Disponible en ligne sur
ScienceDirect www.sciencedirect.com Médecine et maladies infectieuses 45 (2015) 72–77
Original article
Knowledge of HIV and hepatitis B and C status among people living in extreme poverty in France, in 2012 Connaissance des statuts sérologiques VIH, VHB et VHC chez les personnes en situation de grande précarité en France, 2012 M. Chappuis a,∗,1 , M.-D. Pauti a , A. Tomasino a,2 , G. Fahet b,3 , F. Cayla b,4 , J.-F. Corty a,5 b
a Médecins du Monde, 62, rue Marcadet, 75018 Paris, France Observatoire régional de la santé de Midi Pyrénées, 37, allées Jules-Guesde, 31073 Toulouse cedex, France
Received 28 March 2014; received in revised form 8 September 2014; accepted 14 January 2015 Available online 7 February 2015
Abstract Objective. – “Médecins du Monde” healthcare centers receive individuals living in extremely precarious conditions for primary health care; 94% of these are foreigners. These medical consultations are an opportunity to discuss their serological status and to offer them screening tests. Patients and method. – Two standardized questionnaires were implemented in all healthcare centers in 2000. The medical record covers knowledge of HIV and hepatitis B and C status. Results. – 41,033 consultations were given in 2012 in the 20 healthcare centers, for 23,181 patients. Only 29% of the patients knew their hepatitis status and 35% their HIV status. 42% of French patients were unaware of their HIV status compared to 67% of foreign patients. The lack of knowledge of foreign patients’ HIV status was more frequent among men and in age classes < 20 and > 60 years of age. Patients from non-EU Europe, the Middle East, and Asia were significantly more likely to be unaware of their HIV status compared to people from Sub-Saharan Africa and Oceania/America. The rate of foreigners not having undergone screening remained stable, regardless of the duration of residence in France. Conclusion. – These results highlight the need to develop specific prevention projects among immigrant populations in precarious situations. © 2015 Elsevier Masson SAS. All rights reserved. Keywords: Hepatitis; HIV; France; Immigrant; Precariousness
Résumé Objectifs. – La population rec¸ue dans les centres d’accueil de soins et d’orientations de Médecins du Monde est à 94 % étrangère et vit dans des conditions extrêmement précaires. Les consultations permettent de faire le point sur les statuts sérologiques des patients et de leur proposer une orientation vers un dépistage. Patients et méthode. – Depuis 2000, un dossier social et un dossier médical standardisés ont été mis en place dans tous les centres. Le dossier médical aborde la connaissance du statut sérologique vis-à-vis du VIH du VHB et du VHC.
∗ 1 2 3 4 5
Corresponding author. E-mail address: [email protected] (M. Chappuis). M. Chappuis participated in the data collection, the statistical analysis, and drafting of the article; MD Pauti participated in drafting of the article. A. Tomasino participated in the data collection, the statistical analysis. G. Fahet participated in the statistical analysis. F. Cayla participated in the statistical analysis. J.F. Corty participated in reviewing the article and finding funds.
http://dx.doi.org/10.1016/j.medmal.2015.01.008 0399-077X/© 2015 Elsevier Masson SAS. All rights reserved.
M. Chappuis et al. / Médecine et maladies infectieuses 45 (2015) 72–77
73
Résultats. – En 2012, les 20 centres ont réalisé 41 033 consultations médicales pour 23 181 patients différents. Parmi les patients, seuls 29 % déclarent connaître leur statut concernant les hépatites et environ 35 % concernant le VIH. Les consultants franc¸ais étaient 42 % à ignorer leur statut VIH contre 67 % des étrangers. Pour les patients étrangers, la méconnaissance vis-à-vis du VIH était plus répandue parmi les hommes et les classes d’âge < 20 et > 60 ans. Les ressortissants d’Europe (hors Union européenne), du Proche- et Moyen-Orient et d’Asie étaient significativement plus nombreux à méconnaître leur statut sérologique par rapport aux personnes originaires d’Afrique sub-Saharienne et d’Océanie/Amériques. La proportion d’étrangers n’ayant pas réalisé de dépistage restait quasiment stable quelle que soit la durée de résidence en France. Conclusion. – Ces résultats soulignent toute la nécessité de développer des projets spécifiques de prévention envers les populations migrantes, en situation précaire. © 2015 Elsevier Masson SAS. Tous droits réservés. Mots clés : Hépatite ; France ; Migrant ; Précarité ; VIH
1. Introduction According to the High Council for Public Health (HCPH), there are 1.5 million people living in extreme poverty6 in France with more than 300,000 people in situations of exclusion7 [1]. This population often escapes usual surveys because of their rather atypical mode of life and extreme living conditions, making it difficult to estimate the magnitude of the problem and acquire knowledge of this population. However, the authors of studies on populations living in precarious conditions (homeless people, receiving some social benefits, users of specific institutions, etc.), agree that, whatever the definition of the precarious population used, there is a strong relationship between precariousness and the health status of this population: people in precarious situations often have a more deteriorated health [2–4] and a less frequent access to care. Giving up access to care for financial reasons and/or delayed access to care is still frequent in these populations [4,5]. This population does not take prevention into consideration [2]. Thus, precarious living conditions are harmful to human health, prevent the implementation of prevention and access to care. More specifically, people in precarious situations and/or state of exclusion accumulate risk factors for HIV and hepatitis B and C infection [6]. “Médecins du Monde” (MdM) has been working with precarious populations since 1986 in France. People consulting in centers for care and guidance (French acronym CASO) often come from areas highly endemic for hepatitis B and C, HIV, and other sexually transmitted infections (STIs). They, therefore, have a higher risk of exposure and infection when coming from these regions [7]. They are also exposed to multiple risks during their migratory journey, with sometimes a difficult access to care, and often-precarious socio-economic conditions in France [8]. This article deals with the current data on HIV, HBV, and HCV status of people in precarious situations having consulted
6 Extreme poverty is defined by the French National Institute for Statistic and Economic Studies (French acronym INSEE) as a household whose income is less than or equal to one third of the median income. 7 The HCPH considers as excluded individuals who, despite their state of poverty, do not benefit from assistance best corresponding to their needs – because they do not qualify, or they do not know their rights, or they do not have the energy to initiate the necessary procedures.
