Individual and healthcare supply-related HIV transmission factors in HIV-positive patients enrolled in the antiretroviral treatment access program in the Centre and Littoral regions in Cameroon (ANRS-12288 EVOLCam survey).

BACKGROUND: Despite great progress in antiretroviral treatment (ART) access in recent decades, HIV incidence remains high in sub-Saharan Africa. We investigated the role of individual and healthcare supply-related factors in HIV transmission risk in HIV-positive adults enrolled in 19 HIV services in the Centre and Littoral regions of Cameroon. METHODS: Factors associated with HIV transmission risk (defined as both unstable aviremia and inconsistent condom use with HIV-negative or unknown status partners) were identified using a multi-level logistic regression model. Besides socio-demographic and behavioral individual variables, the following four HIV-service profiles, identified using cluster analysis, were used in regression analyses as healthcare supply-related variables: 1) district services with large numbers of patients, almost all practicing task-shifting and not experiencing antiretroviral drugs (ARV) stock-outs (n = 4); 2) experienced and well-equipped national reference services, most practicing task-shifting and not experiencing ARV stock-outs (n = 5); 3) small district services with limited resources and activities, almost all experiencing ARV stock-outs (n = 6); 4) small district services with a wide range of activities and half not experiencing ARV stock-outs (n = 4). RESULTS: Of the 1372 patients (women 67%, median age [Interquartile]: 39 [33-44] years) reporting sexual activity in the previous 12 months, 39% [min-max across HIV services: 25%-63%] were at risk of transmitting HIV. The final model showed that being a woman (adjusted Odd Ratio [95% Confidence Interval], p-value: 2.13 [1.60-2.82], p<0.001), not having an economic activity (1.34 [1.05-1.72], p = 0.019), having at least two sexual partners (2.45 [1.83-3.29], p<0.001), reporting disease symptoms at HIV diagnosis (1.38 [1.08-1.75], p = 0.011), delayed ART initiation (1.32 [1.02-1.71], p = 0.034) and not being ART treated (2.28 [1.48-3.49], p<0.001) were all associated with HIV transmission risk. Conversely, longer time since HIV diagnosis was associated with a lower risk of transmitting HIV (0.96 [0.92-0.99] per one-year increase, p = 0.024). Patients followed in the third profile had a higher risk of transmitting HIV (1.71 [1.05-2.79], p = 0.031) than those in the first profile. CONCLUSIONS: Healthcare supply constraints, including limited resources and ARV supply chain deficiency may impact HIV transmission risk. To reduce HIV incidence, HIV services need adequate resources to relieve healthcare supply-related barriers and provide suitable support activities throughout the continuum of care.

Individual and healthcare supply-related barriers to treatment initiation in HIV-positive patients enrolled in the Cameroonian antiretroviral treatment access programme.

Increasing demand for antiretroviral treatment (ART) together with a reduction in international funding during the last decade may jeopardize access to ART. Using data from a cross-sectional survey conducted in 2014 in 19 HIV services in the Centre and Littoral regions in Cameroon, we investigated the role of healthcare supply-related factors in time to ART initiation in HIV-positive patients eligible for ART at HIV diagnosis. HIV service profiles were built using cluster analysis. Factors associated with time to ART initiation were identified using a multilevel Cox model. The study population included 847 HIV-positive patients (women 72%, median age: 39 years). Median (interquartile range) time to ART initiation was 1.6 (0.5-4.3) months. Four HIV service profiles were identified: (1) small services with a limited staff practising partial task-shifting (n = 4); (2) experienced and well-equipped services practising task-shifting and involving HIV community-based organizations (n = 5); (3) small services with limited resources and activities (n = 6); (4) small services providing a large range of activities using task-shifting and involving HIV community-based organizations (n = 4). The multivariable model showed that HIV-positive patients over 39 years old [hazard ratio: 1.26 (95% confidence interval) (1.09-1.45), P = 0.002], those with disease symptoms [1.21 (1.04-1.41), P = 0.015] and those with hepatitis B co-infection [2.31 (1.15-4.66), P = 0.019] were all more likely to initiate ART early. However, patients in the first profile were less likely to initiate ART early [0.80 (0.65-0.99), P = 0.049] than those in the second profile, as were patients in the third profile [association only significant at the 10% level; 0.86 (0.72-1.02), P = 0.090]. Our findings provide a better understanding of the role played by healthcare supply-related factors in ART initiation. In HIV services with limited capacity, task-shifting and support from community-based organizations may improve treatment access. Additional funding is required to relieve healthcare supply-related barriers and achieve the goal of universal ART access.

Sturge Weber syndrome, when brain CT is enough for diagnosis: about a case.

