Bibliographie

2021


  • Abo Yao, Altman Mathias, Bekelynck Anne, Dahourou Désiré, Simo Fotso Arlette, Godin Zélie, Kadio Kadidiatou, Larmarange Joseph, Sondo Apoline et Valentin Louis (2021) Connaissances, attitudes et pratiques liées à la pandémie COVID-19 des médecins au Burkina Faso Vague 2 : septembre - décembre 2020, Policy brief (2), Ouagadougou : Aphro-Cov, 6 p. https://aphro-cov.com/ressources_liste/connaissances-attitudes-et-pratiques-liees-a-la-pandemie-covid-19-des-medecins-au-burkina-faso-vague-2/.
    Résumé : CAP-CoV-BF : une enquête nationale réalisées auprès des médecins au Burkina Faso Le personnel de santé se trouve au cœur du dispositif élaboré dans le cadre de la réponse à l’épidémie de COVID-19, à la fois en tant qu’acteur essentiel du dispositif de réponse à l’épidémie, et en tant que premières personnes exposées et victimes. Il est ainsi essentiel de s’assurer de la compréhension de cette maladie (symptômes, modes de transmission, mesures de prévention, etc.) et de l’acceptabilité et de l’adaptation des médecins du Burkina Faso face aux mesures de santé publique préconisées. Cela permet d’identifier les difficultés et les barrières qu’ils rencontrent afin d’adopter les mesures de protection adéquates, proposer des interventions adaptées pour les surmonter et prioriser les messages qui leur sont destinés. L’objectif principal de cette étude est de fournir aux acteurs nationaux impliqués dans la gestion de la crise des données probantes régulières et représentatives à l’échelle nationale sur les connaissances, attitudes et pratiques des médecins au Burkina Faso. Une enquête quantitative transversale par téléphone a été mise en place auprès d’un échantillon représentatif de médecins sur l’ensemble du territoire. Une 1ère enquête a été menée en septembre 2020 (n=166) et une 2ème en décembre 2020 (n=190).
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  • Abo Yao, Altman Mathias, Bekelynck Anne, Dahourou Désiré, Simo Fotso Arlette, Godin Zélie, Kadio Kadidiatou, Larmarange Joseph, Sondo Apoline et Valentin Louis (2021) Connaissances, attitudes et pratiques liées à la pandémie COVID-19 des médecins au Burkina Faso - Enquêtes 1, 2 et 3 : septembre 2020 - décembre 2020 – février 2021, Policy brief (3), Ouagadougou : Aphro-Cov, 6 p. https://aphro-cov.com/ressources_liste/enquete-cap-cov-bf-resultats-des-3-vagues-denquete-et-evolutions-observees/.
    Résumé : CAP-CoV-BF : une enquête nationale réalisées auprès des médecins au Burkina Faso Le personnel de santé se trouve au cœur du dispositif élaboré dans le cadre de la réponse à l’épidémie de COVID-19, à la fois en tant qu’acteur essentiel du dispositif de réponse à l’épidémie, et en tant que premières personnes exposées et victimes. Il est ainsi essentiel de s’assurer de la compréhension de cette maladie (symptômes, modes de transmission, mesures de prévention, etc.) et de l’acceptabilité et de l’adaptation des médecins du Burkina Faso face aux mesures de santé publique préconisées. Cela permet d’identifier les difficultés et les barrières qu’ils rencontrent afin d’adopter les mesures de protection adéquates, proposer des interventions adaptées pour les surmonter et prioriser les messages qui leur sont destinés. L’objectif principal de cette étude est de fournir aux acteurs nationaux impliqués dans la gestion de la crise des données probantes régulières et représentatives à l’échelle nationale sur les connaissances, attitudes et pratiques des médecins au Burkina Faso. Une enquête quantitative transversale par téléphone a été mise en place auprès d’un échantillon représentatif de médecins sur l’ensemble du territoire. Une 1ère enquête a été menée en septembre 2020 (n=166) et une 2ème en décembre 2020 (n=190).
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  • Boye Sokhna, Bouaré Seydou, Ky-Zerbo Odette, Rouveau Nicolas, Simo Fotso Arlette, d'Elbée Marc, Silhol Romain, Maheu-Giroux Mathieu, Vautier Anthony, Breton Guillaume, Keita Abdelaye, Bekelynck Anne, Desclaux Alice, Larmarange Joseph et Pourette Dolorès (2021) « Challenges of HIV Self-Test Distribution for Index Testing When HIV Status Disclosure Is Low: Preliminary Results of a Qualitative Study in Bamako (Mali) as Part of the ATLAS Project », Frontiers in Public Health, 9 (mai 19). DOI : 10.3389/fpubh.2021.653543. https://www.frontiersin.org/articles/10.3389/fpubh.2021.653543/full?&utm_source=Email_to_authors_&utm_medium=Email&utm_content=T1_11.5e1_author&utm_campaign=Email_publication&field=&journalName=Frontiers_in_Public_Health&id=653543.
