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1.  Tobacco Smoking in HIV-Infected versus General Population in France: Heterogeneity across the Various Groups of People Living with HIV 
PLoS ONE  2014;9(9):e107451.
Background
Although the various groups of people living with HIV (PLWHIV) considerably differ regarding socioeconomic and behavioral characteristics, their specificities regarding tobacco smoking have been poorly investigated. We aimed to assess patterns of tobacco consumption across the various groups of PLWHIV and to compare them to the general population, accounting for the specific socioeconomic profile of PLWHIV.
Methods
We used data of the ANRS-Vespa2 study, a national representative survey on PLWHIV conducted in France in 2011. Prevalence of past and current tobacco consumption, heavy smoking and strong nicotine dependence were assessed among the various groups of PLWHIV as defined by transmission category, gender and geographic origin, and compared to the French general population using direct standardization and multivariate Poisson regression models, accounting for gender, age, education and geographic origin.
Results
Among the 3,019 participants aged 18–85 years (median time since HIV diagnosis: 12 years), 37.5% were current smokers and 22.1% were past smokers, with marked differences across the various groups of PLWHIV. Compared to the general population, the prevalence of regular smoking was increased among HIV-infected men who have sex with men (MSM) (adjusted prevalence rate ratio (aPRR): 1.19, 95% confidence interval (95% CI): 1.07–1.32), French-native women (aPRR: 1.32, 95% CI: 1.10–1.57), and heterosexual French-native men (although not significantly, aPRR: 1.19, 95% CI: 0.98–1.45). Additionally, HIV-infected MSM were significantly less likely to be ex-smokers (aPRR: 0.73, 95% CI: 0.64–0.82) than the general population and similar trends were observed among heterosexual French-native men (aPRR: 0.89, 95% CI: 0.78–1.02) and women (aPRR: 0.84, 95% CI: 0.70–1.01). HIV-infected sub-Saharan African migrants were less likely to be regular smokers than the general population.
Conclusions
Smoking constitutes a major concern in various groups of PLWHIV in France including MSM and heterosexual French-natives, probably resulting from PLWHIV being less likely to quit smoking than their counterparts in the general population.
doi:10.1371/journal.pone.0107451
PMCID: PMC4159331  PMID: 25202968
2.  Decrease in sexual risk behaviours after early initiation of antiretroviral therapy: a 24-month prospective study in Côte d'Ivoire 
Introduction
Whether early antiretroviral therapy (ART) initiation could impact sexual risk behaviours remains to be documented. We aimed to investigate changes in sexual behaviours within the 24 months following an early versus standard ART initiation in HIV-positive adults with high CD4 counts.
Methods
We used data from a prospective behavioural study nested in a randomized controlled trial of early ART (Temprano-ANRS12136). Time trends in sexual behaviours from enrolment in the trial (M0) to 12-month (M12) and 24-month (M24) visits were measured and compared, using Generalized Estimating Equations models, between participants randomly assigned either to initiate ART immediately (early ART) or to defer ART initiation until on-going WHO starting criteria are met (standard ART). Indicators of sexual behaviours included 1) sexual activity in the past year, 2) multiple partnership in the past year, 3) unprotected sex at last intercourse and 4) risky sex (i.e. unprotected sex with a partner of HIV negative/unknown status) at last intercourse.
Results
Analyses included 1952 participants (975 with early ART and 977 with standard ART; overall median baseline CD4 count: 469/mm3). Among participants with early ART, significant decreases were found between M0 and M24 in sexual activity (Odds Ratio [OR] 0.72, 95% Confidence Interval [95% CI] 0.57–0.92), multiple partnership (OR 0.57, 95% CI 0.41–0.79), unprotected sex (OR 0.59, 95% CI 0.47–0.75) and risky sex (OR 0.58, 95% CI 0.45–0.76). Among participants with standard ART, sexual behaviours showed similar trends over time. These decreases mostly occurred within the 12 months following enrolment in the trial in both groups and prior to ART initiation in participants with standard ART. For unprotected sex and risky sex, decreases were or tended to be more pronounced among patients reporting that their last sexual partner was non-cohabiting.
