Joseph Larmarange

Assoumou Nelly, Bekelynck Anne, Carillon Séverine, Kouadio Alexis, Ouantchi Honoré, Doumbia Mohamed, Larmarange Joseph et Kone Mariatou (2020) « Organisation du financement du dépistage du VIH à base communautaire en Côte d'Ivoire : une recherche d'efficience potentiellement contre-productive ? » (poster), présenté à INTEREST 2020, online. http://interestworkshop.org/.

Résumé : Contexte: Depuis le début des années 2010, le President’s Emergency Plan for AIDS Relief (Pepfar) et le Fonds mondial de lutte contre le VIH/ sida, la tuberculose et le paludisme, ont accentué leurs stratégies d’efficience basées sur la gestion axée sur les résultats (GAR). L’objectif ici est d’analyser les effets de ces stratégies sur la mise en oeuvre locale des activités, à travers l’exemple du dépistage du VIH à base communautaire. Matériels et Méthodes: L’étude a été menée en 2015 et 2016 dans trois districts sanitaires de la Côte d’Ivoire. Une cartographie des acteurs impliqués dans le dépistage à base communautaire et des entretiens semi-directifs ont été réalisés auprès de dix-huit membres des ONG dites «communautaires» : coordonnateurs de projet (8), chargés de suivi et évaluation (5), superviseur des activités (1), conseillers communautaires (4). Résultats: Les deux bailleurs mettent en place des systèmes de financement qui se déclinent sous forme de chaines à plusieurs maillons d’acteurs (bailleurs, organisations intermédiaires, ONG communautaires), de trois niveaux pour le Pepfar à quatre ou cinq pour le Fonds mondial. A chaque niveau, des comptes rendus et validations des données mensuelles, trimestrielles et annuelles sont exigées comme conditions de décaissements des fonds. Leur caractère chronophage, conjugué au manque de ressources humaines et/ou techniques des ONG communautaires génèrent d’importants retards. Au final, sur une année, seuls huit à neuf mois (sur douze) sont généralement consacrés à la mise en oeuvre effective des activités de dépistage ; et chaque mois, seules deux semaines (sur quatre) y sont dédiées. Conclusion: Tandis que les bailleurs de fonds portent une attention croissante à l’obtention de données précises et actualisées dans le but d’améliorer l’efficience de leurs stratégies, celles-ci produisent des effets contre-productifs, qui tendent à nuire à la mise en oeuvre effective des activités. Un juste équilibre entre mise en oeuvre et suivi et évaluation est ainsi à trouver, en fonction des capacités humaines et techniques des acteurs.

Becquet Valentine, Nouaman Marcellin, Plazy Mélanie, Masumbuko Jean-Marie, Anoma Camille, Kouame Soh, Danel Christine, Eholie Serge Paul, Larmarange Joseph et ANRS 12361 PrEP-CI Study group (2020) « Sexual health needs of female sex workers in Côte d’Ivoire: a mixed-methods study to prepare the future implementation of pre-exposure prophylaxis (PrEP) for HIV prevention », BMJ Open, 10 (1) (janvier 1). DOI : 10/ggnfnk. https://bmjopen.bmj.com/content/10/1/e028508.

Résumé : Objective To describe sexual and reproductive health (SRH) needs of female sex workers (FSWs) to inform the future implementation of pre-exposure prophylaxis (PrEP) for HIV prevention in this population. Design and setting The ANRS 12361 PrEP-CI cross-sectional and mixed-methods study was designed and implemented with two community-based organisations in Côte d’Ivoire. Participants A convenience sample of 1000 FSWs aged ≥18, not known as HIV-positive, completed a standardised questionnaire assessing sociodemographic characteristics, sexual practices, use of community health services and a priori acceptability of PrEP. Twenty-two indepth interviews and eight focus group discussions were also conducted to document FSWs’ risky practices and sexual behaviours, experiences with violence and discrimination, attitudes regarding HIV and sexually transmitted infections (STIs), and barriers to SRH services. Results Although 87% described consistent condom use with clients, more than 22% declared accepting condomless sexual intercourse for a large sum of money. Furthermore, condom use with their steady partner and knowledge of their partner’s HIV status were low despite their acknowledged concurrent sexual partnerships. While inconsistent condom use exposed FSWs to STIs and undesired pregnancies, the prevalence of contraceptive strategies other than condoms was low (39%) due to fear of contraception causing sterility. FSWs faced obstacles to accessing SRH care and preferred advice from their peers or self-medication. Conclusions Despite adoption of preventive behaviour in most cases, FSWs are still highly exposed to HIV. Furthermore, FSWs seem to face several barriers to accessing SRH. Implementing PrEP among FSWs in West Africa, such as in Côte d’Ivoire, constitutes an opportunity to consider the regular follow-up of HIV-negative FSWs. PrEP initiation should not condition access to SRH services; conversely, SRH services could be a way to attract FSWs into HIV prevention. Our results highlight the importance of developing a people-focused approach that integrates all SRH needs when transitioning from PrEP efficacy trials to implementation.

Mots-clés : demography, epidemiology, HIV & AIDS, public health, qualitative research.

Bekelynck Anne et Larmarange Joseph (2020) « La politique de dépistage du VIH de Pepfar 3.0 en Côte d'Ivoire (2014 à 2018) : fragmentation, accélération et déconnexion », Aidspan, 96, février 28. https://www.aidspan.org/fr/node/5224.

Bekelynck Anne et Larmarange Joseph (2020) « PEPFAR’s 3.0 HIV testing policy in Côte d'Ivoire reveals fragmentation, acceleration and disconnection », Aidspan, 376, avril 1. https://www.aidspan.org/gfo_article/pepfar%E2%80%99s-30-hiv-testing-policy-c%C3%B4te-divoire-reveals-fragmentation-acceleration-and.

