Accelerated aging in people living with HIV: The neuroimmune feedback model.

People living with HIV (PLWH) experience earlier onset of aging-related comorbidities compared to their counterparts without HIV. This paper lays out a theoretical model to explain why PLWH experience accelerated aging. Briefly, the model is structured as follows. PLWH experience disproportionately heavy burdens of psychosocial stress across the life course. This psychosocial stress increases risks for depressive symptoms and problematic substance use. Depressive symptoms and problematic substance use interfere with long-term adherence to antiretroviral therapy (ART). Lower ART adherence, in turn, exacerbates the elevated systemic inflammation stemming from HIV infection. This inflammation increases risks for aging-related comorbidities. Systemic inflammation also reduces connectivity in the brain's central executive network (CEN), a large-scale brain network that is critical for coping with stressful circumstances. This reduced capacity for coping with stress leads to further increases in depressive symptoms and problematic substance use. Together, these changes form a neuroimmune feedback loop that amplifies the impact of psychosocial stress on aging-related comorbidities. In this paper, I review the existing evidence relevant to this model and highlight directions for future research.

Infectious Illness Symptoms Are Associated with Elevated Anxiety in a Sample of Sexual and Gender Minority Young Adults During the COVID-19 Pandemic.

BACKGROUND: To evaluate whether infectious illness symptoms (IIS) are associated with generalized anxiety symptoms during the COVID-19 pandemic in sexual/gender (SGM) minority young adults assigned male at birth (AMAB). METHOD: Four hundred eighteen participants (median age = 25; range, 20-40) were recruited through RADAR, an ongoing Chicago-based cohort study of SGM-AMAB between September 2020 and February 2021. Participants completed online surveys. A subset (n = 145) provided dried blood spot samples to assess SARS-CoV-2 serostatus. RESULTS: One hundred twenty participants (28.7%) had GAD-7 scores of 10 or greater, which indicates generalized anxiety symptoms that may be clinically significant. In a binomial logistic regression model adjusting age, gender identity, race/ethnicity, substance use, and HIV status, the authors found that having a higher IIS count since March 1, 2020, was associated with greater odds of having a GAD-7 score of 10 or greater (OR = 1.14; 95% CI, 1.04, 1.25; P = 0.007). This effect was more pronounced in a binomial logistic regression model adjusting for the same covariates but using current IIS count as the independent variable (OR = 1.39; 95% CI, 1.13, 1.74; P = 0.002). CONCLUSION: Among SGM-AMAB young adults, those who experienced ISS reported higher scores on the GAD-7, a widely used and validated screening measure for generalized anxiety symptoms. These findings highlight the importance of screening for anxiety disorders when patients present with IIS in clinical settings and psychobehavioral health follow-ups when indicated.

Trauma History Predicts Decoupling of C-Reactive Protein and Somatic Symptoms: Results From a Cohort Study of Sexual and Gender Minority Youth.

OBJECTIVE: Systemic inflammation can induce somatic symptoms (e.g., pain, nausea, fatigue) through neuroimmune signaling pathways. Previous research suggests that early-life adversity amplifies signaling between peripheral inflammation and the brain. We therefore hypothesized that greater lifetime trauma exposure at baseline would predict stronger associations between systemic inflammation and somatic symptoms at 2.5-year follow-up in a cohort study of sexual and gender minority youth assigned male at birth ( n = 694). METHODS: We measured prior trauma exposure (lifetime count of traumatic event types reported at baseline), somatic symptoms (Brief Symptom Inventory somatization score), and systemic inflammation (C-reactive protein, interleukin 6, interleukin 1ß, and tumor necrosis factor α). All models included age, gender, education, recent trauma exposure, substance use, body mass index, and HIV status as covariates. RESULTS: Higher C-reactive protein concentrations were associated with greater somatic symptoms in the main effects model ( ß = 0.019, 95% confidence interval [CI] = 0.006 to 0.031). Contrary to our hypothesis, we observed a negative interaction between prior trauma exposure and C-reactive protein levels in predicting somatic symptoms ( ß = -0.017, 95% CI = -0.030 to -0.004). Higher C-reactive protein was associated with greater somatic symptoms only in participants without prior trauma exposure at baseline ( ß = 0.044, 95% CI = 0.026 to 0.062). Specificity analyses revealed similar patterns when nonsomatic depressive symptoms were used as the outcome variable. CONCLUSIONS: These results suggest that sexual and gender minority youth assigned male at birth who have a history of prior trauma exposure may experience decoupling of systemic inflammation and somatic symptoms. The absence of inflammation-related symptoms may prevent individuals from seeking necessary medical care by reducing interoceptive awareness of pathological states.