Conclusions
In these sub-Saharan adults with high CD4 counts, entry into HIV care, rather than ART initiation, resulted in decreased sexual activity and risky sexual behaviours. We did not observe any evidence of a risk compensation phenomenon associated with early ART initiation. These results illustrate the potential behavioural preventive effect of early entry into care, which goes hand in hand with early ART initiation.
doi:10.7448/IAS.17.1.18977
PMCID: PMC4078101  PMID: 24985779
HIV; AIDS; antiretroviral treatment; sexual behaviours; early ART initiation; HIV prevention; sub-Saharan Africa
3.  Management of Upper Respiratory Tract Infections by Different Medical Practices, Including Homeopathy, and Consumption of Antibiotics in Primary Care: The EPI3 Cohort Study in France 2007–2008 
PLoS ONE  2014;9(3):e89990.
Background
Prescribing of antibiotics for upper respiratory tract infections (URTI) varies substantially in primary care.
Objectives
To describe and compare antibiotic and antipyretic/anti-inflammatory drugs use, URTI symptoms' resolution and occurrence of potentially-associated infections in patients seeking care from general practitioners (GPs) who exclusively prescribe conventional medications (GP-CM), regularly prescribe homeopathy within a mixed practice (GP-Mx), or are certified homeopathic GPs (GP-Ho).
Method
The EPI3 survey was a nationwide population-based study of a representative sample of 825 GPs and their patients in France (2007–2008). GP recruitment was stratified by self-declared homeopathic prescribing preferences. Adults and children with confirmed URTI were asked to participate in a standardized telephone interview at inclusion, one-, three- and twelve-month follow up. Study outcomes included medication consumption, URTI symptoms' resolution and potentially-associated infections (sinusitis or otitis media/externa) as reported by patients. Analyses included calibration to account for non-respondents and groups were compared using multivate analyses adjusting for baseline differences with a propensity score.
Results
518 adults and children with URTI (79.3% rhinopharyngitis) were included (36.9% response rate comparable between groups). As opposed to GP-CM patients, patients in the GP-Ho group showed significantly lower consumption of antibiotics (Odds ratio (OR) = 0.43, 95% confidence interval (CI): 0.27–0.68) and antipyretic/anti-inflammatory drugs (OR = 0.54, 95% CI: 0.38–0.76) with similar evolution in related symptoms (OR = 1.16, 95% CI: 0.64–2.10). An excess of potentially-associated infections (OR = 1.70, 95% CI: 0.90–3.20) was observed in the GP-Ho group (not statistically significant). No difference was found between GP-CM and GP-Mx patients.
Conclusion
Patients who chose to consult GPs certified in homeopathy used less antibiotics and antipyretic/anti-inflammatory drugs for URTI than those seen by GPs prescribing conventional medications. No difference was observed in patients consulting GPs within mixed-practice. A non-statistically significant excess was estimated through modelling for associated infections in the GP-Ho group and needs to be further studied.
doi:10.1371/journal.pone.0089990
PMCID: PMC3960096  PMID: 24646513
4.  Effect of Early Antiretroviral Therapy on Sexual Behaviors and HIV-1 Transmission Risk Among Adults With Diverse Heterosexual Partnership Statuses in Côte d'Ivoire 
The Journal of Infectious Diseases  2013;209(3):431-440.
Background. The effect of early initiation of antiretroviral therapy (ART; ie, at CD4+ T-cell counts >350 cells/mm3) on sexual behaviors and human immunodeficiency virus type 1 (HIV) transmission risk has not been documented in populations other than HIV-serodiscordant couples in stable relationships.
Methods. On the basis of data from a behavioral study nested in a randomized, controlled trial (Temprano-ANRS12136) of early ART, we compared proportions of risky sex (ie, unprotected sex with a partner of negative/unknown HIV status) reported 12 months after inclusion between participants randomly assigned to initiate ART immediately (hereafter, “early ART”) or according to ongoing World Health Organization criteria. Group-specific HIV transmission rates were estimated on the basis of sexual behaviors and viral load–specific per-act HIV transmission probabilities. The ratio of transmission rates was computed to estimate the protective effect of early ART.
Results. Among 957 participants (baseline median CD4+ T-cell count, 478 cells/mm3), 46.0% reported sexual activity in the past month; of these 46.0%, sexual activity for 41.5% involved noncohabiting partners. The proportion of subjects who engaged in risky sex was 10.0% in the early ART group, compared with 12.8% in the standard ART group (P = .17). After accounting for sexual behaviors and viral load, we estimated that the protective effect of early ART was 90% (95% confidence interval, 81%–95%).