in MdM CASO in 2012 and identification of socio-demographic factors related to the lack of knowledge of serological status. 2. Patients and methods MdM has been active since 1986 in France, working with this precarious population with a difficult access to prevention and care. MdM was active in 30 cities in 2012, with 98 programs in centers (CASO) or in outreach units. CASO are managed by multidisciplinary teams that provide medical and social care to anyone with a difficult access to care. In 2000, the association implemented an Observatory on Access to Care in France to acquire objective data on the difficult access to mainstream health services for the population received. The observatory developed tools for standardized data collection (socio-medical record) used by all CASO. A social record is completed for every individual received in a CASO, by a reception officer or a social worker, with an interpreter whenever necessary. This record documents the social status of the person the day of his/her first visit to the CASO, the socio-demographic characteristics (age, sex, nationality, etc.) and the social characteristics (marital status, living conditions, administrative situation, etc.). A physician collects and documents the medical data in a medical record: medical history and vaccination and serological status. A medical re-consultation file is completed at each visit, stating the nature of the complaint(s), the physician’s diagnosis, treatment, and complementary examination(s) prescribed. The CNIL’s (French Data Protection Authority) agreement was requested for socio-medical records. Interviews were held in rooms respecting confidentiality. The patient’s consent was obtained after information on the purpose and objectives of data collection. Data was collected with the Sphinx-Plus2 software. Data processing was performed with the Stata statistical software (version 11.2). Variables were compared with Pearson Chi2 test for qualitative variables and Kruskal-Wallis non-parametric test or variance analysis for quantitative variables. The observed differences were listed in the tables with the following codes: • ns: non significant at a threshold of 5%; • * : significant difference at a threshold of 5%;
74
• •
M. Chappuis et al. / Médecine et maladies infectieuses 45 (2015) 72–77 ** :
significant difference at a threshold of 1%; significant difference at a threshold of 1‰.
*** :
The data was adjusted by multiple logistic regression.
Table 2 Characteristics associated with ignorance of HIV status among foreign patients having consulted in CASO, in 2012. Caractéristiques associées à la méconnaissance du statut sérologique VIH parmi les patients étrangers re¸cus dans les CASO, 2012. Ignorance of HIV status
3. Results 3.1. Socio-demographic features of patients having consulted in CASO 30,560 patients (63,212 consultations) consulted in the 20 CASO in 2012. During that year, 41,033 medical consultations were recorded for 23,181 patients, giving an average 1.8 medical consultations per patient. Patients consulting in the CASO were predominantly male (60.7%). The average age was 32.8 years (min = 0, max = 80). 75% were single (with or without children) and only 30% had a permanent residence. More than 94% of patients were foreigners. Sub-Saharan African nationals were the largest group (25.8%), followed by Maghreb nationals (23.2%), European Union nationals excluding France (17.9%), and non-EU European nationals (12.4%). 66.8% of foreigners consulting in CASO in 2012, had been living in France for less than a year, 50% of these for less than 3 months. 71% of legal age foreigners did not have a residence permit at their first visit to the CASO, 7.3% had applied for political asylum application (request or appeal pending). Finally, only 12% of interviewed patients were entitled to healthcare coverage in France on their first visit.
All foreign patients Sex Male Female Age Less than 20 years of age 20−39 years of age 40−59 years of age 60 years of age and more Continental group EU (other than France) Non-EU Europe Sub-Saharan Africa North-Africa Far and Middle-East Asia Oceania, South-America, WI Duration of residence in France ≤ 1 year 1 year to < 3 years ≥ 3 years
%
n
66.7
5,135
69.4 62.5
3,263 1,864
87.0 64.4 62.8 78.4
583 3,097 1,074 290
74.6 81.9 58.3 76.7 81.1 82.8 39.8
769 447 1,635 1,220 426 309 329
65.7 66.3 66.3
420 381 4,058
Pa
*
*** *** **
*** *** ** *** *** ***
ns ns
Source: Observatory of access to care of the MdM Mission France, 2012. * P < 0.05; ** P < 0.01; *** P < 0.001; ns: non-significant. a Multiple analysis adjusted on all variables of the table.
HIV serological status was not significantly associated with the duration of residence in France (Table 2).
3.2. Knowledge of serological status (HIV, HBV, and HCV)
4. Discussion
Healthcare professionals questioned the patient on their HIV or hepatitis status in 35% of the consultations. Only 29.4% of questioned patients knew their hepatitis B and C status and 35% knew their HIV status (Table 1). 42% of questioned French patients ignored their HIV status compared to 67% of foreign nationals. Ignorance of the HIV status was significantly higher among male foreign nationals and among extreme age groups (less than 20 years of age and 60 years of age or more). There were also significant variations according to geographical origin. Non-EU European, Middle East, and Asian nationals were significantly more likely to ignore their HIV serological status; conversely, this lack of knowledge was less common in sub-Saharan Africa, Oceania, South America, and West Indies nationals. Finally, the knowledge of
Only 29.4% of patients knew about their hepatitis B and C status, and 35% about their HIV status. These results prove a significant lack of awareness of serological status among patients consulting in CASO and these proportions were probably underestimated due to memory bias or risk behavior that may have occurred since the latest screening and the study period. Our study revealed that ignorance about HIV status was higher among extreme age classes (less than 20 years of age and 60 years of age or more). This was confirmed by other authors who reported that age was associated with less knowledge of the HIV status, presenting as a U-shaped curve [9,10]. Moreover, the lack of knowledge of the serological status for HIV was higher among foreign nationals than in French nationals (only 33% knew about their HIV status compared to 58%
Table 1 Knowledge of HIV and hepatitis B and C status for patients having consulted in CASO, in 2012. Connaissance des statuts sérologiques (VHB, VHC et VIH) des personnes re¸cues dans les CASO, 2012. HBV
Known serological status
HCV
HIV
%
n
%
n
%
n
29.4
2,443
29.0
2,408
34.7
2,924
Source: Observatory of access to care of the MdM Mission France, 2012.
M. Chappuis et al. / Médecine et maladies infectieuses 45 (2015) 72–77
for French nationals). These results were confirmed by several authors who reported less knowledge of HIV status or less use of screening tests among immigrants [11]. Several hypotheses may explain these differences.
