High PrEP acceptability and need for tailored implementation in Cambodian key populations: results from a qualitative assessment.

The HIV epidemics in Cambodia is concentrated in key populations (KPs). Pre-exposure prophylaxis (PrEP) has been officially approved in the country since 2019. However, its use may still be controversial after a PrEP clinical trial was interrupted in Cambodia after being deemed unethical in 2004. In this context, it was necessary to evaluate PrEP acceptability and administration preferences of KPs in Cambodia, with a view to increasing roll-out and uptake. We conducted a qualitative study in 2022 comprising six focus groups and four semi-structured individual interviews with transgender women, men who have sex with men, male entertainment workers, venue-based female entertainment workers (FEW), street-based FEW, and PrEP users who participated in a PrEP pilot study that started in 2019. Overall, KPs positively perceived PrEP, with some reservations. They preferred daily, community-based PrEP to event-driven, hospital-based PrEP, and highlighted that injectable PrEP would be a potential option if it became available in Cambodia. We recommend (i) proposing different PrEP regimens and PrEP delivery-models to broaden PrEP acceptability and adherence in Cambodia (ii) increasing the number of community-based organisations and improving the services they offer, (iii) rolling out injectable PrEP when it becomes officially available, and (iv) improving PrEP side effects information.

Men Who Have Sex with Both Men and Women in West Africa: Factors Associated with a High Behavioral Risk of Acquiring HIV from Male Partners and Transmission to Women (CohMSM ANRS 12324-Expertise France).

HIV is highly prevalent in men who have sex with men (MSM) in West Africa. Many MSM in the region also have sex with women (MSMW). Accordingly, they are a potential bridge subpopulation for HIV transmission to women. We aimed to evaluate the proportions and characteristics of West African MSMW at high behavioral risk of acquiring HIV from male partners and transmitting it to female partners (HBRMF). The cohort ANRS-12324 CohMSM Study included 630 HIV-negative MSM in Burkina Faso, Cote d'Ivoire, Mali, and Togo. Among MSMW (i.e., with ≥ 1 female partner) in the cohort, HBRMF was identified using trajectory models based on seven at-risk sexual practices with male and female partners, including inconsistent condom use, multiple partnerships, and receptive same-sex anal intercourse. To assess the relevance of using trajectory models, we compared the proportions of participants who seroconverted during the cohort follow-up among those at HBRMF and those not at HBRMF. Factors associated with HBRMF were identified using a generalized estimation equation logistic regression model accounting for longitudinal data. Approximately half (47%) of the 304 MSMW (22% of all CohMSM study participants) were at HBRMF. This group accounted for 75% of the 28 HIV seroconversions observed during follow-up (p = 0.001). HBRMF was positively associated with being aged < 25 years (aOR 95% CI 1.67 [1.23-2.27]), being sexually attracted only to men (1.97 [1.38-2.78]), feelings of loneliness (1.92 [1.38-2.65]), and homonegative violence score (1.22 [1.05-1.41]). HBRMF was negatively associated with having had both stable and casual female partners in the previous 6 months (0.34 [0.20-0.60] vs. only a stable female partner). HBRMF tended to be negatively associated with having ≥ 4 sexual intercourses with female partners in the previous four weeks (0.54 [0.27-1.06] vs. no intercourse). Establishing official relationships with women might be a strategy for young and/or stigmatized MSMW to comply with social pressure to display a heterosexual lifestyle. However, this seems to increase the risk of HIV transmission to female partners. In the present study, almost half of MSMW were at HBRMF. This result stresses the need to adapt HIV research and prevention to MSMW and their female partners.

Highly precarious general and sexual health conditions of young domestic servants: results from a qualitative exploratory study and perspectives for community-based research in Bamako, Mali.