Conclusion. Twelve months after inclusion, patients in the early and standard ART groups reported similar sexual behaviors. Early ART decreased the estimated risk of HIV transmission by 90%, suggesting a major prevention benefit among seronegative sex partners in stable or casual relationships with seropositive individuals.
doi:10.1093/infdis/jit470
PMCID: PMC3883172  PMID: 23990567
HIV prevention; antiretroviral treatment; sexual behaviors; HIV-1 sexual transmission; treatment as prevention; epidemiology; sub-Saharan Africa
5.  Evaluation of the impact of immediate versus WHO recommendations-guided antiretroviral therapy initiation on HIV incidence: the ANRS 12249 TasP (Treatment as Prevention) trial in Hlabisa sub-district, KwaZulu-Natal, South Africa: study protocol for a cluster randomised controlled trial 
Trials  2013;14:230.
Background
Antiretroviral therapy (ART) suppresses HIV viral load in all body compartments and so limits the risk of HIV transmission. It has been suggested that ART not only contributes to preventing transmission at individual but potentially also at population level. This trial aims to evaluate the effect of ART initiated immediately after identification/diagnosis of HIV-infected individuals, regardless of CD4 count, on HIV incidence in the surrounding population. The primary outcome of the overall trial will be HIV incidence over two years. Secondary outcomes will include i) socio-behavioural outcomes (acceptability of repeat HIV counselling and testing, treatment acceptance and linkage to care, sexual partnerships and quality of life); ii) clinical outcomes (mortality and morbidity, retention into care, adherence to ART, virologic failure and acquired HIV drug resistance), iii) cost-effectiveness of the intervention. The first phase will specifically focus on the trial’s secondary outcomes.
Methods/design
A cluster-randomised trial in 34 (2 × 17) clusters within a rural area of northern KwaZulu-Natal (South Africa), covering a total population of 34,000 inhabitants aged 16 years and above, of whom an estimated 27,200 would be HIV-uninfected at start of the trial. The first phase of the trial will include ten (2 × 5) clusters. Consecutive rounds of home-based HIV testing will be carried out. HIV-infected participants will be followed in dedicated trial clinics: in intervention clusters, they will be offered immediate ART initiation regardless of CD4 count and clinical stage; in control clusters they will be offered ART according to national treatment eligibility guidelines (CD4 <350 cells/μL, World Health Organisation stage 3 or 4 disease or multidrug-resistant/extensively drug-resistant tuberculosis). Following proof of acceptability and feasibility from the first phase, the trial will be rolled out to further clusters.
Discussion
We aim to provide proof-of-principle evidence regarding the effectiveness of Treatment-as-Prevention in reducing HIV incidence at the population level. Data collected from the participants at home and in the clinics will inform understanding of socio-behavioural, economic and clinical impacts of the intervention as well as feasibility and generalizability.
Trial registration
Clinicaltrials.gov: NCT01509508; South African Trial Register: DOH-27-0512-3974.
doi:10.1186/1745-6215-14-230
PMCID: PMC3750830  PMID: 23880306
HIV infections; Antiretroviral therapy; Prevention; South Africa
6.  Who seeks primary care for sleep, anxiety and depressive disorders from physicians prescribing homeopathic and other complementary medicine? Results from the EPI3 population survey 
BMJ Open  2012;2(6):e001498.
Objectives
To describe and compare patients seeking treatment for sleep, anxiety and depressive disorders (SADD) from physicians in general practice (GPs) with three different practice preferences: strictly conventional medicine (GP-CM), mixed complementary and conventional medicine (GP-Mx) and certified homeopathic physicians (GP-Ho).
Design and setting
The EPI3 survey was a nationwide, observational study of a representative sample of GPs and their patients, conducted in France between March 2007 and July 2008.
Participants
1572 patients diagnosed with SADD.
Primary and secondary outcomes
The patients’ attitude towards complementary and alternative medicine; psychotropic drug utilisation.
Results
Compared to patients attending GP-CM, GP-Ho patients had healthier lifestyles while GP-Mx patients showed similar profiles. Psychotropic drugs were more likely to be prescribed by GP-CM (64%) than GP-Mx (55.4%) and GP-Ho (31.2%). The three groups of patients shared similar SADD severity.
