Spatial dynamics and epidemiology for AIDS in remote areas in French Guiana.

Although AIDS care is generally improving in French Guiana, disparities among regions and certain key populations remain significant. The purpose of this study was to describe the spatial and clinical characteristics of people living with HIV (PLHIV) in remote areas in comparison to those followed in hospitals on the urban coast of French Guiana. The data presented were obtained from outpatient on primary care centers located in rural regions away from the urban coast. Data were compared with that from medical records of PLHIV treated in French Guiana's urban care. The evolution of the annual rate of discovery of HIV seropositivity indicates a lag in remote areas as compared to urban and coastal areas. In recent years, the epidemic appeared as particularly active in rural areas among Brazilian patients. The median age of PLHIV in remote areas was 43.8 years, the sex ratio (M/F) was 0.93. Nearly 37% of PLHIV were discovered with advanced disease (<200 CD4/mm3). The percentage of virological success after six months of HAART was 80% and 88% in remote areas and urban area, respectively. Efforts must be made to control and halt the spread of the HIV epidemic, as these remote sites represent strategic points.

Renouncing care in French Guiana: the national health barometer survey.

BACKGROUND: In French Guiana, health inequalities are patent for a broad range of pathologies for all age groups. The objective of the present study was to quantify the proportion of the population that had renounced care in the past year, to study predictive factors, and to compare results with other French territories. METHODS: A two-stage random sample of 2015 individuals aged 15 to 75 years was surveyed by telephone. A descriptive analysis of variables relative to renouncing care, use of health care, screening, and vaccination was initially performed. Multivariate analysis was then used to determine variables associated with renouncing care for financial reasons and renouncing for reasons linked to time were directly estimated using a Poisson model on weighted data. Variables with a significance level < 0.2 in the bivariate analysis were included in the full multivariate model. RESULTS: In French Guiana, during the past 12 months, 30.9% of surveyed persons renounced care whatever the type for financial reasons. Results of the multivariate analysis showed that gender, perceived financial situation, perceived health and complementary insurance status were independent predictive factors of care renouncement for financial reasons. Overall, 24% of the surveyed population declared having renounced to care for time-related motives. The independent predictors for time-related renouncing were different than those for renouncing care for financial reasons: a higher education level and a poor perceived health were independently associated with time-related renouncement; retired persons and students were found to renounce care less frequently than persons with a job. CONCLUSIONS: Renouncing for financial reasons, a major target of the 2016 health law, represented a public health problem in French Guiana. Renouncing for lack of time was an important motive for renouncing, which is aggravated by the insufficient number of health professionals, but may benefit from organizational solutions. There are avenues for improvement of health for the most vulnerable: promote health, act on risk factors, and facilitate the readability and accessibility of the health system. Recent reforms to stabilize health insurance may however have some adverse consequences for migrants.

Factors associated with sexual risk taking behavior by precarious urban migrants in French Guiana.

BACKGROUND: French Guiana is highly affected by HIV. The migrant population is particularly susceptible. The objective of this study was to evaluate the level of risk of HIV transmission and its perception among migrants in French Guiana and to identify predictive factors. METHODS: An HIV/AIDS Knowledge, Attitudes, Behaviors and Practices study was conducted in 2012 among migrants living in precarious neighborhoods of French Guiana. RESULTS: Of the 1039 participants surveyed, 893 were analyzed, of which 35.6% had risky sex during the past 12 months. Sexual risk taking was higher among the migrant population than in the general population. The predictors of sexual risk taking behavior were: younger age groups, males, having a job, not living with a spouse, having first had sex before age 16, using alcohol or drugs before sex, and having engaged in commercial sex recently. The factors associated with not being aware of one's risk were: being a woman, being from Guyana or Suriname, non-systematic use of condoms with a regular partner, and never or not recently having been tested for HIV. CONCLUSIONS: The results suggest there is still a need for information on HIV risks in a highly vulnerable population.

The use of structural equation modelling and behavioural theory to target priority interventions to increase condom use among the intimate partners of sex workers in French Guiana.

French Guiana is the French overseas territory that is most affected by HIV. Sex work seems to be an important driver of the epidemic. Although female sex workers are informed by local NGOs, they still have risky behaviours, including not using condoms with their intimate partner despite knowing HIV is highly prevalent. The objective of this study was to find intervention targets on this specific behaviour. For this, a structural equation model (SEM) was built using assumptions from behavioural theories. Behaviour theories attempt to connect research and practice. Within the health belief model framework, perceived threats, perceived benefits, and self-perceived efficacy were tested. Vulnerability was added because of the particular context of French Guiana. The results highlight that female sex workers' perceived self-efficacy was central in condom use with the intimate partner (with a significant correlation coefficient of 0.52 in the SEM). The perceived self-efficacy was strongly influenced by sociodemographic factors, particularly by nationality. Female sex workers from Brazil seemed to be more comfortable about asking their intimate partner to use condoms (OR: 7.81; CI: 1.87-32.63) than sex workers of other nationalities. These results emphasize that prevention interventions for female sex workers should emphasize their empowerment.