One of the main manifestations of Sturge Weber syndrome is seizures. We report the case of a child received in the context of generalized seizures and in whom a cerebral contrast CT was sufficient to make the diagnosis of Sturge Weber syndrome.

Intimate partner violence against HIV-positive Cameroonian women: Prevalence, associated factors and relationship with antiretroviral therapy discontinuity-results from the ANRS-12288 EVOLCam survey.

BACKGROUND: Intimate partner violence in its various forms increases HIV exposure in female victims and potentially jeopardizes the HIV treatment cascade, for instance, by impeding engagement in and adherence to care. Elevated rates of HIV and intimate partner violence are reported in Central Africa. Evidence on the effect of intimate partner violence on antiviral therapy interruption is lacking in Cameroon, where only 330,000 women live with HIV and only 19% of HIV-positive people are virally suppressed. This study aimed to assess the prevalence and factors of intimate partner violence against HIV-positive women and its relationship with antiretroviral therapy interruption ⩾1 month. METHODS: The EVOLCam cross-sectional survey was conducted in 19 hospitals in the Center and Littoral regions. The study sample comprised antiviral therapy-treated women declaring at least one sexual partner in the previous year. Scores of recent emotional, physical, extreme physical and sexual intimate partner violence were built using principal component analysis and categorized under no, occasional or frequent intimate partner violence. Multivariate logistic analyses were performed to investigate the relationship between intimate partner violence and recent antiretroviral therapy interruption ⩾1 month, and associated factors. RESULTS: Among the 894 analyzed women, the prevalence of intimate partner violence was 29% (emotional), 22% (physical), 13% (extreme physical) and 18% (sexual). Frequent physical intimate partner violence was a significant risk factor of antiretroviral therapy interruption ⩾1 month (adjusted odds ratio = 2.42 (95% confidence interval = 1.00; 5.87)). It was also associated with HIV-related stigma (2.53 (1.58; 4.02)), living with a main partner (2.03 (1.20; 3.44) and non-defensive violence against this partner (5.75 (3.53; 9.36)). CONCLUSION: Intimate partner violence is a potential barrier to antiviral therapy continuity and aggravates vulnerability of Cameroonian HIV-positive women. The prevention and detection of intimate partner violence by HIV services might help to reach the last "90" of the 90-90-90 targets.

Impact of an educational intervention on risks associated with drug injection, and on psychosocial factors (PSF) involved in initiating and maintaining new health behaviors over time.

BACKGROUND/AIMS: In line with Self-determination Theory, individuals who feel they are able to adopt new behaviors autonomously, and who perceive their social environment as supportive of their autonomy and confident in their competencies, are more likely to engage in sustainable behavioral change over time. We aimed to study the impact of an educational intervention, which has already shown its effectiveness in reducing transmission-risk behaviors and injection-related complications among drug users (Roux et al., 2016), on three psychosocial factors (PSF) involved in initiating and maintaining new health behaviors over time, as follows: A) self-regulation of behaviors (autonomous vs. controlled regulation); B) perceived competence in adopting new behaviors (a feeling of being able or unable to adopt new behaviors) and C) perceived autonomy support (social environment perceived by drug users as supportive of autonomy vs. controlling). METHODS: This non-random clustered intervention study was conducted in 9 intervention groups (programs offering the intervention) and 8 control groups (programs not offering it). Each participant was followed up through a phone interview at enrolment, at 6 months and 12 months. Of the 271 participants, 113 received at least one educational session in the first six months. We used the "Health-Care Self-Determination Theory Questionnaire" to assess the impact of this intervention on the development of self-regulation, perceived competence and perceived autonomy support. RESULTS: Participants exposed to the intervention at least once were associated with a higher level of perceived competence and perceived autonomy support at M12. However, the intervention did not impact self-regulation (either autonomous or controlled). In addition, the study revealed that other factors, such as gender, age, drug use patterns and participants' healthcare pathways, also have an impact on these PSF. CONCLUSIONS: This educational intervention significantly increases patients' perceived competence but has no impact on the factors specifically involved in maintaining new behaviors over time. This study also highlights the existence of user profiles whose socio-demographic characteristics, use patterns and care pathways can influence these FPS involved in motivation to change and maintain new health behaviors over time.

Factors associated with perceived loss of libido in people who inject opioids: Results from a community-based survey in France.