Most domestic servants (DS) in Mali are very young female migrants living in precarious conditions. We aimed to understand their living and working conditions in relation to their general and sexual health. Seven focus groups (53 participants) were conducted by the DS community-based organization ADDAD. Narratives were thematically analyzed using an inductive method. The dominant emerging theme was DS' strong dependence on their employers. Employers' attitudes regarding DS workload, the provision of food, water and hygiene products, housing conditions, and healthcare cover, appeared decisive for DS' physical and mental health, and the type of healthcare they used (self-medication, traditional care, healthcare facilities). Psychological, physical and sexual violence in employers' households was frequent. HIV/STI prevention knowledge was poor. These results highlight the serious risks for DS in terms of HIV/STI and unwanted pregnancies. DS were interested in receiving healthcare from ADDAD; this was motivated by the organization's trusting and understanding community-based environment, and DS' fear of discrimination in healthcare facilities. This study highlights the relevance of tackling the defense of rights and sexual health promotion for DS at the community level. Its findings can help identify research questions to evaluate the extent to which DS constitute a key HIV population.

Early ART Initiation Improves HIV Status Disclosure and Social Support in People Living with HIV, Linked to Care Within a Universal Test and Treat Program in Rural South Africa (ANRS 12249 TasP Trial).

We investigated the effect of early antiretroviral treatment (ART) initiation on HIV status disclosure and social support in a cluster-randomized, treatment-as-prevention (TasP) trial in rural South Africa. Individuals identified HIV-positive after home-based testing were referred to trial clinics where they were invited to initiate ART immediately irrespective of CD4 count (intervention arm) or following national guidelines (control arm). We used Poisson mixed effects models to assess the independent effects of (a) time since baseline clinical visit, (b) trial arm, and (c) ART initiation on HIV disclosure (n = 182) and social support (n = 152) among participants with a CD4 count > 500 cells/mm3 at baseline. Disclosure and social support significantly improved over follow-up in both arms. Disclosure was higher (incidence rate ratio [95% confidence interval]: 1.24 [1.04; 1.48]), and social support increased faster (1.22 [1.02; 1.46]) in the intervention arm than in the control arm. ART initiation improved both disclosure and social support (1.50 [1.28; 1.75] and 1.34 [1.12; 1.61], respectively), a stronger effect being seen in the intervention arm for social support (1.50 [1.12; 2.01]). Besides clinical benefits, early ART initiation may also improve psychosocial outcomes. This should further encourage countries to implement universal test-and-treat strategies.

Subclinical inflammation affects iron and vitamin A but not zinc status assessment in Senegalese children and Cambodian children and women.

OBJECTIVE: To assess the impact of the acute-phase response (APR) during inflammation on Fe, Zn and vitamin A biomarkers to allow accurate evaluation of micronutrient status in populations. DESIGN: Ferritin (FER), soluble transferrin receptor (TfR), retinol-binding protein (RBP), Zn, α1-acid glycoprotein and C-reactive protein concentrations were measured. Correction factors (CF) for each biomarker were calculated as the ratio for groups at different stages of inflammation v. the reference group without inflammation.Setting/SubjectsSenegalese (n 594) and Cambodian schoolchildren (n 2471); Cambodian women of reproductive age (n 2117). RESULTS: TfR was higher during the incubation phase (CF=1·17) and lower during early and late convalescence (CF=0·87 and 0·78). FER was higher during all phases (CF=0·83, 0·48 and 0·65, respectively). RBP was higher during incubation (CF=0·88) and lower during early convalescence (CF=1·21). No effect of inflammation on Zn status was found. CONCLUSIONS: Inflammation led to overestimation of Fe status and underestimation of vitamin A status. The response of the biomarker for vitamin A status to inflammation depended on the vitamin A status of the populations. Surprisingly, the assessment of Zn status was hardly affected by inflammation. Different phases of the APR had opposite effects on the assessment of Fe status using TfR. More research is needed to define the correct methods to adjust for inflammation in nutritional studies.

Effect of multi-micronutrient-fortified rice on cognitive performance depends on premix composition and cognitive function tested: results of an effectiveness study in Cambodian schoolchildren.