    Résumé : The rate of HIV status disclosure to partners is low in Mali, a West African country with a national HIV prevalence of 1.2%. HIV self-testing (HIVST) could increase testing coverage among partners of people living with HIV (PLHIV). This study aims to improve our understanding of the practices, limitations and issues related to the distribution of HIV self-tests at an HIV care clinic in Bamako, Mali. An ethnographic survey was conducted in 2019. It consisted of (i) individual interviews with 8 health professionals involved in the distribution of HIV self-tests; (ii) 591 observations of medical consultations, including social service consultations, with PLHIV; (iii) 7 observations of peer educator-led PLHIV group discussions. HIVST was discussed in only 9% of the observed consultations (51/591). When HIVST was discussed, the discussion was almost always initiated by the health professional rather than PLHIV. HIVST was discussed infrequently because in most of the consultations, it was not appropriate to propose partner HIVST (e.g., when PLHIV were widowed, did not have partners, or had delegated someone to renew their prescriptions). Some PLHIV had not disclosed their HIV status to their partners. Dispensing HIV self-tests was time-consuming, and medical consultations were very short. Three main barriers to HIV self-test distribution when HIV status had not been disclosed to partners were identified: (1) almost all health professionals avoided offering HIVST to PLHIV when they thought or knew that the PLHIV had not disclosed their HIV status to partners; (2) PLHIV were reluctant to offer HIVST to their partners if they had not disclosed their HIV-positive status to them; (3) there was limited use of strategies to support the disclosure of HIV status. In conclusion, it is essential to strengthen strategies to support the disclosure of HIV+ status. It is necessary to develop a specific approach for the provision of HIV self-tests for the partners of PLHIV by rethinking the involvement of stakeholders. This approach should provide them with training tailored to the issues related to the (non)disclosure of HIV status and gender inequalities, and improving counseling for PLHIV.
    Mots-clés : HIV self-testing, HIV status disclosure, Index testing, Knowledge of HIV status, Mali, Partners of PLHIV, People living with HIV, Screening -.
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  • d'Elbée Marc, Traore Métogara Mohamed, Badiane Kéba, Vautier Anthony, Simo Fotso Arlette, Kabemba Odé Kanku, Rouveau Nicolas, Godfrey-Faussett Peter, Maheu-Giroux Mathieu, Boily Marie-Claude, Medley Graham Francis, Larmarange Joseph, Terris-Prestholt Fern et ATLAS Team (2021) « Costs and Scale-Up Costs of Integrating HIV Self-Testing Into Civil Society Organisation-Led Programmes for Key Populations in Côte d'Ivoire, Senegal, and Mali », Frontiers in Public Health, 9 (mai 24). DOI : 10.3389/fpubh.2021.653612. https://www.frontiersin.org/articles/10.3389/fpubh.2021.653612/full.
    Résumé : Despite significant progress on the proportion of individuals who know their HIV status in 2020, Côte d’Ivoire (76%), Senegal (78%), and Mali (48%) remain far below, and key populations (KP) including female sex workers (FSW), men who have sex with men (MSM), and people who use injectable drugs (PWuID) are the most vulnerable groups with a HIV prevalence at 5%-30%. HIV self-testing (HIVST), a process where a person collects his/her own specimen, performs an HIV test, and interprets the result, was introduced in 2019 as a new testing modality through the ATLAS project coordinated by the international partner organisation Solthis (IPO). In this paper, we estimate the costs of implementing HIVST through twenty-three civil society organisations (CSO)-led models for KP in Côte d’Ivoire (N=7), Senegal (N=11), and Mali (N=5). We modelled costs for programme transition (2021) and early scale-up (2022-2023). Between July 2019 and September 2020, a total of 51,028, 14,472 and 34,353 HIVST kits were distributed in Côte d’Ivoire, Senegal, and Mali, respectively. Across countries, 64%-80% of HIVST kits were distributed to FSW, 20%-31% to MSM, and 5%-8% to PWuID. Average costs per HIVST kit distributed ranged $12-$15 (FSW), $14-$27 (MSM), and $15-$143 (PWuID), driven by personnel costs at various intervention levels (53%-78% of total costs), and HIVST kits costs (2%-15%). Estimated average costs at scale-up ranged $6-$13 (FSW), $6-$23 (MSM), and $14-$50 (PWuID), and were mainly explained by the spreading of IPO costs over higher HIVST distribution volumes. In all three countries, CSO-led HIVST kit provision to KP showed relatively high costs during the study period related to the progressive integration of the programme to CSO activities and contextual challenges (COVID-19 pandemic, country safety concerns). The analysis of costs at scale suggests that, in the transition to scale-up and further integration of the HIVST programme into CSO existing activities, this model can evolve into an affordable HIV testing strategy. This is particularly relevant as it remains today the most promising strategy for reaching KP of the HIV epidemic, their sexual partners, and FSW clients not accessing HIV testing. Further research will assess the overall cost-effectiveness of this model.
    Mots-clés : Costs and Cost Analysis, Côte d'Ivoire, diagnosis, Female sex workers, HIV self-testing, Key populations, Knowledge of HIV status, Mali, Men who have sex with men, People who use injectable drugs, Scale-up, screening, Senegal, West Africa.
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  • Inghels Maxime, Kouassi Arsène Kra, Niangoran Serge, Bekelynck Anne, Carillon Séverine, Sika Lazare, Koné Mariatou, Danel Christine, Desgrées du Loû Annabel, Larmarange Joseph et for the research team ANRS 12323 DOD-CI (2021) « Telephone peer recruitment and interviewing during a respondent-driven sampling (RDS) survey: feasibility and field experience from the first phone-based RDS survey among men who have sex with men in Côte d’Ivoire », BMC Medical Research Methodology, 21 (1) (février 5), p. 25. DOI : 10.1186/s12874-021-01208-x. https://doi.org/10.1186/s12874-021-01208-x.
    Résumé : Many respondent-driven sampling (RDS) methodologies have been employed to investigate hard-to-reach populations; however, these methodologies present some limits. We describe a minimally investigated RDS methodology in which peer recruitment and interviewing are phone-based. The feasibility of the methodology, field experiences, validity of RDS assumptions and characteristics of the sample obtained are discussed.
    Mots-clés : Côte d’Ivoire, Men who have sex with men, Phone-based survey, Respondent-driven sampling.