The Evolution of HIV Patient Retention and Care in French Guiana: A Broader View From the Système National des Données de Santé.

BACKGROUND: Although the simplification of antiretroviral (AVR) treatment regimens and follow-up has led to fewer constraints for patients with HIV, their follow-up remains of paramount importance to optimize AVR therapy, to detect and prevent HIV-related morbidity, and prevent secondary infections. The problem of follow-up interruption in French Guiana has been persistent and seemingly impervious to efforts to alleviate it. OBJECTIVE: The objective was to follow the trend of follow-up interruptions and to test the hypothesis that an increasing number of patients was, in fact, followed by private practitioners. METHOD: Using the complementary lenses of the hospital HIV cohort and the health insurance information system, we looked at the incidence of follow-up interruption and the proportion of patients followed by private practitioners. RESULTS: We tallied 803 persons that were not known to have died and who were lost to follow-up. Over time, hospital outpatients were lost to follow-up significantly sooner. By contrast, there was a significant trend with more and more patients exclusively followed by private practitioners. CONCLUSION: While hospital outpatient care remains by far the most common mode of patient care, there seems to be a gradual erosion of this model in favor of private practice.

Knowledge of free voluntary HIV testing centres and willingness to do a test among migrants in Cayenne, French Guiana.

In Cayenne, French Guiana, 80% of HIV-positive patients followed at the hospital are migrants. Behavioural information is crucial for optimising HIV testing for this vulnerable group. Predictors of ignorance of the existence of free voluntary counselling and testing (VCT) centre and willingness to get tested were investigated in 2006 among 398 migrants from Haiti, Guyana, Suriname and Brazil using a structured questionnaire. Only 27% of migrants knew simultaneously about the existence of free VCT, its localisation and its operating hours. Factors associated with ignorance of the existence of free VCT centre were birthplace in Haiti, being in French Guiana for less than three years, not thinking one's birth country as strongly affected by HIV and not thinking to be personally at risk for HIV. Factors independently associated with willingness to get tested were thinking to be at risk for HIV, birthplace in Brazil and Haiti, having a high-integration level and fear of suffering if HIV test was positive. In order to improve testing among migrants, the accessibility of testing facilities and the knowledge of their whereabouts and operating hours must be improved to promote the desired behaviour among the majority of migrants which is often willing to do the test.

A Simple Predictive Score to Distinguish between Disseminated Histoplasmosis and Tuberculosis in Patients with HIV.

Disseminated histoplasmosis is a common differential diagnosis of tuberculosis in disease-endemic areas. We aimed to find a predictive score to orient clinicians towards disseminated histoplasmosis or tuberculosis when facing a non-specific infectious syndrome in patients with advanced HIV disease. We reanalyzed data from a retrospective study in Cayenne Hospital between January 1997-December 2008 comparing disseminated histoplasmosis and tuberculosis: 100 confirmed disseminated histoplasmosis cases and 88 confirmed tuberculosis cases were included. A simple logit regression model was constructed to predict whether a case was tuberculosis or disseminated histoplasmosis. From this model, a score may be obtained, where the natural logarithm of the probability of disseminated histoplasmosis/tuberculosis = +3.917962 × WHO performance score (1 if >2, 0 if ≤2) -1.624642 × Pulmonary presentation (1 yes, 0 no) +2.245819 × Adenopathies > 2 cm (1 yes, 0 no) -0.015898 × CD4 count - 0.001851 × ASAT - 0.000871 × Neutrophil count - 0.000018 × Platelet count + 6.053793. The area under the curve was 98.55%. The sensitivity of the model to distinguish between disseminated histoplasmosis and tuberculosis was 95% (95% CI = 88.7-98.3%), and the specificity was 93% (95% CI = 85.7.3-97.4%). In conclusion, we here present a clinical-biological predictive score, using simple variables available on admission, that seemed to perform very well to discriminate disseminated histoplasmosis from tuberculosis in French Guiana in well characterized patients.

Predictive factors and incidence of anxiety and depression in a cohort of HIV-positive patients in French Guiana.