BACKGROUND: Regular consumption of opioids exposes individuals to several side effects. One of these is a loss of libido, which has a negative impact on quality of life. We used a cross-sectional community-based survey of people who inject opioids to study factors associated with loss of libido, and more particularly the impact of the type of opioid injected. METHODS: This secondary study was conducted throughout France in 2015 and involved 514 people who inject opioids. Self-reported sociodemographic characteristics, drug consumption, injection-related data and loss of libido were collected using a brief questionnaire administered either through face-to-face interviews or online. Two different models were used to identify factors associated with loss of libido: simple logistic regression and a two-step Heckman model. RESULTS: Forty-three percent of the participants reported a loss of libido. The first model showed that filling in the questionnaire online (OR[95%CI] = 2.55[1.64;3.96]; p < 0.001), reporting that morphine sulfate (OR[95%CI] = 2.67[1.56;4.58]; p < 0.001) or methadone (OR[95%CI] = 2.50[1.13;5.56]; p = 0.030) was the opioid they injected most (versus buprenorphine), and reporting benzodiazepine use (OR[95%CI] = 1.62[1.07;2.44]; p = 0.033) were factors strongly associated with loss of libido. In the two-step, Heckman model which corrected for selection bias, along with these factors, reporting heroin as the opioid injected most was also strongly associated. CONCLUSION: Our findings showed that full-opioid agonists could have a negative impact on libido when injected regularly. Libido can improve quality of life and should be routinely discussed through counseling in prevention services with people who inject drugs.

Posttraumatic Stress Disorder as a Significant Correlate of Voluntary Antiretroviral Treatment Interruption in Adult HIV-Infected Patients Followed up in French Hospitals: Data From the ANRS-VESPA2 National Survey.

OBJECTIVE: Although antiretroviral treatment (ART) no longer requires 100% adherence, voluntary treatment interruption (VTI) still may have a negative impact on virologic success. Previous studies have shown that posttraumatic stress disorder (PTSD) is more prevalent in HIV-infected patients than in the general population. However, no study has yet investigated the relationship between PTSD and VTI. We analyzed this relationship using data from a French national survey representative of HIV-infected adults followed up in hospitals. METHODS: A total of 3,022 HIV-infected adults participated in the ANRS-VESPA2 survey (April 2011-January 2012) and answered a face-to-face questionnaire that included the Composite International Diagnostic Interview Short-Form to diagnose PTSD and assess sociobehavioral variables such as VTI. Multivariable logistic regression models were used to study the relationship between PTSD and VTI. RESULTS: Among the 2,768 ART-treated participants with available data for both PTSD screening and ART interruption (study sample), prevalence of PTSD was 13.3%, and 7.2% of individuals reported VTI during the previous month. After adjustment for being a female Sub-Saharan African immigrant and reporting harmful alcohol consumption (Alcohol Use Disorders Identification Test score ≥ 8), lifetime PTSD was found to be independently associated with VTI (adjusted odds ratio [95% CI] = 1.64 [1.07-2.53], P = .025). CONCLUSIONS: PTSD is highly prevalent in HIV-infected patients followed up in French hospitals and is a significant predictor of VTI. PTSD is a psychiatric disorder that is still underdiagnosed and undertreated in many countries despite its negative consequences on health behaviors. As there is evidence of effective treatment for PTSD, HIV care providers need to be trained in screening for this disorder.

Willingness to receive intravenous buprenorphine treatment in opioid-dependent people refractory to oral opioid maintenance treatment: results from a community-based survey in France.

BACKGROUND: Injectable opioids are an interesting option for people who inject drugs (PWID) that do not respond to oral Opioid Maintenance Treatment (OMT). To date, intravenous (IV) buprenorphine - a safer drug than full-opioid agonists in terms of overdose risk - has never been tested in a clinical trial on opioid dependence. We designed a survey to better understand the profile of PWID eligible for IV buprenorphine, and their willingness to receive it. METHODS: This cross-sectional community-based national survey was conducted through face-to-face interviews (in low-threshold and addiction care services) and online questionnaires (on https://psychoactif.org and other websites). Among the 557 participants, we selected those who were eligible for IV buprenorphine treatment (history of oral OMT, regular opioid injection) (n = 371). We used regression models to study factors associated with willingness to receive IV buprenorphine treatment among those with data on willingness (n = 353). In those who were willing (n = 294), we subsequently studied their willingness to receive daily supervised IV buprenorphine treatment. RESULTS: Among the selected 353 participants, 59% mainly injected buprenorphine, 15% heroin, 16% morphine sulfate and 10% other opioids. Eighty-three percent of the sample reported willingness to receive IV buprenorphine treatment. Factors associated with willingness were: more than 5 injection-related complications, regular buprenorphine injection, no lifetime overdose, and completion of the questionnaire online. Factors associated with unwillingness to receive daily supervised treatment were younger age (OR[IC95%]=1.04[1.01; 1.07]) and stable housing (OR[IC95%]=0.61[0.37;1.01]) while regular heroin injectors were more willing to receive daily supervision (OR[IC95%]=2.94 [1.42; 6.10]). CONCLUSIONS: PWID were very willing to receive intravenous buprenorphine as a treatment, especially those with multiple injection-related complications. In addition, our findings show that IV buprenorphine may be less acceptable to PWID who inject morphine sulfate. Young PWID and those with stable housing were unwilling to receive IV buprenorphine if daily supervision were required. This preliminary study provides useful information for the development of a clinical trial on IV buprenorphine treatment.