Conclusion
Our results showed that patients with SADD, while differing principally in their sociodemographic profiles and conventional psychotropic prescriptions, were actually rather similar regarding the severity of SADD in terms of comorbidities and quality of life. This information may help to better plan resource allocation and management of these common health problems in primary care.
doi:10.1136/bmjopen-2012-001498
PMCID: PMC3532988  PMID: 23180389
Epidemiology
7.  Barriers to HIV Testing in Côte d'Ivoire: The Role of Individual Characteristics and Testing Modalities 
PLoS ONE  2012;7(7):e41353.
Background
Expanding HIV testing requires a better understanding of barriers to its uptake. We investigated barriers to HIV testing in Côte d'Ivoire, taking into account test circumstances (client vs. provider-initiated).
Methods
We used data from the 2005 nationally representative Demographic and Health Survey conducted in Côte d'Ivoire. Socio-demographic characteristics, sexual behaviour and knowledge and attitudes toward HIV/AIDS associated with recent (<2 years) HIV testing were identified using gender-specific univariate and multivariate logistic regressions. Among women, differential effects of barriers to testing according to test circumstance (whether they have been offered for a prenatal test or not) were assessed through interaction tests.
Results
Recent HIV testing was reported by 6.1% of men and 9.5% of women (including 4.6% as part of antenatal care). Among men, having a low socioeconomic status, having a low HIV-related knowledge level and being employed [compared to those inactive: adjusted Odds Ratio (aOR) 0.46; 95% confidence interval (CI) 0.25–0.87] were associated with lower proportions of recent HIV testing. Among women without a prenatal HIV testing offer, living outside the capital (aOR 0.38; CI 0.19–0.77) and reporting a unique lifetime sexual partner constituted additional barriers to HIV testing. By contrast, among women recently offered to be tested in prenatal care, none of these variables was found to be associated with recent HIV testing.
Conclusions
Various dimensions of individuals' characteristics constituted significant barriers to HIV testing in Côte d'Ivoire in 2005, with gender specificities. Such barriers are substantially reduced when testing was proposed in the framework of antenatal care. This suggests that provider-initiated testing strategies may help overcome individual barriers to HIV testing.
doi:10.1371/journal.pone.0041353
PMCID: PMC3399867  PMID: 22815995
8.  ANRS–COM'TEST: description of a community-based HIV testing intervention in non-medical settings for men who have sex with men 
BMJ Open  2012;2(2):e000693.
Objective
To describe a community-based HIV testing programme.
Design and setting
An intervention of HIV voluntary testing conducted in non-medical settings in four French cities.
Participants
Men who have sex with men (MSM).
Intervention
Counselling and rapid HIV testing staffed by trained personnel from an HIV/AIDS community-based organisation.
Primary and secondary outcome measures
The population that has taken hold of the intervention and the satisfaction of participants. Data were collected on demographics, HIV testing history, sexual practices and satisfaction with the testing programme.
Results
532 MSM were tested between February 2009 and June 2010, of whom 49 (9%) were tested two or more times. 468 MSM (88%) had casual male partners in the previous 6 months, and 152 (35%) reported having unprotected anal intercourse with risky casual partners (HIV infected or HIV serostatus unknown). 159 men (30%) had not been tested in the previous 2 years, and 50 (31%) of whom had unprotected anal intercourse with risky casual partners. Among the 15 patients who tested positive (2.8%), 12 (80%) received confirmation and were linked to care (median CD4 cell count =550/mm3). Satisfaction was high: 92% reported being ‘very satisfied’ with their experience. Steps of counselling and testing procedure were respected by testers and difficulties in handling tests were rare.
Conclusions
This community-based HIV testing programme reached high-risk MSM, of whom a substantial proportion had not been tested lately. This novel service supplements pre-existing HIV testing services and increases access to HIV testing in high-risk groups.
Article summary
Article focus
How extend testing facilities to reach and test for HIV more MSM and diagnose HIV-infected MSM earlier?
The presence of peers and non-clinical staff members who address sexuality more openly and avoid medical jargon during counselling sessions could offset cultural barriers and reduce fears of HIV and associated stigma.
The article describes an experimental programme of community-based HIV testing: the population reached, the quality of the programme and the satisfaction of participants.
Key messages
This community-based HIV testing and counselling programme reaches MSM with high-risk sexual behaviour, a substantial proportion of whom has not tested for HIV recently.
Community testers are able to perform rapid HIV test into a comprehensive prevention approach in line with participant's life.