COVID-19 symptom severity predicts neutralizing antibody activity in a community-based serological study.

Serological testing for SARS-CoV-2 IgG antibodies is used to assess their presence in blood samples from exposed individuals and provides a measure of the magnitude of immune response to infection. The measurement of neutralizing antibodies (NAbs) in particular provides information about the severity of prior infection and level of protective immunity against re-infection. Much of the work investigating the association between prior infection severity and NAb levels has been conducted among clinical populations, and less is known about this relationship in the general population. Accordingly, we utilize data from a large (n = 790) community-based cohort of unvaccinated, seropositive participants. We analyzed the association between NAb response, measured via surrogate virus neutralization assay, with patterns of symptoms and household exposure. Our results indicate no detectable NAb activity in 63.8% of the seropositive participants (n = 504). Those with detectable NAb levels demonstrated a positive relationship between NAb activity and both self-reported previous symptom severity and household exposure. These findings are significant in light of recent concerns about degree of protective immunity conferred by prior infection or vaccination, and we highlight the value of community-based research for investigating variation in immune response.

Greater chronic morbidity is associated with greater fatigue in six countries: A case of evolutionary mismatch?

Background and objectives: Human susceptibility to chronic non-communicable disease may be explained, in part, by mismatches between our evolved biology and contemporary environmental conditions. Disease-induced fatigue may function to reduce physical activity during acute infection, thereby making more energy available to mount an effective immune response. However, fatigue in the context of chronic disease may be maladaptive because long-term reductions in physical activity increase risks of disease progression and the acquisition of additional morbidities. Here, we test whether cumulative chronic morbidity is associated with subjective fatigue. Methodology: We constructed a cumulative chronic morbidity score using self-reported diagnoses and algorithm-based assessments, and a subjective fatigue score based on four questionnaire items using cross-sectional survey data from the Study on global AGEing and adult health, which features large samples of adults from six countries (China, Ghana, India, Mexico, Russia and South Africa). Results: In a mixed-effects linear model with participants nested in countries (N = 32 455), greater cumulative chronic morbidity is associated with greater subjective fatigue (ß = 0.34, SE = 0.005, P < 2e-16). This association replicates within each country and is robust to adjustment for key sociodemographic and physical covariates (sex, age, household wealth, physical function score, habitual physical activity, BMI and BMI2). Conclusions and implications: Fatigue is a common but perhaps maladaptive neuropsychological response to chronic morbidity. Disease-induced fatigue may mediate a self-perpetuating cycle, in which chronic morbidity reduces physical activity, and less physical activity increases cumulative chronic morbidity. Longitudinal research is needed to test whether chronic morbidity, fatigue and physical activity form a cyclical feedback loop. Lay Summary: Fatigue during acute illness may promote recovery, but persistent fatigue in the context of chronic disease may make matters worse. We present evidence from six countries that more chronic disease is associated with more fatigue. This fatigue may reduce physical activity, which increases risks of acquiring additional chronic health problems.

Does body mass index explain the apparent anti-inflammatory effects of cannabis use? Results From a cohort study of sexual and gender minority youth.

BACKGROUND: Cannabis use has been linked to lower systemic inflammation, but the pathways connecting cannabis use and systemic inflammation are unclear. Here we investigate whether body mass index (BMI) accounts for the association between cannabis use and systemic inflammation in a cohort of sexual and gender minority youth assigned male at birth (n = 712). METHODS: Substance use was assessed across six biannual visits. Cannabis use was measured using the Cannabis Use Disorders Identification Test-Revised (CUDIT-R) and urine screening for tetrahydrocannabinol (THC). At the final visit, BMI was measured, and a plasma sample was collected to measure biomarkers of systemic inflammation: C-reactive protein (CRP), interleukin-6, interleukin-1ß, and tumor necrosis factor-α. Inflammatory markers were log2-transformed. Age, gender, race/ethnicity, education, HIV status, cigarette use, alcohol use, and polydrug use were included as covariates. RESULTS: In models including all covariates except BMI, greater cumulative CUDIT-R score was associated with lower CRP (ß = -0.14; 95% CI: -0.22,-0.05) and lower interleukin-6 (ß = -0.12; 95% CI: -0.21,-0.04). These associations were attenuated when BMI was added to the model. Mediation analyses revealed an indirect effect of cumulative CUDIT-R score on CRP (ß = -0.08; 95% CI: -0.12,-0.05) and interleukin-6 (ß = -0.08; 95% CI: -0.12,-0.05), mediated by BMI. Models using urine THC or self-reported frequency to operationalize cannabis use produced similar results. We found no clear evidence that HIV status moderates these associations. CONCLUSIONS: These results suggest that BMI may partially account for the apparent anti-inflammatory effects of cannabis use. Research on the mechanisms linking cannabis use, adiposity, and inflammation may uncover promising intervention targets.