Boye Sokhna, Bouaré Seydou, Ky-Zerbo Odette, Rouveau Nicolas, d'Elbée Marc, Silhol Romain, Bekelynck Anne, Desclaux Alice, Larmarange Joseph et Pourette Dolorès (2020) « Challenges of HIV self-tests distribution for index testing in a context where HIV status disclosure is low: preliminary experience of the ATLAS project in Bamako, Mali » (poster), présenté à INTEREST 2020, online. http://interestworkshop.org/.

Résumé : Context and Objective: In Côte d'Ivoire, Mali and Senegal, ATLAS project has introduced HIV self-testing (HIVST) as an index testing strategy, distributing HIVST kits to people living with HIV (PLHIV) during consultations for secondary distribution to their partners. Here, we present preliminary results of an ethnographic survey conducted in one HIV clinic in Bamako, Mali, where most HIV patients have not disclosed their HIV status to their partner(s), notably for women for fear of jeopardizing their relationships. In such a context, how non-disclosure affect the distribution of HIVST kits? Method: The study was conducted from September 25 to November 27, 2019, and included individual interviews with 8 health workers; 591 observations of medical consultations; and 7 observations of patient groups discussions led by peer educators. Results: Three principal barriers to HIVST distribution for index testing were identified. (1) Reluctance of PLHIV to offer HIVST to partners to whom they have not (yet) disclosed their status and desire to learn tactics for offering testing without disclosing their HIV status. (2) Near-universal hesitancy among health workers to offer HIVST to persons who, they believe, have not disclosed their HIV status to their partner(s). (3) Absence of strategies, among health workers, to support discussion of status disclosure with PLHIV. In the rare cases where HIVST was offered to a PLHIV whose partner did not know their status, either the PLHIV declined the offer or the provider left it to the patient to find a way to deliver the HIVST without disclosing his/her status. Conclusion: HIV self-testing distribution could serve as an opportunity for PLHIV to disclose their HIV status to partners. The continuing reluctance of PLHIV to heed advice to share their status and promote secondary HIV self-testing distribution highlights the structural factors (social inequalities and stigma) that limit awareness of HIV status and that favour the persistence of the epidemic.

Boye Sokhna, Bouaré Seydou, Ky-Zerbo Odette, Rouveau Nicolas, Simo Fotso Arlette, d'Elbée Marc, Silhol Romain, Keita Adbelaye, Bekelynck Anne, Desclaux Alice, Larmarange Joseph, Pourette Dolorès et ATLAS Team (2020) « Challenges of HIV self-tests distribution for index testing in a context where HIV status disclosure is low: preliminary experience of the ATLAS project in Bamako, Mali » (poster PED1255), présenté à 23rd AIDS International Conference, San Francisco (virtual). https://cattendee.abstractsonline.com/meeting/9289/Presentation/2271.

Résumé : BACKGROUND: In Côte d''Ivoire, Mali and Senegal, ATLAS project has introduced HIV self-testing (HIVST) as an index testing strategy, distributing HIVST kits to people living with HIV (PLHIV) during consultations for secondary distribution to their partners. Here, we present preliminary results of an ethnographic survey conducted in one HIV clinic in Bamako, Mali, where most HIV patients have not disclosed their HIV status to their partner(s), notably for women for fear of jeopardizing their relationships. In such a context, how non-disclosure affect the distribution of HIVST kits? METHODS: The study was conducted from September 25 to November 27, 2019, and included individual interviews with 8 health workers; 591 observations of medical consultations; and 7 observations of patient groups discussions led by peer educators. RESULTS: Three principal barriers to HIVST distribution for index testing were identified. (1) Reluctance of PLHIV to offer HIVST to partners to whom they have not (yet) disclosed their status and desire to learn tactics for offering testing without disclosing their HIV status. (2) Near-universal hesitancy among health workers to offer HIVST to persons who, they believe, have not disclosed their HIV status to their partner(s). (3) Absence of strategies, among health workers, to support discussion of status disclosure with PLHIV. In the rare cases where HIVST was offered to a PLHIV whose partner did not know their status, either the PLHIV declined the offer or the provider left it to the patient to find a way to deliver the HIVST without disclosing his/her status. CONCLUSIONS: HIV self-testing distribution could serve as an opportunity for PLHIV to disclose their HIV status to partners. The continuing reluctance of PLHIV to heed advice to share their status and promote secondary HIV self-testing distribution highlights the structural factors (social inequalities and stigma) that limit awareness of HIV status and that favour the persistence of the epidemic.

d'Elbée Marc, Badiane Kéba, Ky-Zerbo Odette, Boye Sokhna, Kanku Kabemba Odé, Traore Mohamed, Simo Fotso Arlette, Pourette Dolorès, Desclaux Alice, Larmarange Joseph et Terris-Prestholt Fern (2020) « Can task shifting improve efficiency of HIV self-testing kits distribution? A case study in Mali » (poster), présenté à INTEREST 2020, online. http://interestworkshop.org/.