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  • Larmarange Joseph (2021) « Enseigner R sur YouTube en temps de Covid : retours d’expérience des webin-R » (communication orale), présenté à Journées d'étude : Compter, Mesurer, Calculer.. Raisonner ? Enseigner le quanti en sciences sociales dans le supérieur : pratiques et défis", Nantes. https://quanti.hypotheses.org/2157.
    Résumé : En raison du contexte sanitaire, plusieurs formations intensives sur l’analyse d’enquêtes avec R et RStudio à destination de mastorants, doctorants et post-doctorants en sciences sociales que je devais animer en France et en Afrique de l’Ouest ont dues être annulées ou reportées. En réponse, a été mis en place à partir de novembre 2019 un webinaire en ligne hebdomadaire d’enseignement à R : les webin-R. Face à la demande (plus de 400 inscrits à la mailing liste dédiée mise en place début novembre 2020), il a été choisi de diffuser le webin-R en live sur YouTube, avec possibilité de visionnage en différé. Les séances durent entre 1h30 et 2h. L’intervenant partage son écran pour tester le code R en direct et permettre aux participants de visualiser l’interface RStudio. Comme les interactions avec les participants sont limitées (uniquement le chat YouTube pendant le live), des sessions interactives du type Foire aux questions (FAQ) sont organisées sur Zoom tous les 4 à 6 séances, enregistrées et rediffusées sur YouTube. YouTube a également été choisi pour sa facilité d’utilisation, sa bande passante élevée (notamment pour les spectateurs africains) et la possibilité de visionner les vidéos dans différentes qualités (dont en HD 1080p, indispensable pour que la capture d’écran et le code R soient bien lisibles). La captation vidéo est réalisée avec le service https://streamyard.com/ qui permet un flux video live en 1080p, le suivi en direct du chat et la possibilité d’afficher à l’image des commentaires choisis par l’intervenant. Les webin-R s’accompagnent d’une mailing listes dédiée, d’une chaîne YouTube et d’un site d’accompagnement (https://larmarange.github.io/webin-R/) où pour chaque séance sont fournies des ressources additionnelles, notamment les scripts R des séances et des liens vers des chapitres analyse-R (https://larmarange.github.io/analyse-R/), une sorte de manuel pratique en ligne existant depuis une dizaine d’années (les contenus correspondent à l’équivalent d’un ouvrage de plus de 1200 pages et le site enregistre ~50 000 pages vues par mois). L’ensemble des contenus des webin-R et d’analyse-R sont accessibles gratuitement et sous licence libre Creative Commons. Les webin-R n’ont pas pour vocation d’enseigner les statistiques proprement dites mais plutôt comment réaliser des statistiques avec les logiciels R et RStudio. Ils se focalisent sur la mise en œuvre pratique, l’objectif étant de donner les clés de départ pour permettre aux participants de pouvoir continuer à s’autoformer par la suite. Au 1er mars 2021, la chaîne YouTube des webinaires totalisait 485 abonnés, 11 vidéos (9 webin-R et 2 FAQ) et 8213 vues. Selon les données analytiques des 90 derniers jours : le nombre moyen de vue par spectateur est de 4,0 et les abonnés représentent 48% des vues. Mi-février 2021, après les neuf premières séances, une enquête a été mené auprès des participants aux webin-R. Il s’agissait d’un questionnaire en ligne dont la promotion a été réalisée via la liste de diffusion : 152 questionnaires complets ont été reçus. Les répondants étaient en majorité des hommes (61%). Ils étaient âgés de 33 ans en médiane (IQR : 28-41). Les deux tiers (64%) résident en France, 31% en Afrique francophone. Ils relèvent de situations diverses : étudiant·e·s en licence (1%), mastorant·e·s (16%), doctorant·e·s (29%), post-doctorant·e·s (5%), ingénieur·e·s de recherche (15%), chercheur·e·s ou enseignant-chercheur·e·s (14%), personnes travaillant dans le secteur privé (19%). Les disciplines sont toutes aussi variées : épidémiologie (19%), sociologie (15%), démographie (14%), économie (11%), statistique (9%), géographie (6%), … En termes de participation, on observe un léger phénomène de fatigue, avec un taux de participation de 80-90% pour les premières séances et de 61-76% pour les dernières séances. Surtout, la proportion suivant les séances en direct a diminué au profit d’un suivi en différé. Parmi les points forts mentionnés par les participants : visualisation en direct de la mise en œuvre du code via l’écran partagé ; la mise à disposition des scripts et de ressources en ligne ; l’approche pratique et pragmatique ; le fait que les vidéos et les ressources soient en français ; la possibilité de revoir les vidéos en différé ; l’existence du site analyse-R en complément des vidéos (78% l’utilisent régulièrement) ; l’existence de sessions FAQ… Parmi les points faibles sont mentionnés : l’absence d’exercice ; la non-possibilité de valider des crédits d’enseignement ; le fait que toutes les explications données pendant les vidéos ne sont pas forcément reprises sur analyse-R ; le souhait de plus d’applications concrètes sur des données existantes ; un temps insuffisant consacré à l’interprétation des résultats ; une organisation et structuration des sessions FAQ à améliorer… Une enquête complémentaire est prévue en mai 2021. La présentation portera sur les leçons apprises de l’expérience des webin-R, ses atouts et ses limites.
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  • Rouveau Nicolas, Ky-Zerbo Odette, Boye Sokhna, Fotso Arlette Simo, d’Elbée Marc, Maheu-Giroux Mathieu, Silhol Romain, Kouassi Arsène Kra, Vautier Anthony, Doumenc-Aïdara Clémence, Breton Guillaume, Keita Abdelaye, Ehui Eboi, Ndour Cheikh Tidiane, Boilly Marie-Claude, Terris-Prestholt Fern, Pourette Dolorès, Desclaux Alice, Larmarange Joseph et ATLAS Team (2021) « Describing, analysing and understanding the effects of the introduction of HIV self-testing in West Africa through the ATLAS programme in Côte d’Ivoire, Mali and Senegal », BMC Public Health, 21 (1) (janvier 21), p. 181. DOI : 10.1186/s12889-021-10212-1. https://doi.org/10.1186/s12889-021-10212-1.