OBJECTIVE: Even though current policy is strongly focused on the crucial first '1000 days', it might be still possible to enhance cognitive function during the pre-adolescent and adolescent years by improving micronutrient status. In Cambodia, nutritional status is poor. Provision of rice fortified with micronutrients through a school meal programme (SMP) could be a cost-effective strategy to help improve health and school performance. The present study aimed to evaluate the effect of three different micronutrient-fortified rice formulations on cognitive function in Cambodian children. SETTING: Sixteen Cambodian schools receiving SMP. DESIGN: The FORISCA-UltraRice®+NutriRice® study was a randomized, double-blind, placebo-controlled trial. Four groups of four schools were randomly allocated to receive normal rice, UltraRice®Original, UltraRice®New or NutriRice®. Within each school, 132 children were randomly selected. Data on cognitive performance (picture completion, block design and Raven's coloured progressive matrices (RCPM)), anthropometry, parasite infestation and micronutrient status were collected before the intervention and after 6 months. SUBJECTS: Cognitive data were available for 1796 children aged 6-16 years. RESULTS: All cognitive scores improved after 6 months (P<0·001). Block design score improvement was significantly higher in children consuming UltraRice®Original (P=0·03) compared with the other fortified rice groups and placebo. No difference among groups was found on RCPM or picture completion scores. Stunting, parasite infestation and inflammation negatively affected the impact of the intervention. CONCLUSIONS: Combined with other interventions, using SMP to distribute fortified rice to schoolchildren may be a cost-effective way to increase cognitive performance and thereby improve school performance and educational achievements.

Sexual behaviours and risk with women in MSM in sub-Saharan Africa.

In sub-Saharan Africa (SSA), MSM - a high HIV prevalence group - experience strong social stigma and pressure to have female partners. Accordingly, they could constitute a bridging group for HIV transmission to cisgender women. We developed a multilevel summary of MSM sexual behaviors and risk with women in various SSA regions. Following PRISMA guidelines, we conducted a mixed-method systematic review of data of sex with women in MSM in SSA. We performed meta-analyses on quantitative data (i.e. percent of recent sex and condomless sex with women) for each SSA region (when proportions reported in ≥4 studies). Pooled proportions were calculated using random-effects models. Qualitative data were analyzed using the three-step thematic synthesis methodology. The pooled proportion of MSM who had sex with women was 58% (33-83%) in East Africa (in the previous 3 months), and 27% (13-48%) in Southern Africa and 50% (95% CI 39-62%) in West Africa (in the previous 6 months); 23% (16-32%) of MSM in West Africa had condomless sex with a woman (during the most recent encounter). Approximately one quarter of MSM had recent multiple female partners. MSM reported having sex with women because of heteronormative pressure, erotic/romantic attraction, or financial needs leading to transactional sex. MSM may act as a bridging population to women in SSA, as they commonly practice sex with women and risky sexual behaviors with them. HIV programmes and community-based support for MSM should be adapted to this population to reduce this risk.

Faecal microbiota of schoolchildren is associated with nutritional status and markers of inflammation: a double-blinded cluster-randomized controlled trial using multi-micronutrient fortified rice.

Faecal microbiota plays a critical role in human health, but its relationship with nutritional status among schoolchildren remains under-explored. Here, in a double-blinded cluster-randomized controlled trial on 380 Cambodian schoolchildren, we characterize the impact of six months consumption of two types of rice fortified with different levels of vitamins and minerals on pre-specified outcomes. We investigate the association between the faecal microbiota (16SrRNA sequencing) and age, sex, nutritional status (underweight, stunting), micronutrient status (iron, zinc and vitamin A deficiencies, anaemia, iron deficient anaemia, hemoglobinopathy), inflammation (systemic, gut), and parasitic infection. We show that the faecal microbiota is characterised by a surprisingly high proportion of Lactobacillaceae. We discover that deficiencies in specific micronutrients, such as iron and vitamin A, correlate with particular microbiota profiles, whereas zinc deficiency shows no such association. The nutritional intervention with the two rice treatments impacts both the composition and functions predicted from compositional analysis in different ways. (ClinicalTrials.gov (Identifier: NCT01706419)).

The Perceived Added Value of Bimonthly Injectable Pre-Exposure Prophylaxis According to West African Men Who Have Sex with Men: A Focus Group Study.