4.1. Reception and living conditions of immigrants in France: a first barrier to access to care The lesser knowledge of their HIV serological status among immigrants may be explained by the low economic development of their native countries as well as the deteriorated economic and social conditions of immigrants in France. Indeed, it is acknowledged that reception and living conditions of immigrants may have a deleterious effect on their health [12]. The precarious living conditions are a first barrier to screening access for these populations who often have other priorities (finding housing, a job, etc.) than their health [13,14]. Thus, immigrants delay access to care and are prone to using curative rather than preventive care. [15]. Access to social rights, including social protection, is more difficult for migrants and also constitutes a barrier for access to care [8,16]. Furthermore, only very few people have access to screening and hepatitis B and C treatment in their native country. [17]. Finally, although considerable progress has been made in access to treatment for HIV, in 2012, in countries with low and middle incomes, only a third of eligible patients (as per the 2013 World health Organization) will actually have access to HIV treatment [18]. Thus, it is possible that people who believe they cannot have access to treatment because of their social or administrative condition, or because they did not always have access to care in their native country will not use screening tests even if they are free. These problems of access to care may be enhanced by difficulties of communicating in and understanding the French language. We can point out on this issue a lack of investment of institutions and professionals to hold consultation with a professional interpreter [6,19]. Schwarzinger et al., in a recent study in France, reported that few physicians knew they could use a professional interpreter (whether in city or hospital practice); and less than 5% (95% CI = [1.9 to 9.3]) of allophonic patients surveyed used professional interpreting services. So, even if this situation was not anticipated or deliberately chosen by units or physicians, a significant number of allophonic patients come to consultations without being able to speak with the physician [19]. It is likely that in these conditions health education and prevention of STI are seldom addressed. Moreover, several authors report a lack of knowledge of existing systems and institutions offering free and anonymous screening for HIV and hepatitis, and difficulty in using the health care system, especially for immigrants in precarious situations [2,6,13]. It should be brought to mind that a bad understanding of the French healthcare and social system is the first barrier for health care access, for patients seen by MdM in 2012 [8]. Furthermore, some authors report a lesser knowledge about HIV or hepatitis in immigrant populations [20] and a lower perception of the HIV risk [21–23]. Lot et al. confirmed this and mentioned that exposure to risk was a less common reason for
75
using screening tests for immigrants (women or men) than for people born in France [7]. Finally, the lack of knowledge about HIV was significantly higher among men. This was demonstrated in several studies by authors who suggested that women were offered more screening opportunities during pregnancy [24]. Furthermore, some authors suggested that men were less frequently proposed screening tests and were also less likely to accept the test [14]. 4.2. Disparities between countries of origin Differences were identified according to the geographical origin of foreigners. Thus, the risk to ignore their serological status was higher among non-EU European, Middle East, and Asian nationals compared to sub-Saharan Africa, Oceania, South America, and West-Indies nationals. Some authors confirmed such differences according to the country of origin. Lot et al. indicated that immigrants from Asia were tested for HIV later than patients born in France, while HIV testing was not delayed for immigrants from sub-Saharan Africa compared to patients born in France [7]. These results may be explained by cultural habits and economic characteristics specific to the native country [12,25]. Rigal et al. also pointed out that the geographical origin of patients could be a factor related to a lack of screening proposed by health professionals [9]. Finally, migration usually concerns a very precarious population, subject to discrimination in their native country that makes access to care even more difficult than for the global population, such as Romani in Bulgaria or Romania. 4.3. The duration of stay in France: a variable not influencing access to screening tests The assumption that the length of stay in France increases opportunities for screening and therefore the number of people ignoring their serological status was not verified in our study. Indeed, the rate of foreigners not having undergone screening tests remained virtually stable, regardless of the duration of residence in France. This highlights the importance of the factors of resistance and the impact of the aforementioned barriers. Furthermore, this demonstrates the importance of raising awareness and the role of professionals for these populations; it confirms the importance of the new 2013 recommendations advocating, instead of proposing to systematize screening in the global population, to increase screening in population groups for whom the prevalence is the highest, such as immigrants from highly endemic countries [26]. 4.4. Limitations of the study Our study was based on data collection performed by physicians during the consultation. They did not systematically address the serological status of patients, proven by the response rates of 35%, because of lack of time or because of medical confidentiality. Indeed, the consultation was sometimes held in presence of a third party (spouse, child, friend, etc.) providing translation when the patient did not speak French. The presence
76
M. Chappuis et al. / Médecine et maladies infectieuses 45 (2015) 72–77
of a third party could impair the quality of the interview and be a reporting bias, especially for the most sensitive or intimate questions.
