-based HPV or pap-smear test the year after receiving the HPVss. 12-month follow-up data will be collected through the French National Health Insurance database. We expect to increase the return rate of HPV self-samples by at least 10% (from 20% to 30%) compared with the postal return without economic incentive. ETHICS AND DISSEMINATION: Ethics approval was first obtained on 2 April 2020, then on July 29 2022. The ethics committee classified the study as interventional with low risk, thus no formal consent is required for inclusion. The use of health insurance data was approved by the Commission Nationale Informatique et Libertés on 14 September 2021 (ref No 920276). An independent data security and monitoring committee was established. The main trial results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT04312178.

Willingness to use and distribute HIV self-test kits to clients and partners: A qualitative analysis of female sex workers' collective opinion and attitude in Côte d'Ivoire, Mali, and Senegal.

BACKGROUND: In West Africa, female sex workers are at increased risk of HIV acquisition and transmission. HIV self-testing could be an effective tool to improve access to and frequency of HIV testing to female sex workers, their clients and partners. This article explores their perceptions regarding HIV self-testing use and the redistribution of HIV self-testing kits to their partners and clients. METHODS: Embedded within ATLAS, a qualitative study was conducted in Côte-d'Ivoire, Mali, and Senegal in 2020. Nine focus group discussions were conducted. A thematic analysis was performed. RESULTS: A total of 87 participants expressed both positive attitudes toward HIV self-testing and their willingness to use or reuse HIV self-testing. HIV self-testing was perceived to be discreet, confidential, and convenient. HIV self-testing provides autonomy from testing by providers and reduces stigma. Some perceived HIV self-testing as a valuable tool for testing their clients who are willing to offer a premium for condomless sex. While highlighting some potential issues, overall, female sex workers were optimistic about linkage to confirmatory testing following a reactive HIV self-testing. Female sex workers expressed positive attitudes toward secondary distribution to their partners and clients, although it depended on relationship types. They seemed more enthusiastic about secondary distribution to their regular/emotional partners and regular clients with whom they had difficulty using condoms, and whom they knew enough to discuss HIV self-testing. However, they expressed that it could be more difficult with casual clients; the duration of the interaction being too short to discuss HIV self-testing, and they fear violence and/or losing them. CONCLUSION: Overall, female sex workers have positive attitudes toward HIV self-testing use and are willing to redistribute to their regular partners and clients. However, they are reluctant to promote such use with their casual clients. HIV self-testing can improve access to HIV testing for female sex workers and the members of their sexual and social network.

[Pregnancy and medical follow-up of women living with HIV/AIDS in Guadeloupe and Martinique (French West Indies): medical progress and social problems]. / Grossesse et suivi médical des femmes vivant avec le VIH/sida en Guadeloupe et en Martinique : entre avancées médicales et difficultés sociales.

After sub-Saharan Africa, the Caribbean is the region of the world most affected by HIV/AIDS. Guadeloupe and Martinique (French West Indies) are located in the heart of this region. Although the AIDS incidence here is lower than in other Caribbean countries, it is much higher than in mainland France. Transmission is mostly heterosexual, and the proportion of women infected is high, almost half of all those infected. Moreover, in Guadeloupe a large proportion of them are foreigners (mainly from Haïti). This qualitative study was conducted in 2009 among health professionals, advocacy and support groups, and women living with HIV/AIDS. It analysed the characteristics of women's follow-up during and after their pregnancy. It also analysed the practices that health professionals have developed to provide follow-up for these women, despite various obstacles. Antiretroviral therapy makes it possible to health professionals to reduce the risk of mother-to-child transmission of HIV infection. They inform their patients of the possibilities for infected women to have a child with less risk of infection provided that she has a medical follow-up and that she is treated. But they note that the pregnancies are rarely planned in consultation with them: patients are generally already pregnant when they discuss the subject with their doctors. The pregnancy is nevertheless a special moment for medical monitoring: women are particularly compliant during their pregnancy, because their priority is the protection of the child's health. After the child's birth, however, the social and administrative difficulties of many of these women serve as obstacles to their continued medical care. Some women stop treatment and medical follow-up after delivery, even when they make sure the child has medical follow-up. To continue the follow-up of women and their children, or to contact women who have been lost to follow-up, professionals resort to various practices: compliance consultations, house calls, hospitalization... These practices are based on multidisciplinary collaboration, between medical departments (infectious diseases, obstetrics/gynaecology, and paediatrics), as well as with social services and support groups for persons living with HIV/AIDS.