Résumé : Background: The ATLAS project introduced HIV self-testing (HIVST) in consultations of people living with HIV (PLHIV) at public health facilities in Côte d'Ivoire, Mali and Senegal for secondary distribution to their partners. Preliminary data from a qualitative study (observations of consultations, interviews with distributing agents) carried out in two clinics in Mali highlight implementation challenges associated with the counselling on self-testing and kit distribution currently done by the medical staff (doctor/nurse) and reported time-consuming. While implementation teams are considering the possibility of delegating certain tasks, it is important to consider the cost of alternative delivery models. Materials & Methods: We analysed preliminary economic costs data for the provision of rapid HIV testing services (HTS) (analysis period: October 2018 – September 2019) and HIVST services (August 2019 – October 2019) in these same two Malian clinics. Above service level costs are excluded. We then modelled the costs of provision using alternative cadres of medical and non-medical staff (psychosocial counsellors/peer educators) and the consumables used to simulate task shifting scenarios for the provision of HTS and HIVST services. The three scenarios correspond to 1. partial delegation: individual counselling done by non-medical staff and HIVST distribution by the medical staff ; 2. total delegation: individual counselling and distribution done by non-medical staff only; and 3. total delegation with group counselling: where group counselling and distribution are done by non-medical staff only. Results: Findings show that the unit costs per HIVST provided for the observed model are 58% higher than those of a conventional rapid test: $7,50 and $4.75, respectively. The costs are less high in scenarios of partial ($5.45, +15%) or total ($5.29, +11%) delegation but always higher than those of a rapid test due to the greater costs of consumables (HIVST kit). Finally, in the case where counselling on self-testing were carried out in a group, the costs per kit provided ($4.44, -6%) would become slightly lower than those of a rapid test, where counselling is always done individually. Conclusion: Task delegation from medical to non-medical staff can generate substantial cost savings. These preliminary results can guide the implementation strategy of HIVST in care consultations, to ensure sustainability from early introduction through scale-up.

Fiorentino Marion, Nishimwe Marie, Protopopescu Camelia, Iwuji Collins, Okesola Nonhlanhla, Spire Bruno, Orne-Gliemann Joanna, McGrath Nuala, Pillay Deenan, Dabis François, Larmarange Joseph, Boyer Sylvie et for the ANRS 12249 TaSP Study Group (2020) « 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) », AIDS and Behavior (novembre 18). DOI : 10.1007/s10461-020-03101-y. https://doi.org/10.1007/s10461-020-03101-y.

Résumé : 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.

Gantner Pierre, Laurent Christian, Larmarange Joseph et Ghosn Jade (2020) « Prophylaxie préexposition (PrEP) », in VIH, Hépatites virales, Santé sexuelle, par Christine Katlama, Jade Ghosn, et Gilles Wandeler, Paris : AFRAVIH, EDP sciences, p. 715-726. ISBN : 978-2-7598-2403-8. https://www.livre-afravih.org/.

Gantner et al. - 2020 - Prophylaxie préexposition (PrEP).pdf

Havlir Diane, Lockman Shahin, Ayles Helen, Larmarange Joseph, Chamie Gabriel, Gaolathe Tendani, Iwuji Collins, Fidler Sarah, Kamya Moses, Floyd Sian, Moore Janet, Hayes Richard, Petersen Maya et Dabis Francois (2020) « What do the Universal Test and Treat trials tell us about the path to HIV epidemic control? », Journal of the International AIDS Society, 23 (2) (février 24), p. e25455. DOI : 10/ggnfnb. https://onlinelibrary.wiley.com/doi/abs/10.1002/jia2.25455.

Résumé : Introduction Achieving HIV epidemic control globally will require new strategies to accelerate reductions in HIV incidence and mortality. Universal test and treat (UTT) was evaluated in four randomized population-based trials (BCPP/Ya Tsie, HPTN 071/PopART, SEARCH, ANRS 12249/TasP) conducted in sub-Saharan Africa (SSA) during expanded antiretroviral treatment (ART) eligibility by World Health Organization guidelines and the UNAIDS 90-90-90 campaign. Discussion These three-year studies were conducted in Botswana, Zambia, Uganda, Kenya and South Africa in settings with baseline HIV prevalence from 4% to 30%. Key observations across studies were: (1) Universal testing (implemented via a variety of home and community-based testing approaches) achieved >90% coverage in all studies. (2) When coupled with robust linkage to HIV care, rapid ART start and patient-centred care, UTT achieved among the highest reported population levels of viral suppression in SSA. Significant gains in population-level viral suppression were made in regions with both low and high baseline population viral load; however, viral suppression gains were not uniform across all sub-populations and were lower among youth. (3) UTT resulted in marked reductions in community HIV incidence when universal testing and robust linkage were present. However, HIV elimination targets were not reached. In BCPP and HPTN 071, annualized HIV incidence was approximately 20% to 30% lower in the intervention (which included universal testing) compared to control arms (no universal testing). In SEARCH (where both arms had universal testing), incidence declined 32% over three years. (4) UTT reduced HIV associated mortality by 23% in the intervention versus control communities in SEARCH, a study in which mortality was comprehensively measured. Conclusions These trials provide strong evidence that UTT inclusive of universal testing increases population-level viral suppression and decreases HIV incidence and mortality faster than the status quo in SSA and should be adapted at a sub-country level as a public health strategy. However, more is needed, including integration of new prevention interventions into UTT, in order to reach UNAIDS HIV elimination targets.

Mots-clés : antiretroviral therapy, HIV care continuum, HIV elimination, HIV prevention, HIV testing, public health, universal access.

Inghels Maxime, Carillon, Séverine S., Desgrées du Loû Annabel et Larmarange Joseph (2020) « Effect of organizational models of provider-initiated testing and counseling (PITC) in health facilities on adult HIV testing coverage in sub-Saharan Africa », AIDS Care, 32 (2) (février 1), p. 163-169. DOI : 10/gf3krx. https://doi.org/10.1080/09540121.2019.1626339.

Résumé : The purpose of this paper is to identify which Provider-Initiated HIV Testing and Counseling (PITC) organizational models are the most efficient to maximize testing coverage. We conducted a systematic literature review to identify published articles that evaluated routine PITC programs implemented in adult health facilities in Sub-Saharan Africa. We considered only articles measuring PITC offer, PITC acceptability and PITC coverage. Adjusted meta-regression models were performed to measure the association between PITC offer, acceptability and coverage with PITC organizational model. A total of 30 articles were included in the meta-analysis. Overall, 85.4% [95%CI: 77.2–93.5] of patients were offered a test, and 87.1% [82.4–91.7] accepted the test resulting in a PITC coverage of 74.3% [66–82.6]. Four types of PITC organizational models were identified: PITC initiated and performed during the consultation (model A), PITC initiated before consultation (model B), PITC referred on-site (model C) and PITC referred off-site (model D). Compared to model A, model B had a similar coverage (aOR: 1.02 [0.82–1.26]). However, coverage was lower for model C (aOR: 0.81 [0.68–0.97]) and model D (aOR: 0.58 [0.44–0.77]). Initiating the testing process before or during medical consultation is recommended for maximizing testing coverage among patients.