undocumented immigrants, and could be a solution to increase prevention and screening for precarious populations. Disclosure of interest
5. Conclusion Very precarious populations, and particularly precarious immigrants face many barriers to access to prevention of HIV, hepatitis, and STIs. Given the frequency of these diseases in precarious populations, especially among immigrant populations in France, it is essential to continue prevention and strengthen strategies for screening, as recommended by experts for these populations with a particularly difficult access to care. Thus, it is clearly necessary to develop specific prevention projects in all institutions receiving precarious immigrants to facilitate access to the healthcare system for the most vulnerable populations. A program to strengthen the prevention of HIV, STIs, and hepatitis B and C, and to improve access to screening for the population managed by MdM, was implemented in 2003 at the Paris CASO, initiator of the project. It has been extended to 19 programs since. Our teams have created numerous partnerships with CDAG (Free and anonymous screening center)/CIDDIST (Information, screening, and diagnosis center for STD). These partnerships have multiple aspects: referral of patients to these structures, external actions of CDAG/CIDDIST with mobile MdM activities or in CASO Partnerships were also developed with vaccination centers. The objective was to facilitate access of vulnerable populations to screening and vaccination, to guide and/or to help them access to centers they often are unaware of. The rapid diagnostic tests (RDT) available since 2010 in several of these programs are also a new opportunity to test these people who have little access to screening facilities. Thus, it is necessary to develop partnerships among CIDDIST/CDAG mobile teams and/or immunization centers and associations or institutions hosting precarious populations (e.g. mental hospitals, CADDA (welcoming centers for refugees), associations, etc.) to increase opportunities for screening. Raising the incentive for screening and prevention should motivate all stakeholders through specific information campaigns and communication which can be extended to all infectious diseases, or preventive in nature (such as for STIs, vaccination, screening for female cancers, etc.). This is why training MdM teams and public health advisors in counseling is a priority so as to deliver messages to patients that take into account intercultural features and image of the disease, according to the various populations met. It is essential to secure the existence, sustainability and improvement of the healthcare access offices (PASS) that were created by the 1998 law against exclusion. They are the only gateway to the hospital for a precarious population without any social security coverage. Finally, a check-up, covering all infectious diseases or preventive in nature, should be systematically offered when opening rights to State Medical Aid (French acronym AME) for
The authors declare that they have no conflicts of interest concerning this article. Acknowledgments We thank all the teams working in MdM CASO and patients who agreed to answer questions. References [1] La progression de la précarité en France et ses effets sur la santé. HCSP; 1998. p. 350. [2] Cambois E. Les personnes en situation sociale difficile et leur santé. Les travaux de l’observatoire; 2003–2004. p. 101–26. [3] Dumesnil S, Le Fur P. État de santé des enfants pauvres et recours aux soins en ambulatoire. In: Conseil de l’Emploi, des Revenus et de la Cohésion sociale ; Les enfants pauvres en France; 2003. [4] Chauvin P, Parizot P, Lebas J. État de santé, recours aux soins et mode de fréquentation des personnes en situation précaire consultant des centres de soins gratuits : le projet PRECAR. In: Joubert M, Chauvin P, Facy F, Ringa V, editors. Précarisation, risque et santé. Paris: Inserm; 2001. [5] Parizot I, Chauvin P, Firdion JM, Paugam S. Santé, inégalités et ruptures sociales : résultat de la pré-enquête conduite dans 5 zones urbaines sensibles de l’Ile de France, synthèse des premiers résultats pour l’observatoire national de la pauvreté et de l’exclusion sociale. INED/Inserm; 2002. [6] Alvarez-del Arco D, Monge S, Azcoaga A, Rio I, Hernando V, Gonzalez C, et al. HIV testing and counselling for migrant populations living in high-income countries: a systematic review. Eur J Public Health 2012;23:1039–45. [7] Lot F, Antoine D, Pioche C, Larsen C, Che D, Cazein F, et al. Trois pathologies infectieuses fréquemment rencontrées chez les migrants en France : le VIH, la tuberculose et l’hépatite B. BEH 2012;2–4:25–30. [8] Médecins du Monde France. Observatoire de l’accès aux soins de la mission France. Rapport 2012; 2013. p. 210. [9] Rigal L, Rouessé C, Collignon A, Domingo A, Deniaud F. Facteurs liés à l’absence de proposition de dépistage du VIH-sida et des hépatites B et C aux immigrés en situation de précarité. RESP 2011;59:213–21. [10] Merchant RC, Catanzaro BM, Seage 3rd GR, Mayer KH, Clark MA, Degruttola VG, et al. Demographic variations in HIV testing history among emergency department patients: implications for HIV screening in US emergency departments. J Med Screen 2009;16(2):60–6. [11] Dourgnon P, Jusot F, Sermet C, Silva J. Le recours aux soins de ville des immigrés en France. Question Econ Sante 2009;146:1–6. [12] Berchet C, Jusot F. État de santé et recours aux soins des immigrés en France : une revue de la littérature. BEH 2012;2–4:17–21. [13] Burns FM, Imrie JY, Nazroo J, et al. Why the(y) wait? Key informant understandings of factors contributing to late presentation and poor utilization of HIV health and social care services by African migrants in Britain. AIDS Care 2007;19:102–8. [14] Fakoya I, Reynolds R, Caswell G, Shiripinda I. Barriers to HIV testing for migrant black Africans in Western Europe. HIV Med 2008;9(Suppl. 2):23–5. [15] Alberts JF, Sanderman R, Gerstenbluth I, Van den Heuvel WJ. Sociocultural variations in help seeking behavior for everyday symptoms and chronic disorders. Health Policy 1998;44:57–72. [16] Mizrahi A, Mizrahi A. Morbidité et soins médicaux aux personnes nées à l’étranger. J Econ Med 2008;26:159–76. [17] Access M.S.F. Campaign. Diagnosis and treatment of hepatitis C: a technical landscape. Geneva: Médecins Sans Frontières; 2013. [18] ONUSIDA. Rapport sur l’épidémie mondiale de sida; 2013. p. 274.
M. Chappuis et al. / Médecine et maladies infectieuses 45 (2015) 72–77 [19] Schwarzinger M. Usage et opportunité du recours à l’interprétariat professionnel dans le domaine de la santé–analyse des pratiques d’interprétariat en matière de prévention et de prise en charge du VIH/SIDA, de la tuberculose et du diabète. DGS; 2012. p. 139. [20] Sahajian F, Voirin N, Vanhems P, Fabry J. Connaissances des populations précaires à propos des hépatites virales B et C. RESP 2005;53:25–42. [21] Prost A, Elford J, Imrie J, Petticrew M, Hart G. Social, behavioural, and intervention research among people of Sub-Saharan African origin living with HIV in the UK and Europe: literature review and recommendations for intervention. AIDS Beh 2008;12:170–94. [22] Lopez-Quintero C, Shtarkshall R, Neumark YD. Barriers to HIV-testing among hispanics in the United States: analysis of the National Health Interview Survey, 2000. AIDS Patient Care STDs 2005;10:672–83.
77
[23] Carnicer-Pont D, de Olalla PG, Cayl˘a JA. HIV infection late detection in AIDS patients of an European city with increased immigration since mid 1990s. Curr HIV Res 2009;7:237–43. [24] Southgate J, Mital D, Stock A. Are women from high-risk ethnic minority groups more likely to decline antenatal HIV screening? Int J STD AIDS 2008;19:206–7. [25] Jusot F, Silva J, Dourgnon P, Sermet C. Inégalités de santé liées à l’immigration en France/Effet des conditions de vie ou sélection à la migration. Rev Econ 2009;60:385–411. [26] Morlat P. Prise en charge médicale des personnes vivant avec le VIH. Recommandations du groupe d’experts. Rapport 2013. Paris: La documentation franc¸aise; 2013. p. 478.