A retrospective cohort study was conducted to determine the predictive factors and the incidence of anxiety and depression in a cohort of patients followed in French Guiana. A total of 2315 patients were followed for a total of 9116 years of follow-up. The incidence rate of first observed depression was 1.89 per 100 person years. The incidence rate of first observed generalized anxiety was 1.27 per 100 person years. A single failure Cox proportional hazards model showed that patients diagnosed <1 year (Hazard ratio (HR)=4.15; 95% CI=1.15-14.9; P=0.029), patients treated

Temporal trend of the proportion of patients presenting with advanced HIV in French Guiana: stuck on the asymptote?

OBJECTIVE: In French Guiana, the French territory with the most preoccupying HIV epidemic, there have been great efforts to intensify and diversify HIV testing strategies. The aim of the present study was to review the temporal trends of patients diagnosed with advanced HIV disease in French Guiana. Data trends from the HIV cohort of French Guiana between 1996 and 2016 were thus analyzed. RESULTS: The proportion of patients diagnosed with advanced disease did not decline over time. Males had lower CD4 counts at the time of diagnosis and there was a plateau for both males (around 40%) and females (around 25%) with no apparent reduction of the proportion of advanced disease. Older age groups and migrants presented more often with advanced disease. By contrast, the proportion of patients diagnosed with stage B and C disease declined over time and the CD4 count at antiretroviral initiation and the CD4 nadir increased over time. Despite some progress, the group of patients with advanced disease reached a plateau around 30% suggesting this particular group still has epidemiological importance in driving the epidemic and in fueling morbidity and mortality, and thus remains a challenge for testing strategies.

Country of infection among HIV-infected patients born abroad living in French Guiana.

BACKGROUND: Over 75% of patients in the HIV cohort in French Guiana are of foreign origin. Our objective was to estimate what proportion of the migrant population of HIV-infected patients in Cayenne had been infected in French Guiana. METHODS: We included patients of known foreign origin who were followed in Cayenne, for whom the year of arrival in French Guiana was known and the initial CD4 count at the time of diagnosis was available. The time between seroconversion and time at diagnosis was estimated using the formula [square root (CD4 at seroconversion)-square root(CD4 at HIV diagnosis)] / slope of CD4 decline.CD4 counts at the time of infection and the slope were computed in an age and ethnicity-dependent variable. RESULTS: The median estimated time between infection and diagnosis was 4.5 years (IQR = 0.2-9.2). Overall, using a median estimate of CD4 count at the time of infection, it was estimated that 53.2% (95% CI = 48.3-58%) of HIV infected foreign patients had acquired HIV after having arrived in French Guiana. Patients having arrived in French Guiana before and during the 1990s and those receiving their HIV diagnosis before 2010 were more likely to have been infected in French Guiana. CONCLUSIONS: Contrary to widespread belief suggesting that most migrants are already HIV-infected when they arrive in French Guiana, a large proportion of foreign HIV patients seem acquire the virus in French Guiana.There is still much to do in terms of primary prevention and testing among migrants.

Modeling of the HIV epidemic and continuum of care in French Guiana.

BACKGROUND: In order to compute the continuum of care for French Guiana, it is necessary to estimate the total number of persons living with HIV. The main objective was to determine how many persons were infected with HIV and how many were unaware of it. METHODS: We used 2 different models to calculate the total number of persons infected with HIV: Spectrum's AIM module using CSAVR to compute incidence from case registration and vital statistics; and the ECDC model from the French Guiana HIV cohort data. RESULT: The present results show that both models led to similar results regarding the incident number of cases (i.e. for 2016 174 versus 161) and the total HIV population (in 2016 3206 versus 3539) respectively. The ECDC modeling tool showed that the proportion of undiagnosed HIV infections declined from 50% in 1990 to 15% in 2015. This amounted to a stable or slightly increasing total number of undiagnosed patients of 520. CONCLUSIONS: The estimations of the total HIV population by both models show that the HIV population is still growing. The incidence rate declined in 2000 and the decline of the number of newly acquired HIV infections, after a decline after 2003 is offset by population growth. The proportion of undiagnosed infections has declined to 15% but the number of undiagnosed infections remains stable. The HIV cascade shows that despite good results for treatment in care, reaching the 90*90*90 UNAIDS target may be difficult because a significant proportion of patients are lost to follow-up.

High mortality among male HIV-infected patients after prison release: ART is not enough after incarceration with HIV.