Geographic disparities in COVID-19 case rates are not reflected in seropositivity rates using a neighborhood survey in Chicago.

To date, COVID-19 case rates are disproportionately higher in Black and Latinx communities across the US, leading to more hospitalizations, and deaths in those communities. These differences in case rates are evident in comparisons of Chicago neighborhoods with differing race and/or ethnicities of their residents. Disparities could be due to neighborhoods with more adverse health outcomes associated with poverty and other social determinants of health experiencing higher prevalence of SARS-CoV-2 infection or due to greater morbidity and mortality resulting from equivalent SARS-CoV-2 infection prevalence. We surveyed five pairs of adjacent ZIP codes in Chicago with disparate COVID-19 case rates for highly specific and quantitative serologic evidence of any prior infection by SARS-CoV-2 to compare with their disparate COVID-19 case rates. Dried blood spot samples were self-collected at home by internet-recruited participants in summer 2020, shortly after Chicago's first wave of the COVID-19 pandemic. Pairs of neighboring ZIP codes with very different COVID-19 case rates had similar seropositivity rates for anti-SARS-CoV-2 receptor binding domain IgG antibodies. Overall, these findings of comparable exposure to SARS-CoV-2 across neighborhoods with very disparate COVID-19 case rates are consistent with social determinants of health, and the co-morbidities related to them, driving differences in COVID-19 rates across neighborhoods.

Low prevalence of anemia among Shuar communities of Amazonian Ecuador.

OBJECTIVE: Anemia is an important global health challenge. We investigate anemia prevalence among Indigenous Shuar of Ecuador to expand our understanding of population-level variation, and to test hypotheses about how anemia variation is related to age, sex, and market integration. METHODS: Hemoglobin levels were measured in a total sample of 1650 Shuar participants (ages 6 months to 86 years) from 46 communities between 2008 and 2017 to compare anemia prevalence across regions characterized by different levels of market integration. RESULTS: Shuar anemia rates among children under 15 years (12.2%), adult women (10.5%), and adult men (5.3%) were less than half of those previously documented in other neo-tropical Indigenous populations. Anemia prevalence did not vary between more traditional and market integrated communities (OR = 0.47, p = .52). However, anemia was negatively associated with body mass index (OR = 0.47, p = .002). CONCLUSIONS: Compared to other South American Indigenous populations, anemia prevalence is relatively low among Shuar of Ecuador and invariant with market integration. Understanding this pattern can provide valuable insights into anemia prevention among at-risk populations.

Why we don't move: The importance of somatic maintenance and resting.

A compelling ecological theory of movement and vigor must explain why humans and other animals spend so much time not moving. When we rest, our somatic maintenance systems continue to work. When our somatic maintenance requirements increase, we place greater subjective value on resting. To explain variation in movement and vigor, we must account for the subjective value of resting.

Traumatic events and mental health: The amplifying effects of pre-trauma systemic inflammation.