Bimonthly long-acting injectable pre-exposure prophylaxis (LAI-PrEP) can become an important additional tool for HIV prevention among West African men who have sex with men (MSM). The objective was to explore the perceived added value of LAI-PrEP as an HIV prevention tool among MSM in Burkina Faso, Côte d'Ivoire, Mali, and Togo. We conducted eight focus group discussions among 62 HIV-negative MSM between April and May 2021. Participants were recruited via local community-based clinics. Data collection and analysis were guided by grounded theory and community-based participatory approaches. Participants were generally knowledgeable about HIV, and explained particular barriers for HIV prevention in their communities (e.g., denial of HIV). The added value of LAI-PrEP relative to condoms was similar to oral pre-exposure prophylaxis (PrEP) in terms of perceived advantages (e.g., improved sexual satisfaction) or disadvantages (e.g., no protection against other sexually transmitted infections). Compared with oral PrEP, LAI-PrEP was perceived to provide better protection against HIV and to be more convenient (e.g., no need to be mindful of intake and less risk for stigma). Concerns included fear of needles, doubts about efficacy, potential side effects, and difficulties for ensuring timely injections (e.g., when traveling abroad). The results demonstrate that injectable PrEP can be of particular interest to subgroups of West African MSM, although existing HIV prevention tools such as condoms and oral PrEP will remain valuable alongside of, or instead of, LAI-PrEP. Increasing awareness about HIV and tackling discrimination based on sexual orientation continue to be crucial factors to be addressed for HIV prevention.

Intimate partner violence by men living with HIV in Cameroon: Prevalence, associated factors and implications for HIV transmission risk (ANRS-12288 EVOLCAM).

OBJECTIVES: Intimate partner violence (IPV) against women is frequent in Central Africa and may be a HIV infection risk factor. More data on HIV-positive men (MLHIV) committing IPV are needed to develop perpetrator-focused IPV and HIV prevention interventions. We investigated the relationship between IPV and HIV transmission risk and IPV-associated factors. METHODS: We used data from the cross-sectional survey EVOLCam which was conducted in Cameroonian outpatient HIV structures in 2014. The study population comprised MLHIV declaring at least one sexual partner in the previous year. Using principal component analysis, we built three variables measuring, respectively, self-reported MLHIV-perpetrated psychological and physical IPV (PPV), severe physical IPV (SPV), and sexual IPV (SV). Ordinal logistic regressions helped investigate: i) the relationship between HIV transmission risk (defined as unstable aviremia and inconsistent condom use) and IPV variables, ii) factors associated with each IPV variable. RESULTS: PPV, SPV and SV were self-reported by 28, 15 and 11% of the 406 study participants, respectively. IPV perpetrators had a significantly higher risk of transmitting HIV than non-IPV perpetrators. Factors independently associated with IPV variables were: i) socio-demographic, economic and dyadic factors, including younger age (PPV and SPV), lower income (PPV), not being the household head (SPV and SV), living with a main partner (SPV), and having a younger main partner (SPV); ii) sexual behaviors, including ≥2 partners in the previous year (PPV and SPV), lifetime sex with another man (SPV), inconsistent condom use (SV), and >20 partners during lifetime (SV); iii) HIV-related stigma (PPV and SV). CONCLUSION: IPV perpetrators had a higher risk of transmitting HIV and having lifetime and recent risky sexual behaviors. Perpetrating IPV was more frequent in those with socioeconomic vulnerability and self-perceived HIV-related stigma. These findings highlight the need for interventions to prevent IPV by MLHIV and related HIV transmission to their(s) partner(s).

Homonegativity, sexual violence and condom use with women in men who have sex with men and women in West Africa.

OBJECTIVE: The study aimed to explore longitudinal interactions between homonegativity and sexual behaviors with female partners among HIV-negative West African men who have sex with men and women (MSMW). DESIGN AND METHOD: The community-based cohort CohMSM ANRS 12324 - Expertise France enrolled MSM in Togo, Burkina Faso, Côte d'Ivoire and Mali. Sociobehavioral data were collected every 6 months. Using 30-month follow-up data, a multiprobit analysis was performed to investigate the relationship between psychosocial and behavioral variables ex-ante (t - 1) and ex-post (t). RESULTS: MSMW (n = 326) accounted for half of all participants in CohMSM. They reported inconsistent condom use with women in 39% of visits. Perceived and internalized homonegativity at t - 1 tended to lead to sexual violence toward women at t (P < 0.1), which was associated with inconsistent condom use with them at t (P < 0.05). CONCLUSION: Given the high HIV prevalence in West African MSM, widespread condom-less sex with women in MSMW, and the aggravating effect of social and internalized homonegativity, more research in the MSMW subpopulation is needed to assess the risk of HIV bridging to women and to design support activities.