ScienceDirect www.sciencedirect.com Médecine et maladies infectieuses 45 (2015) 72–77
Original article
Knowledge of HIV and hepatitis B and C status among people living in extreme poverty in France, in 2012 Connaissance des statuts sérologiques VIH, VHB et VHC chez les personnes en situation de grande précarité en France, 2012 M. Chappuis a,∗,1 , M.-D. Pauti a , A. Tomasino a,2 , G. Fahet b,3 , F. Cayla b,4 , J.-F. Corty a,5 b
a Médecins du Monde, 62, rue Marcadet, 75018 Paris, France Observatoire régional de la santé de Midi Pyrénées, 37, allées Jules-Guesde, 31073 Toulouse cedex, France
Received 28 March 2014; received in revised form 8 September 2014; accepted 14 January 2015 Available online 7 February 2015
Abstract Objective. – “Médecins du Monde” healthcare centers receive individuals living in extremely precarious conditions for primary health care; 94% of these are foreigners. These medical consultations are an opportunity to discuss their serological status and to offer them screening tests. Patients and method. – Two standardized questionnaires were implemented in all healthcare centers in 2000. The medical record covers knowledge of HIV and hepatitis B and C status. Results. – 41,033 consultations were given in 2012 in the 20 healthcare centers, for 23,181 patients. Only 29% of the patients knew their hepatitis status and 35% their HIV status. 42% of French patients were unaware of their HIV status compared to 67% of foreign patients. The lack of knowledge of foreign patients’ HIV status was more frequent among men and in age classes < 20 and > 60 years of age. Patients from non-EU Europe, the Middle East, and Asia were significantly more likely to be unaware of their HIV status compared to people from Sub-Saharan Africa and Oceania/America. The rate of foreigners not having undergone screening remained stable, regardless of the duration of residence in France. Conclusion. – These results highlight the need to develop specific prevention projects among immigrant populations in precarious situations. © 2015 Elsevier Masson SAS. All rights reserved. Keywords: Hepatitis; HIV; France; Immigrant; Precariousness
Résumé Objectifs. – La population rec¸ue dans les centres d’accueil de soins et d’orientations de Médecins du Monde est à 94 % étrangère et vit dans des conditions extrêmement précaires. Les consultations permettent de faire le point sur les statuts sérologiques des patients et de leur proposer une orientation vers un dépistage. Patients et méthode. – Depuis 2000, un dossier social et un dossier médical standardisés ont été mis en place dans tous les centres. Le dossier médical aborde la connaissance du statut sérologique vis-à-vis du VIH du VHB et du VHC.
∗ 1 2 3 4 5
Corresponding author. E-mail address: [email protected] (M. Chappuis). M. Chappuis participated in the data collection, the statistical analysis, and drafting of the article; MD Pauti participated in drafting of the article. A. Tomasino participated in the data collection, the statistical analysis. G. Fahet participated in the statistical analysis. F. Cayla participated in the statistical analysis. J.F. Corty participated in reviewing the article and finding funds.
http://dx.doi.org/10.1016/j.medmal.2015.01.008 0399-077X/© 2015 Elsevier Masson SAS. All rights reserved.
M. Chappuis et al. / Médecine et maladies infectieuses 45 (2015) 72–77
73
Résultats. – En 2012, les 20 centres ont réalisé 41 033 consultations médicales pour 23 181 patients différents. Parmi les patients, seuls 29 % déclarent connaître leur statut concernant les hépatites et environ 35 % concernant le VIH. Les consultants franc¸ais étaient 42 % à ignorer leur statut VIH contre 67 % des étrangers. Pour les patients étrangers, la méconnaissance vis-à-vis du VIH était plus répandue parmi les hommes et les classes d’âge < 20 et > 60 ans. Les ressortissants d’Europe (hors Union européenne), du Proche- et Moyen-Orient et d’Asie étaient significativement plus nombreux à méconnaître leur statut sérologique par rapport aux personnes originaires d’Afrique sub-Saharienne et d’Océanie/Amériques. La proportion d’étrangers n’ayant pas réalisé de dépistage restait quasiment stable quelle que soit la durée de résidence en France. Conclusion. – Ces résultats soulignent toute la nécessité de développer des projets spécifiques de prévention envers les populations migrantes, en situation précaire. © 2015 Elsevier Masson SAS. Tous droits réservés. Mots clés : Hépatite ; France ; Migrant ; Précarité ; VIH
1. Introduction According to the High Council for Public Health (HCPH), there are 1.5 million people living in extreme poverty6 in France with more than 300,000 people in situations of exclusion7 [1]. This population often escapes usual surveys because of their rather atypical mode of life and extreme living conditions, making it difficult to estimate the magnitude of the problem and acquire knowledge of this population. However, the authors of studies on populations living in precarious conditions (homeless people, receiving some social benefits, users of specific institutions, etc.), agree that, whatever the definition of the precarious population used, there is a strong relationship between precariousness and the health status of this population: people in precarious situations often have a more deteriorated health [2–4] and a less frequent access to care. Giving up access to care for financial reasons and/or delayed access to care is still frequent in these populations [4,5]. This population does not take prevention into consideration [2]. Thus, precarious living conditions are harmful to human health, prevent the implementation of prevention and access to care. More specifically, people in precarious situations and/or state of exclusion accumulate risk factors for HIV and hepatitis B and C infection [6]. “Médecins du Monde” (MdM) has been working with precarious populations since 1986 in France. People consulting in centers for care and guidance (French acronym CASO) often come from areas highly endemic for hepatitis B and C, HIV, and other sexually transmitted infections (STIs). They, therefore, have a higher risk of exposure and infection when coming from these regions [7]. They are also exposed to multiple risks during their migratory journey, with sometimes a difficult access to care, and often-precarious socio-economic conditions in France [8]. This article deals with the current data on HIV, HBV, and HCV status of people in precarious situations having consulted
6 Extreme poverty is defined by the French National Institute for Statistic and Economic Studies (French acronym INSEE) as a household whose income is less than or equal to one third of the median income. 7 The HCPH considers as excluded individuals who, despite their state of poverty, do not benefit from assistance best corresponding to their needs – because they do not qualify, or they do not know their rights, or they do not have the energy to initiate the necessary procedures.