CONTEXT: French Guiana is a South American French territory, where HIV prevalence consistently exceeds 1% in the adult population. In the only correctional facility, HIV prevalence fluctuates at around 4%. AIMS: After describing the population of HIV-positive inmates, we aimed to evaluate mortality after release from the correctional facility, and to identify its predictive factors. RATIONALE: Outside North American settings, data on treatment outcome and vital status of HIV-positive former inmates are scarce. There were no data in French Guiana. Filling this gap represents a basis for potential improvements. METHODS: All HIV-infected adults released from an incarceration of 30 days or more, between 2007 and 2013, were enrolled in a retrospective cohort study. Mortality was described over time, one to seven years following release, using Kaplan-Meier estimates. Factors associated with mortality were identified through a non-parametric survival regression model. RESULTS: 147 former inmates were included. The male to female ratio was 4.4. The median age was 37.3 years. The majority were migrants, 25.8% were homeless, 70.1% suffered from substance abuse, with 34.0% of crack-cocaine users. On admission, 78.1% had an early HIV-stage infection (CDC-stage A), with a median CD4 count of 397.5/mm3, 34.0% had one comorbidity, mainly hypertension. Upon release, 50.3% were on ART. Reasons for not being treated were not fulfilling the criteria for 74.6%, and refusing for 15.1%. Before release, 84.5% of the patients on ART had a viral load≤200cp/ml. After release, 8.2% of the cohort had died, with a crude incidence of 33.8/1000 person-years. All recorded deaths were males, with an incidence of 42.2/1000 person-years. Comparing with the age-specific mortality rates for males in French Guiana, the standardized mortality ratio was 14.8. In multivariate analysis, factors associated with death were age and CD4 count before release. CONCLUSION: Despite access to ART while incarcerated, with good virological outcome, the post-release mortality was very high for males, almost 15 times what is observed in the general male population living in French Guiana, after age standardization. Access to ART in correctional facilities may be a necessary, but not sufficient condition to protect male inmates from death after release.

HIV-1 Pol Gene Polymorphism and Antiretroviral Resistance Mutations in Treatment-Naive Adult Patients in French Guiana Between 2006 and 2012.

Little information is available on the molecular epidemiologic profile of HIV-1 in French Guiana, the French department with the highest HIV/AIDS incidence. To follow the evolution of HIV-1 diversity, we carried out a molecular analysis of HIV-1 isolates from 305 treatment-naive patients between 2006 and 2012. Protease and reverse-transcriptase sequences were obtained for subtype characterization, polymorphism analysis, and identification of drug resistance mutations. Of 305 HIV-1 strains, 95.1% were subtype B viruses. The overall prevalence of transmitted drug-resistance mutations (TDRMs) was 4.6% (14/305), ranging from 1.9% to 7.1% depending on the year. This study shows a low level of HIV-1 genetic diversity and a moderate prevalence of TDRMs with no evidence of an increasing trend over the study period. Nevertheless, the strong genetic polymorphism observed on both genes may be of concern for long-term treatment of people living with HIV-1 and thus deserves continuous monitoring.

What is AIDS in the Amazon and the Guianas? Establishing the burden of disseminated histoplasmosis.

The pathogen ecology of Amazonian regions may lead to specific differences in the most frequent clinical presentations of acquired immunodeficiency syndrome (AIDS). A retrospective cohort study was thus conducted to describe the main AIDS-defining events in French Guiana. Disseminated histoplasmosis was the most frequent opportunistic infection (15.4/1000 person years).

Risk factors for delayed access to specialized care in French Guiana.

The variables influencing the interval between diagnosis and effective access to specialized care were studied in a cohort of 2,661 human immunodeficiency virus (HIV)-positive patients in French Guiana between 1992 and 2008. Patients with a subsequent follow-up interruption were significantly more likely to have a delayed first consultation after the HIV diagnosis. Ordinal logistic regression showed that younger persons, women, and French citizens were independently associated with greater delays between the HIV diagnosis and the first specialized consultation. However, persons with acquired immunodeficiency syndrome (AIDS) were less likely to have a delay between the HIV diagnosis and the first specialized consultation. Focusing on the link between the private sector and specialized health care may shorten delays and improve care and follow-up.

Crack cocaine use increases the incidence of AIDS-defining events in French Guiana.

We conducted a retrospective cohort study to determine the influence of crack cocaine use on the outcomes of HIV infection. The use of crack cocaine was associated with an increased incidence of AIDS: 27.8 per 100 person-years versus 6.6 per 100 person-years for nonusers, adjusted hazard ratio = 3.8 (1.9-7.5), P < 0.001. More specifically, crack users had a greater incidence of disseminated histoplasmosis, pneumocystosis, pulmonary tuberculosis, bacterial pneumonia, oesophageal candidiasis, cerebral toxoplasmosis, salmonellosis, and genital herpes. The care of HIV-infected crack users is particularly challenging and requires additional efforts to reduce the high morbidity of these patients.