Who are the persons living with HIV who might refuse to participate in HIV cure-related clinical trials with treatment interruption?

: Achieving a HIV cure has become a research priority. As any improvement of knowledge, which could help scientists design new HIV cure-related clinical trials (HCRCT) depends on the risks potential participants are willing to accept, it is important to understand who will agree or refuse to participate and in which proportions. By providing insights into factors associated with reluctance toward HCRCT participation, our results may help clinicians in patient recruitment.

Differences in HIV cure clinical trial preferences of French people living with HIV and physicians in the ANRS-APSEC study: a discrete choice experiment.

INTRODUCTION: Despite the advent of HIV cure-related clinical trials (HCRCT) for people living with HIV (PLWH), the risks and uncertainty involved raise ethical issues. Although research has provided insights into the levers and barriers to PLWH and physicians' participation in these trials, no information exists about stakeholders' preferences for HCRCT attributes, about the different ways PLWH and physicians value future HCRCT, or about how personal characteristics affect these preferences. The results from the present study will inform researchers' decisions about the most suitable HCRCT strategies to implement, and help them ensure ethical recruitment and well-designed informed consent. METHODS: Between October 2016 and March 2017, a discrete choice experiment was conducted among 195 virally controlled PLWH and 160 physicians from 24 French HIV centres. Profiles within each group, based on individual characteristics, were obtained using hierarchical clustering. Trade-offs between five HCRCT attributes (trial duration, consultation frequency, moderate (digestive disorders, flu-type syndrome, fatigue) and severe (allergy, infections, risk of cancer) side effects (SE), outcomes) and utilities associated with four HCRCT candidates (latency reactivation, immunotherapy, gene therapy and a combination of latency reactivation and immunotherapy), were estimated using a mixed logit model. RESULTS: Apart from severe SE - the most decisive attribute in both groups - PLWH and physicians made different trade-offs between HCRCT attributes, the latter being more concerned about outcomes, the former about the burden of participation (consultation frequency and moderate SE). These different trades-offs resulted in differences in preferences regarding the four candidate HCRCT. PLWH significantly preferred immunotherapy, whereas physicians preferred immunotherapy and combined therapy. Despite the heterogeneity of characteristics within the PLWH and physician profiles, results show some homogeneity in trade-offs and utilities regarding HCRCT. CONCLUSIONS: Severe SE, not outcomes, was the most decisive attribute determining future HCRCT participation. Particular attention should be paid to providing clear information, in particular on severe SE, to potential participants. Immunotherapy would appear to be the best HCRCT candidate for both PLWH and physicians. However, if the risk of cancer could be avoided, gene therapy would become the preferred strategy for the latter and the second choice for the former.

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.

What is the effect of self-identified HIV activism in willingness to participate in HIV cure-related clinical trials? Results from the ANRS-APSEC study.

OBJECTIVES: Enrolling people living with HIV with undetectable viral load into HIV cure-related clinical trials (HCRCT) is challenging. Few data are currently available about the individual factors that influence willingness to participate in HCRCT (WPHCRCT). We hypothesised that WPHCRCT would be more frequent among people living with HIV considering themselves HIV activists. The objective of this study was to investigate the individual characteristics associated with both WPHCRCT and self-identification as an HIV activist. METHODS: The study enrolled 195 long-term ART-treated and virologically suppressed people living with HIV, followed-up in 19 French HIV services, 2016-2017. A Bayesian model averaging approach was used to assess correlates of both outcomes i.e. WPHCRCT and self-identified HIV activism. RESULTS: WPHCRCT was reported by 43% of participants and was positively associated with self-identification as an HIV activist (adjusted odds ratio [aOR] 2.90 95% confidence interval [CI] 2.17-3.63], P<0.05) and self-confidence as an HIV positive person (aOR 1.17, 95% CI 0.99-1.35, P<0.1). Self-identified HIV activists (56% of participants) were more likely to have a higher 'relationship with others' score using the post-traumatic growth inventory (aOR 1.10, 95% CI 0.99-1.20, P<0.1), to obtain information about HIV from a greater number of sources (aOR 1.35 [95% CI 1.00-1.68], P<0.1), and to feel greatly affected by mandatory daily treatment (aOR 2.15, 95% CI 1.27-3.03, P<0.1). All associations had relative importance weight>0.75, indicating strong evidence. CONCLUSIONS: WPHCRCT is strongly related to HIV activism, and also to positive psychosocial characteristics as a person living with HIV, especially regarding relationships with others. The desire to contribute to the fight against HIV for the sake of the HIV community and society should be taken into account to improve participation in upcoming HCRCT.