[Knowledge and perception of malnutrition among the rural population in the Central Highlands, Madagascar]. / Connaissances et perceptions de la malnutrition par la population rurale des Hautes Terres Centrales, Madagascar.

INTRODUCTION: malnutrition due to inadequate food supply is a major challenge in low- and middle-income countries. The purpose of this study is to identify the sociocultural drivers of malnutrition. METHODS: we conducted a qualitative study in the Amoron´I Mania region, Madagascar. The study involved pregnant women, mothers and fathers, grandmothers and health actors such as "matrones", community workers and health workers. A total of 24 semi-structured individual interviews and 6 focus groups were used to collect data. Thematic analysis was used. RESULTS: malnutrition refers to a lack of food and undernourishment. It revolves around the amount of rice consumption, socio-cultural factors and insufficient financial resources. Vulnerable groups were mainly composed of children and pregnant women. Severe malnutrition including signs was reported, but there was evidence for local adaptation. Thus, families were trying by different means to fight against malnutrition. CONCLUSION: the socio-cultural context modulates knowledge and perception of the causes, the manifestations and the vulnerability or non-vulnerability of an individual as well as the severity of malnutrition.

Challenges of HIV Self-Test Distribution for Index Testing When HIV Status Disclosure Is Low: Preliminary Results of a Qualitative Study in Bamako (Mali) as Part of the ATLAS Project.

Context: The rate of HIV status disclosure to partners is low in Mali, a West African country with a national HIV prevalence of 1.2%. HIV self-testing (HIVST) could increase testing coverage among partners of people living with HIV (PLHIV). The AutoTest-VIH, Libre d'accéder à la connaissance de son Statut (ATLAS) program was launched in West Africa with the objective of distributing nearly half a million HIV self-tests from 2019 to 2021 in Côte d'Ivoire, Mali, and Senegal. The ATLAS program integrates several research activities. This article presents the preliminary results of the qualitative study of the ATLAS program in Mali. This study aims to improve our understanding of the practices, limitations and issues related to the distribution of HIV self-tests to PLHIV so that they can offer the tests to their sexual partners. Methods: This qualitative study was conducted in 2019 in an HIV care clinic in Bamako. It consisted of (i) individual interviews with eight health professionals involved in the distribution of HIV self-tests; (ii) 591 observations of medical consultations, including social service consultations, with PLHIV; (iii) seven observations of peer educator-led PLHIV group discussions. The interviews with health professionals and the observations notes have been subject to content analysis. Results: HIVST was discussed in only 9% of the observed consultations (51/591). When HIVST was discussed, the discussion was almost always initiated by the health professional rather than PLHIV. HIVST was discussed infrequently because, in most of the consultations, it was not appropriate to propose partner HIVST (e.g., when PLHIV were widowed, did not have partners, or had delegated someone to renew their prescriptions). Some PLHIV had not disclosed their HIV status to their partners. Dispensing HIV self-tests was time-consuming, and medical consultations were very short. Three main barriers to HIVST distribution when HIV status had not been disclosed to partners were identified: (1) almost all health professionals avoided offering HIVST to PLHIV when they thought or knew that the PLHIV had not disclosed their HIV status to partners; (2) PLHIV were reluctant to offer HIVST to their partners if they had not disclosed their HIV-positive status to them; (3) there was limited use of strategies to support the disclosure of HIV status. Conclusion: It is essential to strengthen strategies to support the disclosure of HIV+ status. It is necessary to develop a specific approach for the provision of HIV self-tests for the partners of PLHIV by rethinking the involvement of stakeholders. This approach should provide them with training tailored to the issues related to the (non)disclosure of HIV status and gender inequalities, and improving counseling for PLHIV.