Mots-clés : HIV testing, organizational models, Provider initiated testing and counseling, Sub-Saharan Africa, testing cover.

Inghels Maxime, Kouassi Arsène Kra, Niangoran Serge, Bekelynck Anne, Carillon Séverine, Sika Lazare, Danel Christine, Kone Mariatou, Desgrées du Loû Annabel, Larmarange Joseph et ANRS 12323 DOD-CI Study Group (2020) « Cascade of Provider-Initiated Human Immunodeficiency Virus Testing and Counselling at Specific Life Events (Pregnancy, Sexually Transmitted Infections, Marriage) in Côte d'Ivoire », Sexually Transmitted Diseases, 47 (1) (janvier), p. 54-61. DOI : 10/ggnfnh.

Résumé : BACKGROUND: Despite the implementation of Provider Initiated Testing and Counselling (PITC) in 2009, PITC coverage remains low in Cote d'Ivoire. The purpose of this study is to determine whether an human immunodeficiency virus (HIV) test was offered and performed at specific life events where PITC is recommended by national guidelines. METHODS: In 2017, a cross-sectional telephone survey was conducted among a representative sample of 3,867 adults from the general population in Côte d'Ivoire. The occurrences of the following events over the past 5 years were documented: pregnancy (event A) or partner's pregnancy (event B) of the last child, sexually transmitted infection (event C) and marriage (event D). For each of these events, participants were asked (i) if they consulted a health care professional, (ii) if they were offered an HIV test during that consultation and (iii) if they accepted it. RESULTS: Consulting a health care provider was reported by 94.9%, 58.3%, 70.3% and 19.1% of those who reported events A, B, C and D respectively. In case of medical consultations following events A, B, C and D, respectively 70.1%, 33.1%, 28.1%, and 78.8% of individuals were offered an HIV test. The testing acceptance was high regardless of the event. Overall, testing coverage was 63.7%, 16.9%, 13.4% and 14.5% for events A, B, C and D respectively. CONCLUSIONS: Increasing HIV testing coverage in Côte d'Ivoire requires (i) facilitating attendance to health services in case of sexually transmitted infections, marriage and pregnancy-for men-and (ii) strengthening routine testing offer on these occasions.

Inghels Maxime, Kouassi Arsène Kra, Niangoran Serge, Bekelynck Anne, Carillon Séverine, Sika Lazare, Danel Christine, Kone Mariatou, Desgrees du Lou Annabel, Larmarange Joseph et for the ANRS 12323 DOD-CI Study Group (2020) « Practices and Obstacles to Provider-Initiated HIV Testing and Counseling (PITC) Among Healthcare Providers in Côte d’Ivoire », AIDS and Behavior (mai 24). DOI : 10.1007/s10461-020-02923-0. https://doi.org/10.1007/s10461-020-02923-0.

Résumé : Practices of Provider-Initiated HIV Testing and Counseling (PITC) remains suboptimal in Côte d’Ivoire. The aim of this survey was to identify the practices and obstacles to PITC among healthcare professionals in Côte d'Ivoire. A nationally representative cross-sectional survey was conducted in 2018 by telephone among three separate samples of midwives, nurses and physicians practicing in Côte d'Ivoire. The number of HIV tests proposed during consultation in the month preceding the survey was collected for each professional. Factors associated with the number of proposed tests were identified through ordinal logistic regression models. A total of 298 midwives, 308 nurses and 289 physicians were interviewed. Midwives proposed the test more frequently, followed by nurses and physicians. Among midwives, a higher number of proposed tests was associated with the perception that HIV testing does not require specific consent compared to other diseases (aOR 4.00 [95% CI 1.37–14.29]). Among nurses, having received HIV training and the presence of community HIV counselors were associated with a higher number of proposed tests (aOR 2.01 [1.31–3.09] and aOR 1.75 [1.14–2.70], respectively). For physicians, the presence of a voluntary testing center was associated with a higher number of proposed tests (aOR 1.69 [1.01–2.86]). PITC practices and barriers differed across professions. Beyond improving environmental opportunities such as dedicated staff or services, strengthening the motivations and capabilities of healthcare professionals to propose testing could improve PITC coverage.

Inghels Maxime, Kouassi Arsène Kra, Niangoran Serge, Bekelynck Anne, Carillon Séverine, Sika Lazare, Koné Mariatou, Danel Christine, Desgrées du Loû Annabel et Larmarange Joseph (2020) « Perceptions, préférences et recours aux offres communautaires de dépistage du VIH chez les hommes ayant des relations sexuelles avec d’autres hommes (HSH) en Côte d’Ivoire » (communication orale (session SPD1), présenté à AFRAVIH 2020, Dakar. http://www.afravih2020.org/.