Increased Uptake of HCV Testing through a Community-Based Educational Intervention in Difficult-to-Reach People Who Inject Drugs: Results from the ANRS-AERLI Study.

AIMS: The community-based AERLI intervention provided training and education to people who inject drugs (PWID) about HIV and HCV transmission risk reduction, with a focus on drug injecting practices, other injection-related complications, and access to HIV and HCV testing and care. We hypothesized that in such a population where HCV prevalence is very high and where few know their HCV serostatus, AERLI would lead to increased HCV testing. METHODS: The national multisite intervention study ANRS-AERLI consisted in assessing the impact of an injection-centered face-to-face educational session offered in volunteer harm reduction (HR) centers ("with intervention") compared with standard HR centers ("without intervention"). The study included 271 PWID interviewed on three occasions: enrolment, 6 and 12 months. Participants in the intervention group received at least one face-to-face educational session during the first 6 months. MEASUREMENTS: The primary outcome of this analysis was reporting to have been tested for HCV during the previous 6 months. Statistical analyses used a two-step Heckman approach to account for bias arising from the non-randomized clustering design. This approach identified factors associated with HCV testing during the previous 6 months. FINDINGS: Of the 271 participants, 127 and 144 were enrolled in the control and intervention groups, respectively. Of the latter, 113 received at least one educational session. For the present analysis, we selected 114 and 88 participants eligible for HCV testing in the control and intervention groups, respectively. In the intervention group, 44% of participants reported having being tested for HCV during the previous 6 months at enrolment and 85% at 6 months or 12 months. In the control group, these percentages were 51% at enrolment and 78% at 12 months. Multivariable analyses showed that participants who received at least one educational session during follow-up were more likely to report HCV testing, compared with those who did not receive any intervention (95%[CI] = 4.13[1.03;16.60]). CONCLUSION: The educational intervention AERLI had already shown efficiency in reducing HCV at-risk practices and associated cutaneous complications and also seems to have a positive impact in increasing HCV testing in PWID.

Innovative community-based educational face-to-face intervention to reduce HIV, hepatitis C virus and other blood-borne infectious risks in difficult-to-reach people who inject drugs: results from the ANRS-AERLI intervention study.

AIMS: To study the effectiveness of an educational intervention on risks associated with drug injection, comparing primary [unsafe HIV-hepatitis C virus (HCV) practices] and secondary (local complications at injecting site) end-points in harm reduction (HR) programmes offering this intervention versus HR programmes not offering it. DESIGN: This non-random clustered intervention study was conducted in nine intervention groups (programmes offering the intervention) and eight control groups (programmes not offering it). Each participant was followed-up through a telephone interview at enrolment and at 6 and 12 months. SETTING: The study took place in 17 cities throughout France. PARTICIPANTS: Of the 271 participants, 144 were enrolled into the intervention group and 127 in the control group. Of the latter, 113 received at least one educational session. INTERVENTION: A series of participant-centred face-to-face educational sessions. Each session included direct observation by trained non-governmental organization (NGO) staff or volunteers of participants' self-injecting the psychoactive product they used habitually; analysis by the trained NGO staff or volunteers of the participant's injecting practices, identification of injection-related risks and explanation of safer injecting practices; and an educational exchange on the individual participant's injection practices and the questions he or she asked. MEASUREMENTS: Primary and secondary outcomes were 'at least one unsafe HIV-HCV practice' and at least one injection-related complication (derived from a checklist). FINDINGS: The proportion of participants with at least one unsafe HIV-HCV practice in the intervention group decreased significantly, from 44% at M0 to 25% at M6, as well as complications at the injection site (from 66 to 39% at M12), while in the control group it remained mainly stable. Multivariate probit analyses showed that the intervention group experienced a significant reduction in unsafe HIV-HCV practices at M6 [coefficient, 95% confidence interval (CI) = -0.73 (-1.47 to 0.01)] and in injection-related complications at M12 [coefficient, 95% CI = -1.01 (-1.77 to -0.24)], compared with the control group. CONCLUSIONS: An inexpensive and easily implemented educational intervention on risks associated with drug injection reduces significantly unsafe HIV-HCV transmission practices and injection-related complications.