2.8% of participants tested positive. Infection was confirmed in all cases, 80% were linked to care. Cases were diagnosed at early stages of disease.
Strengths and limitations of this study
This HIV testing and counselling programme is exclusively based on MSM community, and continuing the prevention counselling with the awareness of the HIV serostatus includes testing into a comprehensive prevention approach.
Community-based HIV testing programmes may be attractive and efficient in large urban areas (like Paris), but perhaps less so in smaller cities, where an outreach approach may work better.
The number of HIV diagnoses was small; the prevalence and median CD4 count among the few HIV-infected participants should therefore be interpreted with caution.
doi:10.1136/bmjopen-2011-000693
PMCID: PMC3323802  PMID: 22466158
9.  Benchmarking the burden of 100 diseases: results of a nationwide representative survey within general practices 
BMJ Open  2011;1(2):e000215.
Objective
To assess the burden of diseases and quality of life (QOL) of patients for a large variety of diseases within general practice.
Design
In a representative nationwide cross-sectional study, a total of 825 general practitioners (GPs) were randomly selected from across France. Independent investigators recruited 8559 patients attending the GPs' practices. Data on QOL (12-Item Short Form questionnaire) and other individual characteristics were documented by the independent investigators for all participants in the waiting room. Medical information was recorded by GPs. Sampling was calibrated to national standards using the CALMAR (CALage sur MARges) weighting procedure. Associations of lower scores (ie, below vs above the first quartile) of physical and mental component scores (physical component summary score (PCS) and mental component summary score (MCS), respectively) with main diseases and patients characteristics were estimated using multivariate logistic regression. Weighted morbidity rates, PCS and MCS were computed for 100 diagnoses using the International Classification of Diseases (9th version).
Results
Overall mental impairment was observed among patients in primary care with an average MCS of 41.5 (SD 8.6), ranging from 33.0 for depressive disorders to 45.3 for patients exhibiting fractures or sprains. Musculoskeletal diseases were found to have the most pronounced effect on impaired physical health (OR=2.31; 95% CI 2.08 to 2.57) with the lowest PCS (45.6 (SD 8.8)) and ranked first (29.0%) among main diagnoses experienced by patients followed by cardiovascular diseases (26.7%) and psychological disorders (22.0%). When combining both prevalence and QOL, musculoskeletal diseases represented the heaviest burden in general practice.
Conclusions
Etude épidémiologique de l'Impact de santé public sur 3 groupes de pathologies (EPI3) is the first study to provide reference figures for burden of disease in general practice across a wide range of morbidities, particularly valuable for health-economics and healthcare-system evaluation.
Article summary
Article focus
The impact of diseases on quality of life (QOL) in general practice has been assessed among selected samples of patients, usually from studies including a limited number of medical practices and/or focusing mainly on chronic conditions.
There is a clear need for more data on QOL of patients in primary care; the aim of the Etude épidémiologique de l'Impact de santé public sur 3 groupes de pathologies (EPI3) survey was to provide reference figures for disease burden in this setting.
Key messages
The EPI3 study was a cross-sectional survey combining unique data from patients and general practitioners (GPs), and allowed provision of reference figures for the vast majority of diseases encountered in primary care for a large number of patients.
The study highlighted the burden of musculoskeletal and psychological disorders, experienced by more than half the patients.
Although social and medical determinants of patients' QOL were somewhat similar than those found in previous studies in primary care, the EPI3 survey showed more pronounced mental impairment in French patients.
Strengths and limitations of this study
No nationwide study on burden of disease combining both prevalence measures and QOL assessment has been conducted to date, addressing such a large variety of diseases in general practice.
On-site selection and recruitment by an independent investigator limited the possibility of selection bias among patients, and the participation of physicians added high specificity to medical data collection.
A study design providing a high specificity in data collection led to a relatively low response rate from GPs. However, stratified recruitment phases and sample sizes from both GPs and patients highly representative of national standards ensured the strong external validity of the results.
Home consultations, which are common among GPs in France, were not surveyed which could have led to an underestimation of the burden of disease.
doi:10.1136/bmjopen-2011-000215
PMCID: PMC3221295  PMID: 22102638
10.  Benchmarking clinical management of spinal and non-spinal disorders using quality of life: results from the EPI3-LASER survey in primary care 
European Spine Journal  2011;20(12):2210-2216.