Résumé : Objectifs Depuis la fin des années 2000, se sont développées des offres de dépistage dédiées à destination des HSH. Portées par des ONG communautaires et favorisées par la formation de pairs éducateurs à la réalisation de tests rapides, ce dépistage communautaire serait plus adapté pour atteindre cette population. Mais qu’en est-il du point de vue des intéressés eux-mêmes ? Matériels et Méthodes Une enquête par téléphone de type Respondent driven sampling (RDS) auprès de 518 HSH a été réalisée en 2018 en Côte d’Ivoire. Le questionnaire portait, entre autres, sur la connaissance, la pratique, la satisfaction et les préférences concernant les offres de dépistage dédiées aux HSH. Résultats Seule la moitié des enquêtés (47 %) ont déclaré connaître un lieu de dépistage dédié aux HSH. Parmi ceux-ci, 79 % en avaient déjà fréquenté un. Ces derniers ont rapporté avoir été bien accueillis, s’être sentis en confiance, que la confidentialité avait été respectée et 95 % ont déclaré qu’ils y retourneraient. En termes de préférences, 37 % des enquêtés ont déclaré préférer les lieux de dépistage indifférenciés (c.-à-d. accueillant tout type de patient), 34 % les lieux communautaires et 29 % sans préférence. Ceux préférant le dépistage communautaire mentionnaient une meilleure écoute et s’y sentir plus en confiance, notamment du fait de la présence d’autres HSH. À l’inverse, ceux préférant une offre généraliste mentionnaient le manque de discrétion et d’anonymat des offres communautaires et vouloir éviter le regard des autres. Les hommes les plus éloignés du « milieu HSH », se définissant comme bisexuels/hétérosexuels, attirés principalement par des femmes, ne connaissant pas une association HSH ou n’ayant pas dévoilé leur homosexualité ont plus tendance à préférer un lieu généraliste. Conclusion Si le dépistage communautaire est bien adapté aux HSH qui y ont recours, le maintien d’une offre de dépistage indifférenciée reste essentiel.

Inghels Maxime, Kouassi Arsène Kra, Niangoran Serge, Bekelynck Anne, Carillon Séverine, Sika Lazare, Koné Mariatou, Danel Christine, Desgrées du Loû Annabel et Larmarange Joseph (2020) « Perceptions, preferences and access to community-based HIV testing services among Men who have Sex with Men (MSM) in Côte d'Ivoire » (communication orale (présentation orale de poster), présenté à INTEREST 2020, online. http://interestworkshop.org/.

Résumé : Background: Dedicated HIV testing settings have been developed for Men who have Sex with Men (MSM) since the end of the 2000s. These facilities are supported by community-based NGOs and promoted by peer educators, who are trained in the use of rapid HIV tests. As such, this community-based HIV-testing should be adapted to reach the MSM populations. However, little is known about the direct MSM’ point of view regarding such community-based services. Materials and methods: A respondent-driven sampling telephone survey of 518 MSM was conducted in 2018 in Côte d'Ivoire. The questionnaire examined knowledge, practice, satisfaction, and preferences regarding MSM-community-based HIV testing services. Results: Only half of the respondents (47%) reported knowing a community-based HIV testing site dedicated to MSM. Of these, 79% had already attended one. They reported that they were welcomed, that they felt confident, that confidentiality was respected, and 95% said they would return to one of these sites. In terms of preferences, 37% of respondents said they preferred undifferentiated HIV testing sites (i.e., “all patients” or “general population” HIV testing sites), 34% preferred community-based sites, and 29% had no preference. Those who preferred community-based HIV testing reported better listening and feeling more confident, particularly because of the presence of other MSM. Conversely, those preferring undifferentiated HIV testing sites mentioned the lack of discretion and anonymity of community-based sites and wanting to avoid the gaze of others. They feared to be recognized by other patients in a context where they want to keep secret their sexual preferences. Men who were furthest away from the MSM community, defining themselves as bisexual/heterosexual, attracted primarily to women, not knowing a dedicated MSM NGO, or not having disclosed their homo/bisexuality to one member of their family were more likely to prefer undifferentiated HIV testing sites. Conclusion: Community-based HIV testing is well suited for MSM who identify as homosexual and those close to the MSM community while maintaining undifferentiated HIV testing is essential for others. Both types of activities need to be maintained and developed. It is also crucial that healthcare professionals in undifferentiated HIV testing sites are properly trained in non-judgemental reception of people with diverse sexual practices and identities.

Kouadio Brou Alexis, Carillon Séverine, Bekelynck Anne, Assi Adjoa Nelly Assoumou, Danel Christine, Ouantchi Honoré, Doumbia Mohamed, Koné Mariatou, Larmarange Joseph et Anrs 12323 Équipe projet DOD-CI (2020) « Dépistage du VIH hors les murs en Côte d’Ivoire : des prestataires communautaires sous pression », Sante Publique, Vol. 32 (1) (juin 29), p. 103-111. https://www.cairn.info/revue-sante-publique-2020-1-page-103.htm.

Résumé : Contexte : Les stratégies de dépistage du virus de l’immunodéficience humaine (VIH) « hors les murs » ont fortement contribué à augmenter le nombre des personnes connaissant leur statut sérologique en Afrique subsaharienne. Cet article analyse l’articulation entre les exigences des bailleurs et les contraintes du terrain dans le cadre de la mise en oeuvre du dépistage hors les murs en Côte d’Ivoire. Méthodes : Une recherche qualitative a été menée dans trois districts sanitaires de Côte d’Ivoire (Man, Cocody-Bingerville et Aboisso) en 2015-2016. Les données étaient issues d’entretiens conduits auprès de prestataires communautaires d’organisations non gouvernementales (ONG) d’exécution, et de personnes dépistées, ainsi que par l’observation d’activités de dépistage du VIH hors les murs. Résultats : Les organisations d’exécution se sentent « sous pression » face aux objectifs des bailleurs jugés inatteignables et au déficit de formation et de financement. Dès lors, les prestataires n’observent pas systématiquement les règles en matière de conseil, consentement éclairé et confidentialité, dites des « trois C », et dépistent des personnes « hors cibles » (géographiques et populationnelles). Discussion : Deux types de contraintes pèsent sur les ONG d’exécution : celles issues du fonctionnement de l’aide internationale (financements inadéquats par rapport aux coûts réels, objectifs trop élevés, chaîne d’intermédiaires importante) et celles liées au contexte local (espaces non adaptés pour garantir la confidentialité et activité professionnelle des populations cibles). Conclusion : Les pressions que subissent à différents niveaux les ONG d’exécution se font au détriment de la qualité du dépistage. Il apparaît aujourd’hui essentiel de développer une approche plus qualitative dans la définition des stratégies et de ses critères d’évaluation.