in MdM CASO in 2012 and identification of socio-demographic factors related to the lack of knowledge of serological status. 2. Patients and methods MdM has been active since 1986 in France, working with this precarious population with a difficult access to prevention and care. MdM was active in 30 cities in 2012, with 98 programs in centers (CASO) or in outreach units. CASO are managed by multidisciplinary teams that provide medical and social care to anyone with a difficult access to care. In 2000, the association implemented an Observatory on Access to Care in France to acquire objective data on the difficult access to mainstream health services for the population received. The observatory developed tools for standardized data collection (socio-medical record) used by all CASO. A social record is completed for every individual received in a CASO, by a reception officer or a social worker, with an interpreter whenever necessary. This record documents the social status of the person the day of his/her first visit to the CASO, the socio-demographic characteristics (age, sex, nationality, etc.) and the social characteristics (marital status, living conditions, administrative situation, etc.). A physician collects and documents the medical data in a medical record: medical history and vaccination and serological status. A medical re-consultation file is completed at each visit, stating the nature of the complaint(s), the physician’s diagnosis, treatment, and complementary examination(s) prescribed. The CNIL’s (French Data Protection Authority) agreement was requested for socio-medical records. Interviews were held in rooms respecting confidentiality. The patient’s consent was obtained after information on the purpose and objectives of data collection. Data was collected with the Sphinx-Plus2 software. Data processing was performed with the Stata statistical software (version 11.2). Variables were compared with Pearson Chi2 test for qualitative variables and Kruskal-Wallis non-parametric test or variance analysis for quantitative variables. The observed differences were listed in the tables with the following codes: • ns: non significant at a threshold of 5%; • * : significant difference at a threshold of 5%;
74
• •
M. Chappuis et al. / Médecine et maladies infectieuses 45 (2015) 72–77 ** :
significant difference at a threshold of 1%; significant difference at a threshold of 1‰.
*** :
The data was adjusted by multiple logistic regression.
Table 2 Characteristics associated with ignorance of HIV status among foreign patients having consulted in CASO, in 2012. Caractéristiques associées à la méconnaissance du statut sérologique VIH parmi les patients étrangers re¸cus dans les CASO, 2012. Ignorance of HIV status
3. Results 3.1. Socio-demographic features of patients having consulted in CASO 30,560 patients (63,212 consultations) consulted in the 20 CASO in 2012. During that year, 41,033 medical consultations were recorded for 23,181 patients, giving an average 1.8 medical consultations per patient. Patients consulting in the CASO were predominantly male (60.7%). The average age was 32.8 years (min = 0, max = 80). 75% were single (with or without children) and only 30% had a permanent residence. More than 94% of patients were foreigners. Sub-Saharan African nationals were the largest group (25.8%), followed by Maghreb nationals (23.2%), European Union nationals excluding France (17.9%), and non-EU European nationals (12.4%). 66.8% of foreigners consulting in CASO in 2012, had been living in France for less than a year, 50% of these for less than 3 months. 71% of legal age foreigners did not have a residence permit at their first visit to the CASO, 7.3% had applied for political asylum application (request or appeal pending). Finally, only 12% of interviewed patients were entitled to healthcare coverage in France on their first visit.
All foreign patients Sex Male Female Age Less than 20 years of age 20−39 years of age 40−59 years of age 60 years of age and more Continental group EU (other than France) Non-EU Europe Sub-Saharan Africa North-Africa Far and Middle-East Asia Oceania, South-America, WI Duration of residence in France ≤ 1 year 1 year to < 3 years ≥ 3 years
%
n
66.7
5,135
69.4 62.5
3,263 1,864
87.0 64.4 62.8 78.4
583 3,097 1,074 290
74.6 81.9 58.3 76.7 81.1 82.8 39.8
769 447 1,635 1,220 426 309 329
65.7 66.3 66.3
420 381 4,058
Pa
*
*** *** **
*** *** ** *** *** ***
ns ns
Source: Observatory of access to care of the MdM Mission France, 2012. * P < 0.05; ** P < 0.01; *** P < 0.001; ns: non-significant. a Multiple analysis adjusted on all variables of the table.
HIV serological status was not significantly associated with the duration of residence in France (Table 2).
3.2. Knowledge of serological status (HIV, HBV, and HCV)
4. Discussion
Healthcare professionals questioned the patient on their HIV or hepatitis status in 35% of the consultations. Only 29.4% of questioned patients knew their hepatitis B and C status and 35% knew their HIV status (Table 1). 42% of questioned French patients ignored their HIV status compared to 67% of foreign nationals. Ignorance of the HIV status was significantly higher among male foreign nationals and among extreme age groups (less than 20 years of age and 60 years of age or more). There were also significant variations according to geographical origin. Non-EU European, Middle East, and Asian nationals were significantly more likely to ignore their HIV serological status; conversely, this lack of knowledge was less common in sub-Saharan Africa, Oceania, South America, and West Indies nationals. Finally, the knowledge of
Only 29.4% of patients knew about their hepatitis B and C status, and 35% about their HIV status. These results prove a significant lack of awareness of serological status among patients consulting in CASO and these proportions were probably underestimated due to memory bias or risk behavior that may have occurred since the latest screening and the study period. Our study revealed that ignorance about HIV status was higher among extreme age classes (less than 20 years of age and 60 years of age or more). This was confirmed by other authors who reported that age was associated with less knowledge of the HIV status, presenting as a U-shaped curve [9,10]. Moreover, the lack of knowledge of the serological status for HIV was higher among foreign nationals than in French nationals (only 33% knew about their HIV status compared to 58%
Table 1 Knowledge of HIV and hepatitis B and C status for patients having consulted in CASO, in 2012. Connaissance des statuts sérologiques (VHB, VHC et VIH) des personnes re¸cues dans les CASO, 2012. HBV
Known serological status
HCV
HIV
%
n
%
n
%
n
29.4
2,443
29.0
2,408
34.7
2,924
Source: Observatory of access to care of the MdM Mission France, 2012.
M. Chappuis et al. / Médecine et maladies infectieuses 45 (2015) 72–77
for French nationals). These results were confirmed by several authors who reported less knowledge of HIV status or less use of screening tests among immigrants [11]. Several hypotheses may explain these differences.