    Résumé : Authors Nicolas Rouveau, Odette Ky-Zerbo, Sokhna Boye, Arlette Simo Fotso, Marc d’Elbée, Mathieu Maheu-Giroux, Romain Silhol, Arsène Kra Kouassi, Anthony Vautier, Clémence Doumenc-Aïdara, Guillaume Breton, Abdelaye Keita, Eboi Ehui, Cheikh Tidiane Ndour, Marie-Claude Boilly, Fern Terris-Prestholt, Dolorès Pourette, Alice Desclaux, Joseph Larmarange & for the ATLAS Team Abstract Background The ATLAS programme aims to promote and implement HIV self-testing (HIVST) in three West African countries: Côte d’Ivoire, Mali, and Senegal. During 2019–2021, in close collaboration with the national AIDS implementing partners and communities, ATLAS plans to distribute 500,000 HIVST kits through eight delivery channels, combining facility-based, community-based strategies, primary and secondary distribution of HIVST. Considering the characteristics of West African HIV epidemics, the targets of the ATLAS programme are hard-to-reach populations: key populations (female sex workers, men who have sex with men, and drug users), their clients or sexual partners, partners of people living with HIV and patients diagnosed with sexually transmitted infections and their partners. The ATLAS programme includes research support implementation to generate evidence for HIVST scale-up in West Africa. The main objective is to describe, analyse and understand the social, health, epidemiological effects and cost-effectiveness of HIVST introduction in Côte d’Ivoire, Mali and Senegal to improve the overall HIV testing strategy (accessibility, efficacy, ethics). Methods ATLAS research is organised into five multidisciplinary workpackages (WPs): Key Populations WP: qualitative surveys (individual in-depth interviews, focus group discussions) conducted with key actors, key populations, and HIVST users. Index testing WP: ethnographic observation of three HIV care services introducing HIVST for partner testing. Coupons survey WP: an anonymous telephone survey of HIVST users. Cost study WP: incremental economic cost analysis of each delivery model using a top-down costing with programmatic data, complemented by a bottom-up costing of a representative sample of HIVST distribution sites, and a time-motion study for health professionals providing HIVST. Modelling WP: Adaptation, parameterisation and calibration of a dynamic compartmental model that considers the varied populations targeted by the ATLAS programme and the different testing modalities and strategies. Discussion ATLAS is the first comprehensive study on HIV self-testing in West Africa. The ATLAS programme focuses particularly on the secondary distribution of HIVST. This protocol was approved by three national ethic committees and the WHO’s Ethical Research Committee.
    Mots-clés : Côte d’Ivoire, HIV self-testing, HIV/AIDS, Mali, Senegal, West Africa.
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2020


  • Abo Yao, Altman Mathias, Bekelynck Anne, Dahourou Désiré, Simo Fotso Arlette, Godin Zélie, Kadio Kadidiatou, Larmarange Joseph, Sondo Apoline et Valentin Louis (2020) Connaissances, attitudes et pratiques liées à la pandémie COVID-19 des médecins au Burkina Faso, Policy brief (1), Ouagadougou : Aphro-Cov, 6 p. https://aphro-cov.com/ressources_liste/connaissances-attitudes-et-pratiques-liees-a-la-pandemie-covid-19-des-medecins-au-burkina-faso/.
    Résumé : CAP-CoV-BF : une enquête nationale réalisées auprès des médecins au Burkina Faso Le personnel de santé se trouve au cœur du dispositif élaboré dans le cadre de la réponse à l’épidémie de COVID-19, à la fois en tant qu’acteur essentiel du dispositif de réponse à l’épidémie, et en tant que premières personnes exposées et victimes. Il est ainsi essentiel de s’assurer de la compréhension de cette maladie (symptômes, modes de transmission, mesures de prévention, etc.) et de l’acceptabilité et de l’adaptation des médecins du Burkina Faso face aux mesures de santé publique préconisées. Cela permettra d’identifier les difficultés et les barrières qu’ils rencontrent afin d’adopter les mesures de protection adéquates, proposer des interventions adaptées pour les surmonter et prioriser les messages qui leur sont destinés. L’objectif principal de cette étude est de fournir aux acteurs nationaux impliqués dans la gestion de la crise des données probantes régulières et représentatives à l’échelle nationale sur les connaissances, attitudes et pratiques des médecins au Burkina Faso. Une enquête quantitative transversale par téléphone a été mise en place, menée auprès d’un échantillon représentatif de 166 médecins sur l’ensemble du territoire. Elle sera répétée trois fois à intervalles réguliers. Ce document “Policy Brief” (téléchargeable au lien ci-dessous) présente de façon synthétique les résultats de l’analyse de la 1ère vague d’appels réalisée en Septembre 2020.
    Pièce jointe Abo et al. - 2020 - Connaissances, attitudes et pratiques liées à la p.pdf 824 ko
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  • 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.
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  • 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.
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  • 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.
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  • 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.
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  • 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.
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  • 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.
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  • 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/.


  • 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.
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  • 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.
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  • 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.
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  • 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.
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  • 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.
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  • 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.
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  • 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.
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  • 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.
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  • 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 ?
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  • 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 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/.

  • 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.
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  • 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.
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  • 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.
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  • 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.