Ky-Zerbo Odette, Desclaux Alice, Doumenc Aïdara Clémence, Rouveau Nicolas, Boye Sokhna, Kanku Kabemba Odé, Diallo Sanata, Geoffroy Olivier, Kouadio Brou Alexis, Sow Jules Souleymane, Camara Cheick Sidi et Larmarange Joseph (2020) « “When you provide an HIV self-testing kit […] you also need to know the results”: lay providers’ concerns on HIV self-testing provision to peers, ATLAS project » (poster), présenté à INTEREST 2020, online. http://interestworkshop.org/.

Résumé : Background: HIV self-testing (HIVST) is a process in which a person collects his or her own specimen (oral fluid or blood), using a simple rapid HIV test and then performs the test and interprets the result, often in a private setting, either alone or with someone he/she trusts (WHO, 2018). HIVST is convenient to reach stigmatized groups such as key populations. In the ATLAS project, provision of HIVST kits is done by lay providers to sex workers, drug users and men who have sex with men, or through secondary distribution by primary contacts to their partners and other peers. There is a shifting of paradigm because the result of an HIVST is not necessarily shared with the lay provider. How do lay providers responsible for HIVST kits distribution to key populations in West Africa adopt this new testing strategy? This abstract discusses the concerns of lay providers who offer HIVST kits to peers in the ATLAS Project (Cote d’Ivoire, Mali and Senegal). Material and Methods: We conducted seven focus group discussions with fifty-six lay providers who had experience in offering HIVST to peers (sex workers, men who have sex with men, drug users) in the three countries two months after the ATLAS project started. Results: Lay providers report no major opposition or conflict in offering HIVST kits. Testimonies from primary recipients also suggest that the HIVST was performed correctly in the case of secondary distribution. However, lay providers’ concerns remain with the lack of knowledge of the self-test results. In previous HIV testing strategies, providers usually played a key role to support their client during pre- and post-test counselling, especially when the test result was positive. Therefore, their question is how can they continue to support peers while respecting the private nature of self-testing? The concern is at two levels. At the individual level, lay providers fear that the continuum of care is not guaranteed and peers who self-test with a reactive test result may stay alone. At the collective level, lay providers fear to miss their performance objectives linked to the number of new HIV-positive cases they found and requested by some donors. Consequently, alongside HIVST provision, lay providers share their phone numbers, call back their primary recipients, or apply other indirect strategies to know the self-test result of their recipients. Conclusion: Lay providers develop strategies to learn about the issue of the HIVST they offer and to provide support to their peers following HIVST provision. Is this behaviour related to a cultural context that values social relationships or a sign of empathy to key populations and people living with HIV in a context of high stigmatization? Or is it related to existing performance objectives for new HIV-positive cases finding requested by donors? The meanings of this practice call for a deep reflection on whether or not the WHO guidelines need to be adapted to this context.

Larmarange Joseph (2020) « Catégories épidémiologiques, catégories sociales et catégories d'actions : doit-on repenser les "populations clés" de la lutte contre le VIH ? » (communication orale), présenté à Conférence Anthropo-Med "Dissonances et Convergences entre Anthropologie et Santé Publique", Marseille. https://imera.univ-amu.fr/fr/conference-anthropo-med-dissonances-convergences-entre-anthropologie-sante-publique.

Résumé : Dans de nombreux pays, les populations clés (en particulier les hommes ayant des rapports sexuels avec d'autres hommes, les professionnel(le)s du sexe et les consommateurs de drogues) sont massivement touchées par le VIH et de nombreux programmes se concentrent sur elles. En raison de la modélisation épidémiologique et de la planification des politiques, ces groupes sont trop souvent considérés comme des groupes socialement homogènes plutôt que des catégories hétérogènes aux contours flous. Les identités, la vie sociale, les pratiques sexuelles, l'exposition au VIH varient au sein de ces groupes, en particulier entre le noyau et les périphériques. Leurs réseaux sexuels sont également interconnectés avec des personnes qui ne sont pas perçues comme appartenant à ces "populations clés" : partenaires féminines d'hommes bisexuels, partenaires réguliers et clients de professionnel(le)s du sexe, partenaires sexuels de consommateurs de drogues... Entre les catégories épidémiologiques, les catégories sociales et identitaires et les catégories d'action, comment pouvons-nous appréhender la diversité des populations clés ? La notion de populations périphériques peut-elle faire sens ? Quel est le rôle de ces populations périphériques dans la dynamique des populations clés et comment les prendre en compte dans la riposte au VIH ?

Larmarange Joseph (2020) « Comment déployer la PrEP ? » (communication orale ML1.1), présenté à AFRAVIH, Dakar. http://www.afravih2020.org/.

Larmarange Joseph (2020) « (re)penser la prévention des populations clés ? » (communication orale en session plénière), présenté à AFRAVIH, Dakar. http://www.afravih2020.org/.

Larmarange Joseph (2020) « L’autotest est-il une réponse à l’accès aux soins en temps de COVID-19 ? Opportunités et défis » (communication orale), présenté à Séminaire scientifique virtuel de l’IAS Educational Fund : Comment atteindre les populations clés du VIH pendant la pandémie COVID-19 en Afrique de l'ouest et du centre ?, en ligne. https://joseph.larmarange.net/?article283.