4.1. Reception and living conditions of immigrants in France: a first barrier to access to care The lesser knowledge of their HIV serological status among immigrants may be explained by the low economic development of their native countries as well as the deteriorated economic and social conditions of immigrants in France. Indeed, it is acknowledged that reception and living conditions of immigrants may have a deleterious effect on their health [12]. The precarious living conditions are a first barrier to screening access for these populations who often have other priorities (finding housing, a job, etc.) than their health [13,14]. Thus, immigrants delay access to care and are prone to using curative rather than preventive care. [15]. Access to social rights, including social protection, is more difficult for migrants and also constitutes a barrier for access to care [8,16]. Furthermore, only very few people have access to screening and hepatitis B and C treatment in their native country. [17]. Finally, although considerable progress has been made in access to treatment for HIV, in 2012, in countries with low and middle incomes, only a third of eligible patients (as per the 2013 World health Organization) will actually have access to HIV treatment [18]. Thus, it is possible that people who believe they cannot have access to treatment because of their social or administrative condition, or because they did not always have access to care in their native country will not use screening tests even if they are free. These problems of access to care may be enhanced by difficulties of communicating in and understanding the French language. We can point out on this issue a lack of investment of institutions and professionals to hold consultation with a professional interpreter [6,19]. Schwarzinger et al., in a recent study in France, reported that few physicians knew they could use a professional interpreter (whether in city or hospital practice); and less than 5% (95% CI = [1.9 to 9.3]) of allophonic patients surveyed used professional interpreting services. So, even if this situation was not anticipated or deliberately chosen by units or physicians, a significant number of allophonic patients come to consultations without being able to speak with the physician [19]. It is likely that in these conditions health education and prevention of STI are seldom addressed. Moreover, several authors report a lack of knowledge of existing systems and institutions offering free and anonymous screening for HIV and hepatitis, and difficulty in using the health care system, especially for immigrants in precarious situations [2,6,13]. It should be brought to mind that a bad understanding of the French healthcare and social system is the first barrier for health care access, for patients seen by MdM in 2012 [8]. Furthermore, some authors report a lesser knowledge about HIV or hepatitis in immigrant populations [20] and a lower perception of the HIV risk [21–23]. Lot et al. confirmed this and mentioned that exposure to risk was a less common reason for
75
using screening tests for immigrants (women or men) than for people born in France [7]. Finally, the lack of knowledge about HIV was significantly higher among men. This was demonstrated in several studies by authors who suggested that women were offered more screening opportunities during pregnancy [24]. Furthermore, some authors suggested that men were less frequently proposed screening tests and were also less likely to accept the test [14]. 4.2. Disparities between countries of origin Differences were identified according to the geographical origin of foreigners. Thus, the risk to ignore their serological status was higher among non-EU European, Middle East, and Asian nationals compared to sub-Saharan Africa, Oceania, South America, and West-Indies nationals. Some authors confirmed such differences according to the country of origin. Lot et al. indicated that immigrants from Asia were tested for HIV later than patients born in France, while HIV testing was not delayed for immigrants from sub-Saharan Africa compared to patients born in France [7]. These results may be explained by cultural habits and economic characteristics specific to the native country [12,25]. Rigal et al. also pointed out that the geographical origin of patients could be a factor related to a lack of screening proposed by health professionals [9]. Finally, migration usually concerns a very precarious population, subject to discrimination in their native country that makes access to care even more difficult than for the global population, such as Romani in Bulgaria or Romania. 4.3. The duration of stay in France: a variable not influencing access to screening tests The assumption that the length of stay in France increases opportunities for screening and therefore the number of people ignoring their serological status was not verified in our study. Indeed, the rate of foreigners not having undergone screening tests remained virtually stable, regardless of the duration of residence in France. This highlights the importance of the factors of resistance and the impact of the aforementioned barriers. Furthermore, this demonstrates the importance of raising awareness and the role of professionals for these populations; it confirms the importance of the new 2013 recommendations advocating, instead of proposing to systematize screening in the global population, to increase screening in population groups for whom the prevalence is the highest, such as immigrants from highly endemic countries [26]. 4.4. Limitations of the study Our study was based on data collection performed by physicians during the consultation. They did not systematically address the serological status of patients, proven by the response rates of 35%, because of lack of time or because of medical confidentiality. Indeed, the consultation was sometimes held in presence of a third party (spouse, child, friend, etc.) providing translation when the patient did not speak French. The presence
76
M. Chappuis et al. / Médecine et maladies infectieuses 45 (2015) 72–77
of a third party could impair the quality of the interview and be a reporting bias, especially for the most sensitive or intimate questions.