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2019



  • Assoumou Nelly, Bekelynck Anne, Carillon Séverine, Kouadio Alexis, Ouantchi Honoré, Doumbia Mohamed, Larmarange Joseph et Koné Mariatou (2019) « Organisation du financement du dépistage du VIH à base communautaire en Côte d’Ivoire : une recherche d’efficience potentiellement contre-productive ? », Médecine et Santé Tropicales, 29 (3) (juillet 1), p. 287-293. DOI : 10.1684/mst.2019.0926. http://www.jle.com/fr/revues/mst/e-docs/organisation_du_financement_du_depistage_du_vih_a_base_communautaire_en_cote_divoire_une_recherche_defficience_potentiellement_contre_productive__315337/article.phtml?tab=texte.
    Résumé : Objectif. Dans le champ du VIH, le President's Emergency Plan for AIDS Relief (Pepfar) et le Fond mondial de lutte contre le VIH/sida, la tuberculose et le paludisme ont accentué leurs politiques de gestion des financements qui reposent sur la définition d’indicateurs mesurables, la fixation d’objectifs à atteindre, les comptes rendus rapportage et le contrôle des activités. Cet article vise à montrer la manière dont ces nouvelles formes de gestion des financements, dont l’objectif premier est d’améliorer l’efficience des programmes, ont un impact sur la mise en œuvre locale des activités, à travers l’exemple du dépistage du VIH à base communautaire. Méthodes. Dans trois districts sanitaires de la Côte d’Ivoire, nous avons réalisé en 2015 et 2016 une cartographie des acteurs impliqués dans le dépistage communautaire et dix-huit entretiens semi-directifs. Résultats. Le financement des organisations en charge du dépistage au niveau local transite par des organisations intermédiaires selon un système pyramidal complexe. Combiné à la lourdeur des comptes rendus d’activité et de la validation des données, cela génère des retards dans le décaissement des fonds et réduit fortement le temps effectif de mise en œuvre des activités. Ce processus produit ainsi ses propres effets contre-productifs contre lesquels il était censé lutter, au désavantage des activités de dépistage. La faible marge de manœuvre des acteurs locaux dans l’élaboration des projets conduit à des écarts entre les objectifs visés et les réalités de terrain. Mots clés : financement, dépistage du VIH, Côte d’Ivoire
    Mots-clés : ⚠️ Invalid DOI.
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  • Becquet Valentine et Larmarange Joseph (2019) « La Santé des travailleuses du sexe en Afrique subsaharienne : une population toujours exposée au VIH et soumise à de multiples vulnérabilités » (communication orale), présenté à 2e congrès international de l'Institut du Genre, Anger. https://congresgenre19.sciencesconf.org/.
    Résumé : Les travailleuses du sexe (TS) constituent une des populations prioritaires des programmes de lutte contre le VIH. Pendant longtemps, le focus a été la promotion du préservatif et, dans les années 2000, le dépistage et le traitement des TS infectées. Ces politiques ont-elles véritablement enrayé la vulnérabilité de ces femmes ? Cette communication présentera des résultats issus d'entretiens menés en 2016 (projet ANRS 12361 PrEP-CI) sur différents sites prostitutionnels d'Abidjan et de San Pedro. Les TS sont en réalité exposées au VIH dans de nombreuses situations, notamment avec leurs partenaires réguliers, avec des clients les agressant ou payant davantage d'argent pour un rapport non protégé. Leur faible pouvoir de négociation s'inscrit dans un contexte de domination masculine. À ces vulnérabilités de genre s'ajoutent les vulnérabilités matérielles liées à leurs conditions de travail. Leur mobilité importante pour contourner leur marginalisation sociale est également un facteur de fragilisation. Les nouveaux outils de prévention tels que la prophylaxie préexposition pourraient selon certains compenser ces vulnérabilités et contribuer à leur émancipation en termes de santé. Si cet outil pourrait être approprié, il convient cependant de ne pas considérer ces femmes uniquement au prisme du VIH, puisqu'elles ont de nombreux autres besoins en santé sexuelle et reproductive et font face plus globalement à un problème d'accès aux droits humains fondamentaux.
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  • Becquet Valentine, Nouaman Marcellin, Plazy Mélanie, Masumbuko Jean-Marie, Anoma Camille, Kouamé Soh, Danel Christine, Eholié Serge et Larmarange Joseph (2019) « Sexual health needs of female sex workers reached by two NGOs in Côte d’Ivoire: considerations for the future implementation of PrEP » (communication orale), présenté à AIDS Impact, London. http://www.aidsimpact.com/abstracts/-LZFgxedD3IcXCPGWlOB.
    Résumé : Aim In West Africa, most countries have mixed HIV epidemics; new tools such as pre-exposure prophylaxis (PrEP) should target in priority most affected populations, particularly female sex workers (FSWs). This paper describes sexual and reproductive health (SRH) needs of FSWs in Côte d’Ivoire to inform the future implementation of PrEP in this population. Method/Issue The ANRS 12361 PrEP-CI cross-sectional and mixed-methods study was designed and implemented with two Ivorian community-based organizations. 1000 FSWs completed a standardized questionnaire assessing women’s sociodemographic characteristics, sexual practices and behaviors, use of community health services, a priori acceptability of PrEP. Twenty-two in-depth interviews and eight focus group discussions were conducted at prostitution sites. FSWs were interviewed about risky practices and sexual behaviors, experiences with violence and discrimination, attitudes regarding HIV and sexually transmitted infections (STIs), and barriers to SRH services. Results/Comments The quantitative and qualitative results showed that FSWs were highly exposed to HIV despite their use of condoms with clients. 91% did not use condoms with their regular partner, despite their acknowledged concurrent sexual partnerships. 23% accepted condomless sexual intercourse for a large sum of money, especially when they had had few previous clients. Moreover, FSWs faced many unmet needs regarding SRH beyond HIV prevention and treatment. Inconsistent condom use exposed FSWs to STIs and undesired pregnancies. However, the prevalence of contraceptive use was low (40%) due to fear of contraception causing sterility. FSWs faced obstacles in accessing SRH care and preferred advice from their peers or self-medication. Discussion Implementing PrEP among FSWs in West Africa, such as in Côte d’Ivoire, constitutes an opportunity to consider the chronic 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 practicing 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.