Larmarange Joseph (2020) « Le Traitement antirétroviral comme moyen de prévention (TasP) », in VIH, Hépatites virales, Santé sexuelle, par Christine Katlama, Jade Ghosn, et Gilles Wandeler, Paris : AFRAVIH, EDP sciences, p. 702-711. ISBN : 978-2-7598-2403-8. https://www.livre-afravih.org/.

Larmarange - 2020 - Le Traitement antirétroviral comme moyen de préven.pdf

Larmarange Joseph (2020) « Prévention du VIH - Introduction », in VIH, Hépatites virales, Santé sexuelle, par Christine Katlama, Jade Ghosn, et Gilles Wandeler, Paris : AFRAVIH, EDP sciences, p. 683-686. ISBN : 978-2-7598-2403-8. https://www.livre-afravih.org/.

Larmarange - 2020 - Prévention du VIH - Introduction.pdf

Niangoran Serge, Inghels Maxime, Kouassi Arsène Kra, Bekelynck Anne, Carillon Séverine, Sika Lazare, Danel Christine, Koné Mariatou et Larmarange Joseph (2020) « Physicians' knowledge of Hepatitis B and C in Côte d'Ivoire » (poster), présenté à INTEREST 2020, online. http://interestworkshop.org/.

Résumé : Background: Viral hepatitis is a major public health problem in Côte d'Ivoire, with a prevalence of 8% to 10% for hepatitis B and 1% for hepatitis C. Research indicates that there is a lack of awareness of hepatitis in the general population; however, there remains little evidence concerning physician’s knowledge of the virus. We, thus, investigate physician’s knowledge on viral hepatitis B and C, which can be the first condition for screening and treatment. Materials and methods: In 2018, we conducted a cross-sectional Knowledge, Attitudes and Practices (KAP) telephone survey on a random sample of physicians working in health facilities in Côte d'Ivoire. Data collected included an assessment of knowledge about viral hepatitis B and C and their personal attitudes towards hepatitis screening and vaccination. We created a knowledge score based on 14 variables (screening test variables, HBV viral load variables, treatment indications variables, treatment availability and associated costs variables) and identified the associated factors using a multivariate Poisson model. Results: Among the 542 physicians contacted, 316 physicians participated in the survey (58%). The vast majority of doctors spontaneously cited cirrhosis (79%) and liver cancer (77%) as the main complications of viral hepatitis. Screening modalities were also well known. Knowledge of modes of transmission and prevention were uneven : blood transmission 88%, sexual 78%, saliva 27%, during pregnancy or childbirth 20%. Physicians' knowledge of the prevalence of hepatitis B and hepatitis C in the population remains very limited (32% indicates between 5% and 15% for HBV while 33% indicates less than 5% for HCV) In terms of treatment, less than half knew the conditions for initiating hepatitis B treatment (42%) or the existence of curative treatment for hepatitis C (34%). Similarly, few knew the cost of associated treatments or tests (23%), such as HBV viral load (17%). A higher knowledge score was associated with having a close relative infected by viral hepatitis (RR=1.09 [1.00 – 1.19], p=0.052), receiving training on viral hepatitis (RR=1.16 [1.04 – 1.29], p=0,008) and testing for any viral hepatitis (RR=1.16 [1.04 – 1.29], p=0.008). Conclusion: The fight against viral hepatitis requires the involvement of physicians. Findings suggest that many physicians are in need of ongoing training on prevention and treatment of viral hepatitis.

Niangoran Serge, Inghels Maxime, Kouassi Arsène Kra, Bekelynck Anne, Carillon Séverine, Sika Lazare, Koné Mariatou, Desgrées du Loû Annabel et Larmarange Joseph (2020) « Connaissances des médecins sur les hépatites virales B et C en Côte d’Ivoire et facteurs associés » (poster PL189), présenté à AFRAVIH 2020, Dakar. http://www.afravih2020.org/.

Résumé : Objectifs Avec une prévalence de 8% à 10% pour l’hépatite B et de 1% pour l’hépatite C, les hépatites virales constituent un problème de santé publique majeur en Côte d’Ivoire. Alors que ces infections sont mal connues en population générale, qu’en est-il des médecins ? Matériels et Méthodes Une enquête transversale par téléphone a été réalisée en 2018 auprès d’un échantillon aléatoire de 316 médecins exerçant dans des structures de santé en Côte d’Ivoire. Le questionnaire administré portait notamment sur l’évaluation des connaissances sur les hépatites virales B et C ainsi que leurs attitudes personnelles face au dépistage et à la vaccination. Un score de connaissance a été créé à partir de 14 variables (figure) et les facteurs associés ont été mesurés à l’aide d’un modèle multivarié de Poisson. Résultats La grande majorité des médecins citent spontanément la cirrhose et le cancer du foie comme principales complications des hépatites virales. Les modalités de dépistage sont également bien connues. Les connaissances en termes de modes de transmission et de moyens de prévention sont inégales, tandis qu’un tiers a une idée des prévalences des hépatites B et C en Côte d’Ivoire. En matière de prise en charge, moins de la moitié connaît les indications de traitement pour l’hépatite B ou l’existence d’un traitement curatif pour l’hépatite C (figure). De même, peu connaissent les coûts des traitements ou des examens comme la charge virale VHB. Le score de connaissances varie selon le type de structure, le sexe, le fait de connaître un proche porteur d’une hépatite virale, le fait qu’une ONG intervienne ou non dans la structure de santé, avoir suivi une formation sur les hépatites virales et le fait de s’être soi-même fait dépister. Conclusion La lutte contre les hépatites virales passe nécessairement par une implication accrue de l’ensemble des médecins, et notamment par des formations continues à la prévention et à la prise en charge qui doivent être développées.