BACKGROUND: Traumatic experiences are strongly predictive of adverse mental health outcomes. Experimental studies have demonstrated that systemic inflammation can increase reactivity to threatening stimuli. It is not known whether naturally occurring inflammation amplifies the impact of traumatic experiences on mental health. Here we test whether incident traumatic events are more predictive of adverse mental health outcomes for individuals with greater pre-trauma systemic inflammation in a racially and ethnically diverse cohort study of youth assigned male at birth who identify as sexual or gender minorities (ages 16-29, n = 518), a group at high risk for trauma exposure. METHODS: Measures of inflammation, depression symptom severity, and perceived stress were measured at baseline. One year later, depression symptom severity and perceived stress were measured again, and participants reported the traumatic events they had experienced in the intervening year. RESULTS: In a model adjusted for baseline depression symptom severity and other key covariates, we found that higher baseline levels of interleukin-1ß amplified the effect of incident trauma exposure on depression symptom severity at follow-up (ß = 0.234, SE = 0.080, P = 0.004). In a model adjusted for baseline perceived stress and other key covariates, we found that higher baseline scores on a multi-marker inflammatory index amplified the effect of incident trauma exposure on perceived stress at follow-up (ß = 0.243, SE = 0.083, P = 0.003). CONCLUSIONS: These findings suggest that greater pre-trauma inflammation may predict poorer mental health following trauma exposure. Understanding how inflammation interacts with trauma to shape mental health may generate novel insights for preventing and treating the debilitating psychological consequences of trauma.

Cohabitation With a Known Coronavirus Disease 2019 Case Is Associated With Greater Antibody Concentration and Symptom Severity in a Community-Based Sample of Seropositive Adults.

In a community-based sample of seropositive adults (n = 1101), we found that seropositive individuals who lived with a known coronavirus disease 2019 (COVID-19) case exhibited higher blood anti-severe acute respiratory syndrome coronavirus 2 spike receptor-binding domain immunoglobulin G concentrations and greater symptom severity compared to seropositive individuals who did not live with a known COVID-19 case.

Exposure to SARS-CoV-2 within the household is associated with greater symptom severity and stronger antibody responses in a community-based sample of seropositive adults.

Magnitude of SARS-CoV-2 virus exposure may contribute to symptom severity. In a sample of seropositive adults (n=1101), we found that individuals who lived with a known COVID-19 case exhibited greater symptom severity and IgG concentrations compared to individuals who were seropositive but did not live with a known case (P<0.0001).

Market integration and soil-transmitted helminth infection among the Shuar of Amazonian Ecuador.

BACKGROUND: Soil-transmitted helminth (STH) infections have many negative health outcomes (e.g., diarrhea, nutritional deficiencies) that can also exacerbate poverty. These infections are generally highest among low-income populations, many of which are also undergoing market integration (MI; increased participation in a market-based economy). Yet the direct impact of MI-related social and environmental changes on STH infection patterns is poorly understood, making it unclear which lifestyle factors should be targeted to better control disease spread. This cross-sectional study examines if household infrastructure associated with greater MI is associated with lower STH burdens among Indigenous Ecuadorian Shuar. METHODS: Kato-Katz fecal smears were used to determine STH infection status and intensity (n = 620 participants; 308 females, 312 males, aged 6 months-86 years); Ascaris lumbricoides (ascarid) and Trichuris trichiura (whipworm) were the primary infection types detected. Structured interviews assessing lifestyle patterns (e.g., measures of household infrastructure) measured participant MI. Multilevel regression analyses and zero-inflated negative binomial regression models tested associations between MI measures and STH infection status or intensity, controlling for individual and community characteristics. RESULTS: Participants residing in more market-integrated households exhibited lower infection rates and intensities than those in less market integrated households. Parasite infection status and T. trichiura infection intensity were lower among participants living in houses with wood floors than those with dirt floors, while individuals using well or piped water from a spring exhibited lower A. lumbricoides infection intensities compared to those using river or stream water. Unexpectedly, latrine type was not significantly related to STH infection status or intensity. These results suggest that sources of exposure differ between the two helminth species. CONCLUSIONS: This study documents associations between household measures and STH infection among an Indigenous population undergoing rapid MI. These findings can help healthcare programs better target interventions and reduce STH exposure among at-risk populations.

Soil-transmitted helminth infection and intestinal inflammation among the Shuar of Amazonian Ecuador.