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  • Bekelynck Anne, Carillon Séverine, Assoumou Nelly, Kouadio Alexis, Danel Christine, Ouantchi Honoré, Koné Mariatou et Larmarange Joseph (2019) « Pepfar 3.0’s HIV testing policy in Côte d’Ivoire (2014-2018): a changing strategy between improvement of testing yield and achievement of the first 90? » (communication orale), présenté à AIDS Impact, London. http://www.aidsimpact.com/abstracts/-LZtWmf5VK5Jr8HC_KPj.
    Résumé : Aim Since 2014, the Pepfar has initiated its phase III called ‘Pepfar 3.0’ (2014- now), focusing on ‘Sustainable Control of the Epidemic’, to reach the Joint United Nations Programme on HIV/AIDS’ (UNAIDS) 90-90-90 goal. In this strategic plan, the Pepfar states that it is “pivoting to a data-driven approach that strategically targets geographic areas and populations where [they could] achieve the most impact for [their] investments”. In practice, how were these new targeted HIV screening strategies developed and what were the challenges encountered? Method/Issue We conducted a qualitative study in Côte d’Ivoire in 2015-2018, a country where the HIV program is mainly funded by the Pepfar (73% in 2018). In-depth interviews were conducted with stakeholders in the AIDS public response: CDC/Pepfar (3), Ministry of Health (3), intermediary NGOs (7); and we observed public meetings (nb). In addition, the grey literature of Pepfar (Country Operational Plan – COP, https://www.pepfar.gov/) was reviewed to describe the evolution of Pepfar’s HIV testing strategies from COP 14 to COP 17 (October 2014 – September 2018). Results/Comments Since the COP 14, Pepfar’s HIV testing strategies have been characterized by significant variations: (i) in the targets of the number of people and of HIV positive people to be screened, divided by 2 between COP 14 and COP 15 and multiplied by 4.5 between COP 15 and COP 17; (ii) in the targeted geographical areas, from a regional breakdown to an identification of health districts at high and low impact; and (iii) in the targeted sub-groups, from a focus on key populations to a broader definition of priority populations, including men over 25 years old. A shift was observed in the definition of testing targets, with less room dedicated to programmatic data and feedbacks from field actors and an increasing focus on the use of modelling work to estimate and disaggregate the targets by geographical units and sub-population (even if available data at these fine levels was limited and uncertain); increasingly leading to gaps between targets and results. While the aim of COP 14 and COP 15 seemed to be the improvement of testing efficacy in general and testing yield (i.e. testing positivity rate) in particular, COP 16 and 17 have given priority to fill the gaps in terms of the first 90 (i.e. reducing proportion of PLHIV being undiagnosed). Discussion This study highlights how the Pepfar approach has been changing over the last 5 years as a result of the tension between improving HIV testing yield and achieving the first 90 (90% of PLHIV being diagnosed) in the context of a mixed epidemic, combined with a context of limited resources implying to improve the “value for money” of policies. This study also underlines the limited possibility of very rapidly evolving strategies by the donor - emphasised by the annual system of COPs - in a context where actors have different adaptive capacities. The emphasis on targets to reach tends to underestimate the political and social modalities of
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  • Bekelynck Anne et Larmarange Joseph (2019) « Pepfar 3.0’s HIV testing policy in Côte d'Ivoire (2014 to 2018): fragmentation, acceleration and disconnection », Journal of the International AIDS Society, 22 (12), p. e25424. DOI : 10/ggnfm9. https://onlinelibrary.wiley.com/doi/abs/10.1002/jia2.25424.
    Résumé : Introduction HIV Testing and Counselling (HTC) remains a key challenge in achieving control of the HIV epidemic by 2030. In the early 2010s, the President's Emergency Plan for AIDS Relief (Pepfar) adopted targeted HTC strategies for populations and geographical areas most affected by HIV. We examine how Pepfar defined targeted HTC in Côte d'Ivoire, a country with a mixed HIV epidemic, after a decade of expanding HTC services. Methods We explored the evolution of HTC strategies through the Country Operational Plans (COP) of Pepfar during its phase 3.0, from COP 14 to COP 17 (October 2014 to September 2018) in Côte d'Ivoire. We conducted an analysis of the grey literature over the period 2014 to 2018 (Budget & Target Report, Strategic Direction Summary, Sustainability Index and Dashboard Summary, https://data.pepfar.gov). We also conducted a qualitative study in Côte d'Ivoire (2015 to 2018) using in-depth interviews with stakeholders in the AIDS public response: CDC/Pepfar (3), Ministry of Health (3), intermediary NGOs (7); and public meeting observations (14). Results Since the COP 14, Pepfar's HIV testing strategies have been characterized by significant variations in terms of numerical, geographical and population targets. While the aim of COP 14 and COP 15 seemed to be the improvement of testing efficacy in general and testing yield in particular, COP 16 and COP 17 prioritized accelerating progress towards the “first 90” (i.e. reducing the proportion of people living with HIV who are unaware of their HIV). A shift was observed in the definition of testing targets, with less focus on the inclusion of programmatic data and feedback from field actors, and greater emphasis on the use of models to estimate and disaggregate the targets by geographical units and sub-populations (even if the availability of data by this disaggregation was limited or uncertain); increasingly leading to gaps between targets and results. Conclusions These trials and tribulations question the real and long-term effectiveness of annually-revised, fragmented strategies, which widen an increasing disparity between the realities of the actors on the ground and the objectives set in Washington.