Multi-Micronutrient Fortified Rice Improved Serum Zinc and Folate Concentrations of Cambodian School Children. A Double-Blinded Cluster-Randomized Controlled Trial.

BACKGROUND: Within Cambodia, micronutrient deficiencies continue to be prevalent in vulnerable groups, such as women and children. Fortification of staple foods such as rice could be a promising strategy for Cambodia to improve micronutrient status. OBJECTIVE: Our objective was to investigate the impact of multiple-micronutrient fortified rice (MMFR), distributed through a World Food Program school-meals program (WFP-SMP) on serum zinc concentrations and folate status in a double-blind, cluster-randomized, placebo-controlled trial. METHODS: Sixteen schools were randomly assigned to receive one of three different types of extruded-fortified rice (UltraRice Original (URO), UltraRice New (URN), or NutriRice) or unfortified rice (placebo) six days a week for six months. A total of 1950 schoolchildren (6-16 years old) participated in the study. Serum zinc (all groups) and folate (only in NutriRice and placebo group) concentrations were assessed from morning non-fasting antecubital blood samples and were measured at three time points (baseline and after three and six months). RESULTS: After six months of intervention, serum zinc concentrations were significantly increased in all fortified rice group compared to placebo and baseline (0.98, 0.85 and 1.40 µmol/L for URO, URN and NutriRice, respectively) (interaction effect: p < 0.001 for all). Children in the intervention groups had a risk of zinc deficiencies of around one third (0.35, 039, and 0.28 for URO, URN, and NutriRice, respectively) compared to the placebo (p < 0.001 for all). The children receiving NutriRice had higher serum folate concentrations at endline compared to children receiving normal rice (+ 2.25 ng/mL, p = 0.007). CONCLUSIONS: This study showed that the high prevalence of zinc and folate deficiency in Cambodia can be improved through the provision of MMFR. As rice is the staple diet for Cambodia, MMFR should be considered to be included in the school meal program and possibilities should be explored to introduce MMFR to the general population.

Renunciation of health care by people living with HIV in France is still associated with discrimination in health-care services and social insecurity - results from the ANRS-VESPA2 survey.

BACKGROUND: This study aimed to estimate the frequency of renunciation of health care among people living with HIV (PLHIV) in France, including health care unrelated to HIV, and to characterize associated socioeconomic and psychosocial risk factors. METHODS: The cross-sectional ANRS-VESPA2 survey was conducted on adult PLHIV attending French hospitals in 2011. Correlates of health-care renunciation in the 12 months before the survey were assessed through logistic modelling. RESULTS: Among the 3,020 PLHIV included in the sample, 17% declared health-care renunciation during the preceding year and 42% had a high level of social insecurity. During the previous 2 years, 8% and 11%, respectively, were discriminated against by medical staff and family. In multivariate analysis, positive associations were found between health-care renunciation and a high level of social insecurity (adjusted odds ratio [95% CI] 3.44 [2.54, 4.65]; P<0.001), having children (1.52 [1.10, 2.10]; P=0.01), smoking tobacco (1.50 [1.13, 1.98]; P=0.01), discrimination by medical staff (1.53 [1.22, 2.29]; P=0.04) or family (2.48 [1.75, 3.52]; P<0.001), major depressive episodes (1.46 [1.02, 2.09]; P=0.04), past or current drug injection (1.54 [1.03, 2.30]; P=0.04), and younger age (0.98 [0.97, 1.00]; P=0.03). Health-care renunciation was also negatively associated with HIV diagnosis after 1996 (1996-2002: 0.64 [0.46, 0.90]; P=0.01; ≥2003: 0.56 [0.40, 0.77]; P=0.001). CONCLUSIONS: In spite of universal health insurance in France, barrier- and refusal-renunciation of health care by PLHIV remain frequent. Poor psychosocial outcomes and discrimination by families and health-care providers compound the negative effect of social insecurity on health-care seeking in this population. To ensure optimal medical care, strategies are needed to prevent discrimination against PLHIV in health-care services. Special attention must be provided to patients experiencing social insecurity.