OBJECTIVES: Little research exists documenting levels of intestinal inflammation among indigenous populations where exposure to macroparasites, like soil-transmitted helminths (STHs), is common. Reduced STH exposure is hypothesized to contribute to increased prevalence of elevated intestinal inflammation in wealthy nations, likely due to coevolutionary histories between STHs and human immune systems that favored anti-inflammatory pathways. Here, we document levels of intestinal inflammation and test associations with STH infection among the Shuar of Ecuador, an indigenous population undergoing socioeconomic/lifestyle changes that influence their hygienic environment. We predict that fecal calprotectin (FC; a measure of intestinal inflammation) will be lower in STH infected individuals and that FC will be negatively associated with infection intensity. METHODS: Stool samples to analyze FC levels and STH infection were collected from 69 Shuar participants (ages 5-75 years). Children (<15 years) and adults (15+ years) were analyzed separately to understand the role of exposure in immune system development and the intestinal inflammatory response. RESULTS: Two species of STH were present: Ascaris lumbricoides and Trichuris trichiura. The relationships between infection and intestinal inflammation were age- and species-specific. While no significant relationships were found among adults, children who were singly infected with T. trichiura had lower FC levels than uninfected children. Infection intensity was not significantly associated with FC in children or adults. CONCLUSIONS: These preliminary results provide limited support for our hypotheses, documenting tentative age- and species-specific associations between FC and infection status. Findings may point to the importance of species-specific STH exposure during immune system development.

Cross-cultural invariances in the architecture of shame.

Human foragers are obligately group-living, and their high dependence on mutual aid is believed to have characterized our species' social evolution. It was therefore a central adaptive problem for our ancestors to avoid damaging the willingness of other group members to render them assistance. Cognitively, this requires a predictive map of the degree to which others would devalue the individual based on each of various possible acts. With such a map, an individual can avoid socially costly behaviors by anticipating how much audience devaluation a potential action (e.g., stealing) would cause and weigh this against the action's direct payoff (e.g., acquiring). The shame system manifests all of the functional properties required to solve this adaptive problem, with the aversive intensity of shame encoding the social cost. Previous data from three Western(ized) societies indicated that the shame evoked when the individual anticipates committing various acts closely tracks the magnitude of devaluation expressed by audiences in response to those acts. Here we report data supporting the broader claim that shame is a basic part of human biology. We conducted an experiment among 899 participants in 15 small-scale communities scattered around the world. Despite widely varying languages, cultures, and subsistence modes, shame in each community closely tracked the devaluation of local audiences (mean r = +0.84). The fact that the same pattern is encountered in such mutually remote communities suggests that shame's match to audience devaluation is a design feature crafted by selection and not a product of cultural contact or convergent cultural evolution.

Socioeconomic Status, Financial Strain, and Leukocyte Telomere Length in a Sample of African American Midlife Men.

BACKGROUND: African American men in the USA experience poorer aging-related health outcomes compared to their White counterparts, partially due to socioeconomic disparities along racial lines. Greater exposure to socioeconomic strains among African American men may adversely impact health and aging at the cellular level, as indexed by shorter leukocyte telomere length (LTL). This study examined associations between socioeconomic factors and LTL among African American men in midlife, a life course stage when heterogeneity in both health and socioeconomic status are particularly pronounced. METHODS: Using multinomial logistic regression, we examined associations between multiple measures of SES and tertiles of LTL in a sample of 92 African American men between 30 to 50 years of age. RESULTS: Reports of greater financial strain were associated with higher odds of short versus medium LTL (odds ratio (OR)=2.21, p = 0.03). Higher income was associated with lower odds of short versus medium telomeres (OR=0.97, p = 0.04). Exploratory analyses revealed a significant interaction between educational attainment and employment status (χ 2 = 4.07, p = 0.04), with greater education associated with lower odds of short versus long telomeres only among those not employed (OR=0.10, p = 0.040). CONCLUSION: Cellular aging associated with multiple dimensions of socioeconomic adversity may contribute to poor aging-related health outcomes among African American men. Subjective appraisal of financial difficulty may impact LTL independently of objective dimensions of SES. Self-appraised success in fulfilling traditionally masculine gender roles, including being an economic provider, may be a particularly salient aspect of identity for African American men and have implications for cellular aging in this population.

Food insecurity partially mediates associations between social disadvantage and body composition among older adults in india: Results from the study on global AGEing and adult health (SAGE).