    Mots-clés : Africa, COP (Country operational Plan), Côte d'Ivoire, Health policy, HIV testing, Pepfar.
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  • Calmettes Sophie et Larmarange Joseph (2019) « ATLAS : implementing and evaluating HIV self-testing in West Africa - an example of Community-based Action Research » (communication orale), présenté à Pre-confernence "Community-based Action Research : What can we learn from the HIV field experiences from the Global North and the Global South ?" at 12th European Public Health Conference, Marseille. https://ephconference.eu/2019-pre-conference-208.

  • Carillon Séverine, Bekelynck Anne, Assoumou Nelly, Kouadio Alexis, Danel Christine, Ouantchi Honoré, Koné Mariatou et Larmarange Joseph (2019) « “We need incentives!” Health care professionals’ reluctance to propose systematically HIV testing during general consultation in Cote d’Ivoire » (poster), présenté à AIDS Impact, London. http://www.aidsimpact.com/abstracts/-LZtpxecQfo45SlC9BNU.
    Résumé : Aim To increase access to HIV testing, WHO recommended in 2007 provider-initiated HIV testing using a simplified but still exceptional approach in terms of pre-test counseling and consent. Cote d’Ivoire accepted in 2009 systematic HIV testing proposal in all medical consultations, irrespective of reasons. What are health care professionals (HCPs) perceptions and experiences related to testing proposal? Method/Issue An ethnographic multi-site study was conducted in 3 general medical services (urban, semi-urban, rural) in 2 Ivorian health districts: 37 in-depth interviews with HCPs and 200 observed medical consultations (general medicine). A thematic analysis was performed on HCPs’ practices and discourses. Results/Comments The proportion of patients offered an HIV test was low (around 20%), due to HCPs’ reluctance to propose an HIV test in the absence of clinical suspicion. When offered, HIV test was more often prescribed than proposed. The analysis revealed 4 types of explanations in HCPs discourses. (1) Due to stigma associated to HIV, HCPs feared a negative reaction from their patients: refusal, offence, distrust, loss of patients. (2) Time-consuming specificity of HIV testing in terms of counseling, consent and administrative procedure (separate record and dedicated prescription) is perceived by HCPs as not useful and inducing a work overload that should be financially compensated or realized by dedicated providers, as it was before 2009. (3) In the absence of clinical suspicion, they considered that proposing an HIV test during a general consultation is not medically justified and not their priority. (4) Finally, HCPs felt that they are not sufficiently trained. Discussion HCPs experiences and perceptions are negatively affected by the legacy of the successive HIV policies implemented since the beginning of the epidemy. Some complex procedures, historically implemented due to confidentiality and stigma issues, could maybe be simplified today. Integrating HIV testing in routine is a challenge considering that these activities were previously implemented with dedicated incentives, training and human resources. In a context of limited resources and mixed epidemic, how to prioritize and reorganize HIV testing in general consultations while motivating HCPs and being efficient in terms of public health?
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  • Doumenc Aïdara Clémence et Larmarange Joseph (2019) « ATLAS Project : adapting HIVST distribution models in West Africa to reach those left behind » (communication orale), présenté à 20th ICASA, Kigali. https://www.icasa2019rwanda.org/.


  • Gosset Andréa, Protopopescu Camelia, Larmarange Joseph, Orne-Gliemann Joanna, McGrath Nuala, Pillay Deenan, Dabis François, Iwuji Collins et Boyer Sylvie (2019) « Retention in Care Trajectories of HIV-Positive Individuals Participating in a Universal Test-and-Treat Program in Rural South Africa (ANRS 12249 TasP Trial) », JAIDS Journal of Acquired Immune Deficiency Syndromes, 80 (4) (avril 1), p. 375. DOI : 10/gftjcf. https://journals.lww.com/jaids/Fulltext/2019/04010/Retention_in_Care_Trajectories_of_HIV_Positive.2.aspx.
    Résumé : Objective: To study retention in care (RIC) trajectories and associated factors in patients eligible for antiretroviral therapy (ART) in a universal test-and-treat setting (TasP trial, South Africa, 2012–2016). Design: A cluster-randomized trial whereby individuals identified HIV positive after home-based testing were invited to initiate ART immediately (intervention) or following national guidelines (control). Methods: Exiting care was defined as ≥3 months late for a clinic appointment, transferring elsewhere, or death. Group-based trajectory modeling was performed to estimate RIC trajectories over 18 months and associated factors in 777 ART-eligible patients. Results: Four RIC trajectory groups were identified: (1) group 1 “remained” in care (reference, n = 554, 71.3%), (2) group 2 exited care then “returned” after [median (interquartile range)] 4 (3–9) months (n = 40, 5.2%), (3) group 3 “exited care rapidly” [after 4 (4–6) months, n = 98, 12.6%], and (4) group 4 “exited care later” [after 11 (9–13) months, n = 85, 10.9%]. Group 2 patients were less likely to have initiated ART within 1 month and more likely to be male, young (<29 years), without a regular partner, and to have a CD4 count >350 cells/mm3. Group 3 patients were more likely to be women without social support, newly diagnosed, young, and less likely to have initiated ART within 1 month. Group 4 patients were more likely to be newly diagnosed and aged 39 years or younger. Conclusions: High CD4 counts at care initiation were not associated with a higher risk of exiting care. Prompt ART initiation and special support for young and newly diagnosed patients with HIV are needed to maximize RIC.