Petersen Maya, Larmarange Joseph, Wirth Kathleen E, Skalland Timothy, Ayles Helen, Kamya Moses, Lockman Shahin, Iwuji Collins, Dabis François, Makhema Joseph, Havlir Diane, Floyd Sian, Hayes Richard et UT3C Consortium (2020) « Population-level Viremia Predicts HIV Incidence across the Universal Test and Treat Studies » (communication orale), présenté à Conference on Retroviruses and Opportunitic Infections (CROI), Boston. http://www.croiconference.org/sessions/population-level-viremia-predicts-hiv-incidence-across-universal-test-treat-studies.

Résumé : Improved understanding of the extent to which increased population-level viral suppression will reduce HIV incidence is needed. Using data from four large Universal Test and Treat Trials, we evaluated the relationship between viremia and incidence and its consistency across epidemic contexts. We analyzed data from 105 communities in the PopART (21 communities in South Africa and Zambia, ~ 25,000 adults each), BCPP (30 communities in Botswana, ~3,600 adults each), ANRS 12249 TasP (22 communities in South Africa, ~1,300 adults each) and SEARCH (32 communities in Uganda and Kenya, ~5,000 adults each) studies. Communities ranged from rural to urban and varied in the mobility of their populations and their sex ratio (~30% to 50% male). HIV incidence was measured via repeat testing between 2012-2018. Population viremia – % of all adults (HIV+ or HIV-) with HIV viremia – was estimated at midpoint of follow-up based on HIV prevalence and non-suppression among HIV+, with adjustment for differences between the measurement cohort and underlying population. Community-level regression, adjusted for study, was used to quantify the association between HIV incidence and viremia and to evaluate cross-study heterogeneity. HIV prevalence (measured in 257,929 total persons, PopART: 37,006; BCPP: 12,570; TasP: 20,978; SEARCH: 187,375), ranged from 2% to 40% by community. Non-suppression among HIV+ (measured in 39,928 persons, PopART: 6,233; BCPP: 2,318; TasP: 6,617; SEARCH: 16,209) ranged from 3% to 70%. HIV incidence (measured over 345,844 person-years, PopART: 39,702; BCPP: 8,551; TasP: 26,832; SEARCH: 270,759) ranged from 0.03 to 3.4 per 100PY. Population-level viremia was strongly associated with HIV incidence; pooling across studies, HIV incidence decreased by 0.07/100PY (95% CI: 0.05,0.10, p<0.001) for each 1% absolute decrease in viremia. Incidence was significantly associated with viremia in each study; however, both strength of the incidence-viremia relationship (slope) and projected incidence at 0% viremia (intercept) differed (Figure). Lower population-level HIV viremia was associated with lower HIV incidence in all four Universal Test and Treat Studies, conducted in a wide range of epidemic contexts in sub-Saharan Africa. Differences in external infection rate (due to variation in community size, mobility, and sex ratio) may have contributed to heterogeneity between studies.

Vautier Anthony, Rouveau Nicolas, Diallo Sanata, Traore Marinette, Geoffroy Olivier, Kanku Kabemba Odé, Doumenc Aïdara Clémence et Larmarange Joseph (2020) « Is manufacturer’s Instructions-For-Use sufficient in a multilingual and low literacy context? The example of HIV self-testing in West Africa » (poster), présenté à INTEREST 2020, online. http://interestworkshop.org/.

Résumé : Background: The ATLAS project aims to promote the use of HIV self-testing (HIVST) in Côte d'Ivoire, Mali and Senegal. In order to ensure accurate HIVST use, it was necessary to evaluate if the manufacturer’s Instructions-For-Use (IFUs), standardized at the international level, provides complete, accessible and adapted information in the 3 countries’ contexts. Materials & Methods: In December 2018, cognitive interviews were conducted with 64 participants, mostly Men who have Sex with Men (40,6%) and Female Sex Workers (43,8%) in Côte d'Ivoire, Mali and Senegal. Among them, 17,2 % never performed HIV test before and 38% of participants cannot read. They were invited to perform an oral HIVST (OraQuick®) and were requested, at each step of the procedure to share their understanding of the IFU for HIVST use, of the result interpretation and of related actions to be taken. All participants had in hands the manufacturer's IFUs in French, including the free national hotline number. Half of them additionally received manufacturer's demonstration video translated into local languages. Directive interviews guide included 50 questions to collect participants’ perception of what was missing or unclear in the supporting tools. The methodology was validated with all national AIDS programmes and ministries of health. Results: Out of 64 HIVST performed, 5 results were positive (7,8%) and confirmed with additional tests. Overall, the IFU was well understood: 58 participants (92%) were able to interpret their HIVST result correctly without assistance. However, some misuses were observed at various stages, particularly for people who cannot read, with some instructions misunderstood or perceived as not adapted. Only participants who can read have access to information as “do not eat” or “do not use the test if you are on ART” as it is not illustrated in the IFUs. Most of the participants did not spontaneously identify the promotion of the free hotline number and/or the link to the demonstration video. Some procedure’s steps were misinterpreted: 7 participants (11%) did not swab correctly the flat pad along the gum, 3 participants (5%) have read the result at inaccurate time (at 20 seconds, at 5 minutes or after 40 minutes), 13 participants (20%) did not put the stand (for the tube including the liquid) in the right way and 8 other participants struggled to slide tube into the stand. Among 42 participants who can not read and/or who had not seen the video beforehand, 14 of them (33%) had at least one difficulty to interpret the result or to understand what to do after the test/result. On the other hand, the results of the cognitive interviews showed that demonstration video provides a real added value to the user’s understanding and accurate HIVST use (31 participants out of 32 found it very easy to understand with 9 of them who felt they do not need the IFUs if they previously watched the demonstration video). The video translation into local languages, produced by the ATLAS project, was very much appreciated by the participants. Conclusion: The manufacturer's IFUs alone appear not to be sufficient in a multilingual, low-literacy context to ensure accurate HIVST use. Access to additional supporting tools (complementary leaflet, demonstration video or free hotline) is essential in the 3 countries’ contexts.