OBJECTIVE: Our objective was to test whether food insecurity mediates cross-sectional associations between social disadvantage and body composition among older adults (aged 50+) in India (n = 6556). METHODS: Adjusting for key sociodemographic and dietary variables, we examined whether markers of social disadvantage (lower educational attainment, lower household wealth, belonging to a disadvantaged caste/tribe, and belonging to a minority religion) were associated with food insecurity. We then examined whether food insecurity, in turn, was associated with anthropometric measures of body composition, body mass index (BMI), and waist circumference (WC). We also tested whether food insecurity mediated the relationship between social disadvantage and body composition. RESULTS: In adjusted models, lower household wealth [lowest quintile (Q5) vs highest quintile (Q1): odds ratio (OR) = 13.57, P < .001], having less than a high-school education (OR = 2.12. P < .005), being Muslim (OR = 1.82, P < .001), and being in a scheduled caste (historically marginalized) (OR = 1.49, P < .005) were associated with greater food insecurity. Those who were severely food insecure had greater odds of being underweight (OR = 1.36, P < .01) and lower odds of high WC (OR = 0.70, P < .01). Mediation analyses estimated that food insecurity explained 4.7%-29.7% of the relationship between social disadvantage and body composition, depending on the variables considered. CONCLUSIONS: Our results are consistent with the hypothesis that food insecurity is a mechanism linking social disadvantage and body composition among older adults in India. These analyses contribute to a better understanding of processes leading to variation in body composition, which may help enhance the design of interventions aimed at improving population nutritional status.

Overcoming barriers to health-care access: A qualitative study among African migrants in Guangzhou, China.

Guangzhou is China's third most populous city, and the region's burgeoning manufacturing economy has attracted many young African businessmen and entrepreneurs to the city. The aims of this study were to examine strategies that African migrants in Guangzhou have adopted in response to health-care barriers, and explore their perceptions of how to address their needs. Twenty-five semi-structured interviews and two focus groups were conducted among African migrants residing in Guangzhou, China. Facing multiple barriers to care, African migrants have adopted a number of suboptimal and unsustainable approaches to access health care. These included: using their Chinese friends or partners as interpreters, self-medicating, using personal connections to medical doctors, and travelling to home countries or countries that offer English-speaking doctors for health care. Health-care providers and health organisations in Guangzhou have not yet acquired sufficient cultural competence to address the needs of African migrants residing in the city. Introducing linguistically and culturally competent health-care services in communities concentrated with African migrants may better serve the population. With the growing international migration to China, it is essential to develop sustainable approaches to improving health-care access for international migrants, particularly those who are marginalised.

Physical function and activity among older adults in Jodhpur, India.

BACKGROUND: Physical activity impacts the ageing process; yet, few studies have examined relationships among physical activity, functional abilities and health among older adults in non-Western settings. AIM: This study tests for associations among measures of physical activity, function and self-report health conditions among 200 older adults (49--50 years old) in Jodhpur, Rajasthan, India. METHODS: Seven consecutive days of accelerometry data were used in measures of physical activity (Total Daily Energy Expenditure [TDEE], Physical Activity Level [PAL], Daily Average Activity Count [AC] and Activity Energy Expenditure [AEE]). Measures of physical function included grip strength, timed walk and daily average sit time. Participants reported if they had been diagnosed with diabetes, hypertension, arthritis and/or depression. RESULTS: All four measures of physical activity were positively associated with grip strength (p ≤ 0.05). AC was negatively associated with timed walk (p ≤ 0.05), and both AC and AEE were negatively associated with daily average sit time (p ≤ 0.05). Women who reported diagnosis of hypertension had lower PAL and AC (p ≤ 0.05). CONCLUSION: This study provides further evidence for a positive relationship between physical activity and functional ability among older adults and between physical activity and cardiovascular health among women in India.

Health Care Experiences and Perceived Barriers to Health Care Access: A Qualitative Study Among African Migrants in Guangzhou, Guangdong Province, China.

Guangzhou, one of China's largest cities and a main trading port in South China, has attracted many African businessmen and traders migrating to the city for financial gains. Previous research has explored the cultural and economic roles of this newly emerging population; however, little is known about their health care experiences while in China. Semi-structured interviews and focus groups were used to assess health care experiences and perceived barriers to health care access among African migrants in Guangzhou, China. Overall, African migrants experienced various barriers to accessing health care and were dissatisfied with local health services. The principal barriers to care reported included affordability, legal issues, language barriers, and cultural differences. Facing multiple barriers, African migrants have limited access to care in Guangzhou. Local health settings are not accustomed to the African migrant population, suggesting that providing linguistically and culturally appropriate services may improve access to care for the migrants.