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  • Inghels Maxime, Kra Kouassi Arsène, Niangoran Serge, Bekelynck Anne, Carillon Séverine, Danel Christine, Sika Lazare, Koné Mariatou, Desgrées du Loû Annabel et Larmarange Joseph (2019) « Cascade of provider-initiated HIV testing and counselling at specific life events (pregnancy, STIs, marriage plan) in Côte d’Ivoire » (poster), présenté à AIDS Impact, London. http://www.aidsimpact.com/abstracts/-LZpZjJNQzSUV6vuH4Ku.
    Résumé : Aim In Côte d’Ivoire, only 57.8% of women and 37.0% of men have been HIV-tested at least once, which is insufficient to control the epidemic. The objective of this study is to describe at a population level if an HIV test was offered and performed at specific life-events where provider-initiated HIV testing is recommended. Method/Issue A cross-sectional telephone survey was conducted in 2017 among a representative sample of 3 867 individuals from the general population in Côte d'Ivoire. For each individual, the occurrence of the following events over the past 5 years was documented: birth of a child, Sexually Transmitted Infections—STIs, marriage. For each of these events, they were asked (i) if they have consulted a health professional, (ii) if they were offered an HIV test during that consultation and (iii) if they accepted it. The factors associated with each of these three steps were analyzed in separate logistic regression models stratified by type of event. Results/Comments While 63.7% of women were HIV-tested during their last pregnancy, only 16.9% of men were tested during their partner’s last pregnancy and this proportion fell to 13.4% for people with an STI and 14.5% for people who got married. These levels of HIV testing were mainly driven by a lack of medical consultation (except for pregnant women) and a lack of testing proposal (except for pre-marital check-up). Testing acceptability was high. Discussion Improving HIV testing coverage in Côte d’Ivoire requires (i) facilitating attendance to health services in case of STIs, marriage plans and pregnancy—for men—and (ii) strengthening routine testing proposal during these occasions.
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  • Inghels Maxime, Kra Kouassi Arsène, Niangoran Serge, Bekelynck Anne, Carillon Séverine, Sika Lazare, Danel Christine, Koné Mariatou, Desgrées du Loû Annabel et Larmarange Joseph (2019) « Practices and Barriers to Provider-initiated HIV Testing and Counseling (PITC) among Midwives, Nurses and Physicians in Côte d'Ivoire » (poster WEPEC215), présenté à 20th ICASA, Kigali. http://www.professionalabstracts.com/icasa2019/iplanner/#/presentation/2236.
    Résumé : Background: Despite the implantation of Provider Initiated Testing and Counselling (PITC) in 2009, testing proposal remains lows in Cote d'Ivoire, even in recommended situations. The purpose of this study is to identify the practices and obstacles to PITC among midwives, nurses and physicians in Côte d´Ivoire. Methods: 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. These factors were classified in three dimensions according to the conceptual framework of work performance (Motivation-Capability-Opportunity). Results: 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 test was associated with the perceptions (motivation dimension) that HIV testing do not require a specific consent compared to other diseases (aOR 4,00 [95% CI 1.37-14.29]). Among nurses, having received a HIV training (i.e. capability) and the presence of community HIV counselors (i.e. opportunity) was associated with a higher number of proposed tests (aOR 2.03 [1.33-3.12] and aOR 1.86 [1.21-2.87] respectively). For physicians, the presence of a voluntary testing center (i.e. opportunity) was associated with a higher number of proposed tests (aOR 1.69 [1.01-2.86]). Conclusion: PITC practices and barriers were different 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.
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  • Larmarange Joseph (2019) « De PrEP-CI à PRINCESSE… construction d’une offre en santé sexuelle et reproductive à destination des travailleuses du sexe en Côte d’Ivoire » (communication orale), présenté à Journée d'études “La Recherche en sciences sociales sur la prophylaxie pré-exposition (PrEP)”, Paris. https://shsvih.hypotheses.org/1442.


  • Larmarange Joseph (2019) « Ggplot2 ou la grammaire des graphiques sous R » (communication orale), présenté à Rencontres de statistique appliquée de l'Ined, Paris. DOI : 10/gf3z26. https://larmarange.github.io/seminaire-INED-18juin2019/diaporama.html.
    Résumé : R possède un puissant moteur graphique interne. Toutefois, produire un graphique complet avec les fonctions basiques de R est peu aisée. L’extension ggplot2, développée par Hadley Wickham et mettant en œuvre la grammaire des graphiques théorisée par Leland Wilkinson, est devenue en quelques années l’une des extensions R les plus utilisées. La grammaire des graphiques invite l’utilisateur à repenser sa manière de concevoir un graphique en associant variables (données), paramètres graphiques (esthétiques) et formes géométriques, puis en complexifiant progressivement son graphique (coordonnées, échelles, facettes, étiquettes, légendes, thèmes…).
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  • Larmarange Joseph (2019) « The edges of key populations: how to think, describe and reach these hidden groups? » (communication orale en session plénière), présenté à AIDS Impact, London. http://www.aidsimpact.com/abstracts/-LcerHcNPqtU5HdgnxjE.
    Résumé : In many settings, key populations (in particular men having sex with other men, sex workers and drug users) are overwhelmingly affected by HIV and many programs are focusing on them. Due to epidemiological modelling and policy planning, these groups are too often seen as socially homogeneous groups rather than heterogeneous categories with fuzzy outlines. Identities, social life, sexual practices, exposure to HIV varies within these groups, in particular between the core and the edges. Their sexual networks are also connected to individuals not perceived as “key populations”: female partners of bisexual men, regular partners and clients of sex workers, sexual partners of drug users… Could we better conceptualize the edges of key populations? What do we know about them? What is their role in the dynamic of HIV epidemics? How can we include them in the HIV response? Are some interventions more relevant to reach them?
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  • Larmarange Joseph (2019) « Quelle place pour les autotests VIH dans les pays à faibles ressources ? » (communication orale), présenté à AFRAMED, Casablanca. http://www.aframed2019.org.

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