Nutrient Intake Is Insufficient among Senegalese Urban School Children and Adolescents: Results from Two 24 h Recalls in State Primary Schools in Dakar.

Due to rapid urbanization and high food prices and in the absence of nutrition programs, school children from urban areas in West Africa often have insufficient and inadequate diet leading to nutrient deficiencies that affect their health and schooling performance. Acute malnutrition and micronutrient deficiencies are prevalent in children from primary state schools of Dakar (Senegal). The objectives of the present study were to assess the overall diet of these children, to report insufficient/excessive energy and nutrient intakes and to investigate association between insufficient nutrient intake and micronutrient deficiencies. Children attending urban state primary schools in the Dakar area were selected through a two-stage random cluster sampling (30 schools × 20 children). Dietary intake data were obtained from two 24 h recalls and blood samples were collected from 545 children (aged 5-17 years, 45% < 10 years, 53% girls) and adjusted for intra-individual variability to estimate nutrient usual intakes. Energy intake was insufficient and unbalanced with insufficient contribution of protein and excessive contribution of fat to global energy intake in one third of the children. Proportions of children with insufficient intake were: 100% for calcium, 100% for folic acid, 79% for vitamin A, 69% for zinc, 53% for vitamin C and 46% for iron. Insufficient iron and protein intake were risk factors for iron deficiency (odds ratio, OR 1.5, 2.2). Insufficient zinc intake and energy intake from protein were risk factors for zinc deficiency (OR 1.8, 3.0, 1.7, 2.9). Insufficient iron and vitamin C intake, and insufficient energy intake from protein were risk factors for marginal vitamin A status (OR 1.8, 1.8, 3.3). To address nutritional deficiencies associated with a diet deficient in energy, protein and micronutrients, nutrition education or school feeding programs are needed in urban primary schools of Senegal.

Impact of Multi-Micronutrient Fortified Rice on Hemoglobin, Iron and Vitamin A Status of Cambodian Schoolchildren: a Double-Blind Cluster-Randomized Controlled Trial.

In Cambodia, micronutrient deficiencies remain a critical public health problem. Our objective was to evaluate the impact of multi-micronutrient fortified rice (MMFR) formulations, distributed through a World Food Program school-meals program (WFP-SMP), on the hemoglobin concentrations and iron and vitamin A (VA) status of Cambodian schoolchildren. The FORISCA-UltraRice+NutriRice study was a double-blind, cluster-randomized, placebo-controlled trial. Sixteen schools participating in WFP-SMP were randomly assigned to receive extrusion-fortified rice (UltraRice Original, UltraRice New (URN), or NutriRice) or unfortified rice (placebo) six days a week for six months. Four additional schools not participating in WFP-SMP were randomly selected as controls. A total of 2440 schoolchildren (6-16 years old) participated in the biochemical study. Hemoglobin, iron status, estimated using inflammation-adjusted ferritin and transferrin receptors concentrations, and VA status, assessed using inflammation-adjusted retinol-binding protein concentration, were measured at the baseline, as well as at three and six months. Baseline prevalence of anemia, depleted iron stores, tissue iron deficiency, marginal VA status and VA deficiency were 15.6%, 1.4%, 51.0%, 7.9%, and 0.7%, respectively. The strongest risk factors for anemia were hemoglobinopathy, VA deficiency, and depleted iron stores (all p < 0.01). After six months, children receiving NutriRice and URN had 4 and 5 times less risk of low VA status, respectively, in comparison to the placebo group. Hemoglobin significantly increased (+0.8 g/L) after three months for the URN group in comparison to the placebo group; however, this difference was no longer significant after six months, except for children without inflammation. MMFR containing VA effectively improved the VA status of schoolchildren. The impact on hemoglobin and iron status was limited, partly by sub-clinical inflammation. MMFR combined with non-nutritional approaches addressing anemia and inflammation should be further investigated.