undocumented immigrants, and could be a solution to increase prevention and screening for precarious populations. Disclosure of interest
5. Conclusion Very precarious populations, and particularly precarious immigrants face many barriers to access to prevention of HIV, hepatitis, and STIs. Given the frequency of these diseases in precarious populations, especially among immigrant populations in France, it is essential to continue prevention and strengthen strategies for screening, as recommended by experts for these populations with a particularly difficult access to care. Thus, it is clearly necessary to develop specific prevention projects in all institutions receiving precarious immigrants to facilitate access to the healthcare system for the most vulnerable populations. A program to strengthen the prevention of HIV, STIs, and hepatitis B and C, and to improve access to screening for the population managed by MdM, was implemented in 2003 at the Paris CASO, initiator of the project. It has been extended to 19 programs since. Our teams have created numerous partnerships with CDAG (Free and anonymous screening center)/CIDDIST (Information, screening, and diagnosis center for STD). These partnerships have multiple aspects: referral of patients to these structures, external actions of CDAG/CIDDIST with mobile MdM activities or in CASO Partnerships were also developed with vaccination centers. The objective was to facilitate access of vulnerable populations to screening and vaccination, to guide and/or to help them access to centers they often are unaware of. The rapid diagnostic tests (RDT) available since 2010 in several of these programs are also a new opportunity to test these people who have little access to screening facilities. Thus, it is necessary to develop partnerships among CIDDIST/CDAG mobile teams and/or immunization centers and associations or institutions hosting precarious populations (e.g. mental hospitals, CADDA (welcoming centers for refugees), associations, etc.) to increase opportunities for screening. Raising the incentive for screening and prevention should motivate all stakeholders through specific information campaigns and communication which can be extended to all infectious diseases, or preventive in nature (such as for STIs, vaccination, screening for female cancers, etc.). This is why training MdM teams and public health advisors in counseling is a priority so as to deliver messages to patients that take into account intercultural features and image of the disease, according to the various populations met. It is essential to secure the existence, sustainability and improvement of the healthcare access offices (PASS) that were created by the 1998 law against exclusion. They are the only gateway to the hospital for a precarious population without any social security coverage. Finally, a check-up, covering all infectious diseases or preventive in nature, should be systematically offered when opening rights to State Medical Aid (French acronym AME) for
The authors declare that they have no conflicts of interest concerning this article. Acknowledgments We thank all the teams working in MdM CASO and patients who agreed to answer questions. References [1] La progression de la précarité en France et ses effets sur la santé. HCSP; 1998. p. 350. [2] Cambois E. Les personnes en situation sociale difficile et leur santé. Les travaux de l’observatoire; 2003–2004. p. 101–26. [3] Dumesnil S, Le Fur P. État de santé des enfants pauvres et recours aux soins en ambulatoire. In: Conseil de l’Emploi, des Revenus et de la Cohésion sociale ; Les enfants pauvres en France; 2003. [4] Chauvin P, Parizot P, Lebas J. État de santé, recours aux soins et mode de fréquentation des personnes en situation précaire consultant des centres de soins gratuits : le projet PRECAR. In: Joubert M, Chauvin P, Facy F, Ringa V, editors. Précarisation, risque et santé. Paris: Inserm; 2001. [5] Parizot I, Chauvin P, Firdion JM, Paugam S. Santé, inégalités et ruptures sociales : résultat de la pré-enquête conduite dans 5 zones urbaines sensibles de l’Ile de France, synthèse des premiers résultats pour l’observatoire national de la pauvreté et de l’exclusion sociale. INED/Inserm; 2002. [6] Alvarez-del Arco D, Monge S, Azcoaga A, Rio I, Hernando V, Gonzalez C, et al. HIV testing and counselling for migrant populations living in high-income countries: a systematic review. Eur J Public Health 2012;23:1039–45. [7] Lot F, Antoine D, Pioche C, Larsen C, Che D, Cazein F, et al. Trois pathologies infectieuses fréquemment rencontrées chez les migrants en France : le VIH, la tuberculose et l’hépatite B. BEH 2012;2–4:25–30. [8] Médecins du Monde France. Observatoire de l’accès aux soins de la mission France. Rapport 2012; 2013. p. 210. [9] Rigal L, Rouessé C, Collignon A, Domingo A, Deniaud F. Facteurs liés à l’absence de proposition de dépistage du VIH-sida et des hépatites B et C aux immigrés en situation de précarité. RESP 2011;59:213–21. [10] Merchant RC, Catanzaro BM, Seage 3rd GR, Mayer KH, Clark MA, Degruttola VG, et al. Demographic variations in HIV testing history among emergency department patients: implications for HIV screening in US emergency departments. J Med Screen 2009;16(2):60–6. [11] Dourgnon P, Jusot F, Sermet C, Silva J. Le recours aux soins de ville des immigrés en France. Question Econ Sante 2009;146:1–6. [12] Berchet C, Jusot F. État de santé et recours aux soins des immigrés en France : une revue de la littérature. BEH 2012;2–4:17–21. [13] Burns FM, Imrie JY, Nazroo J, et al. Why the(y) wait? Key informant understandings of factors contributing to late presentation and poor utilization of HIV health and social care services by African migrants in Britain. AIDS Care 2007;19:102–8. [14] Fakoya I, Reynolds R, Caswell G, Shiripinda I. Barriers to HIV testing for migrant black Africans in Western Europe. HIV Med 2008;9(Suppl. 2):23–5. [15] Alberts JF, Sanderman R, Gerstenbluth I, Van den Heuvel WJ. Sociocultural variations in help seeking behavior for everyday symptoms and chronic disorders. Health Policy 1998;44:57–72. [16] Mizrahi A, Mizrahi A. Morbidité et soins médicaux aux personnes nées à l’étranger. J Econ Med 2008;26:159–76. [17] Access M.S.F. Campaign. Diagnosis and treatment of hepatitis C: a technical landscape. Geneva: Médecins Sans Frontières; 2013. [18] ONUSIDA. Rapport sur l’épidémie mondiale de sida; 2013. p. 274.
M. Chappuis et al. / Médecine et maladies infectieuses 45 (2015) 72–77 [19] Schwarzinger M. Usage et opportunité du recours à l’interprétariat professionnel dans le domaine de la santé–analyse des pratiques d’interprétariat en matière de prévention et de prise en charge du VIH/SIDA, de la tuberculose et du diabète. DGS; 2012. p. 139. [20] Sahajian F, Voirin N, Vanhems P, Fabry J. Connaissances des populations précaires à propos des hépatites virales B et C. RESP 2005;53:25–42. [21] Prost A, Elford J, Imrie J, Petticrew M, Hart G. Social, behavioural, and intervention research among people of Sub-Saharan African origin living with HIV in the UK and Europe: literature review and recommendations for intervention. AIDS Beh 2008;12:170–94. [22] Lopez-Quintero C, Shtarkshall R, Neumark YD. Barriers to HIV-testing among hispanics in the United States: analysis of the National Health Interview Survey, 2000. AIDS Patient Care STDs 2005;10:672–83.
77
[23] Carnicer-Pont D, de Olalla PG, Cayl˘a JA. HIV infection late detection in AIDS patients of an European city with increased immigration since mid 1990s. Curr HIV Res 2009;7:237–43. [24] Southgate J, Mital D, Stock A. Are women from high-risk ethnic minority groups more likely to decline antenatal HIV screening? Int J STD AIDS 2008;19:206–7. [25] Jusot F, Silva J, Dourgnon P, Sermet C. Inégalités de santé liées à l’immigration en France/Effet des conditions de vie ou sélection à la migration. Rev Econ 2009;60:385–411. [26] Morlat P. Prise en charge médicale des personnes vivant avec le VIH. Recommandations du groupe d’experts. Rapport 2013. Paris: La documentation franc¸aise; 2013. p. 478.