Concerns have been raised regarding sub-optimal utilization of analgesics and psychotropic drugs in the treatment of patients with chronic musculoskeletal disorders (MSDs) and their associated co-morbidities. The objective of this study was to describe drug prescriptions for the management of spinal and non-spinal MSDs contrasted against a standardized measure of quality of life. A representative population sample of 1,756 MSDs patients [38.5% with spinal disorder (SD) and 61.5% with non-spinal MSDs (NS-MSD)] was drawn from the EPI3-LASER survey of 825 general practitioners (GPs) in France. Physicians recorded their diagnoses and prescriptions on that day. Patients provided information on socio-demographics, lifestyle and quality of life using the Short Form 12 (SF-12) questionnaire. Chronicity of MSDs was defined as more than 12 weeks duration of the current episode. Chronic SD and NS-MSD patients were prescribed less analgesics and non-steroidal anti-inflammatory drugs than their non-chronic counterpart [odds ratios (OR) and 95% confidence intervals (CI), respectively: 0.4, 0.2–0.7 and 0.5, 0.3–0.6]. They also had more anxio-depressive co-morbidities reported by their physicians (SD: 16.1 vs.7.4%; NS-MSD: 21.6 vs. 9.5%) who prescribed more antidepressants and anxiolytics with a difference that was statistically significant only for spinal disorder patients (OR, 95% CI: 2.0, 1.1–3.6). Psychotropic drugs were more often prescribed in patients in the lower quartile of SF-12 mental score and prescriptions of analgesics in the lower quartile of SF-12 physical score (P < 0.001). In conclusion, anxiety and depressive disorders were commonly reported by GPs among chronic MSD patients. Their prescriptions of psychotropic and analgesic drugs were consistent with patients’ self-rated mental and physical health.
doi:10.1007/s00586-011-1780-z
PMCID: PMC3229736  PMID: 21487774
Spinal disorders; Musculoskeletal disorders; Epidemiology; Population health
11.  Who seeks primary care for musculoskeletal disorders (MSDs) with physicians prescribing homeopathic and other complementary medicine? Results from the EPI3-LASER survey in France 
Background
There is a paucity of information describing patients with musculoskeletal disorders (MSDs) using complementary and alternative medicines (CAMs) and almost none distinguishing homeopathy from other CAMs. The objective of this study was to describe and compare patients with MSDs who consulted primary care physicians, either certified homeopaths (Ho) or regular prescribers of CAMs in a mixed practice (Mx), to those consulting physicians who strictly practice conventional medicine (CM), with regard to the severity of their MSD expressed as chronicity, co-morbidity and quality of life (QOL).
Methods
The EPI3-LASER study was a nationwide observational survey of a representative sample of general practitioners and their patients in France. The sampling strategy ensured a sufficient number of GPs in each of the three groups to allow comparison of their patients. Patients completed a questionnaire on socio-demographics, lifestyle and QOL using the Short Form 12 (SF-12) questionnaire. Chronicity of MSDs was defined as more than twelve weeks duration of the current episode. Diagnoses and co-morbidities were recorded by the physician.
Results
A total of 825 GPs included 1,692 MSD patients (predominantly back pain and osteoarthritis) were included, 21.6% in the CM group, 32.4% Ho and 45.9% Mx. Patients in the Ho group had more often a chronic MSD (62.1%) than the CM (48.6%) or Mx (50.3%) groups, a result that was statistically significant after controlling for patients' characteristics (Odds ratio = 1.43; 95% confidence interval (CI): 1.07 - 1.89). Patients seen by homeopaths or mixed practice physicians who were not the regular treating physician, had more often a chronic MSD than those seen in conventional medicine (Odds ratios were1.75; 95% CI: 1.22 - 2.50 and 1.48; 95% CI: 1.06 - 2.12, respectively). Otherwise patients in the three groups did not differ for co-morbidities and QOL.
Conclusion
MSD patients consulting primary care physicians who prescribed homeopathy and CAMs differed from those seen in conventional medicine. Chronic MSD patients represented a greater proportion of the clientele in physicians offering alternatives to conventional medicine. In addition, these physicians treated chronic patients as consulting rather than regular treating physicians, with potentially important impacts upon professional health care practices and organisation.
doi:10.1186/1471-2474-12-21
PMCID: PMC3034723  PMID: 21247493
12.  Mapping HIV/STI behavioural surveillance in Europe 
BMC Infectious Diseases  2010;10:290.
Background
Used in conjunction with biological surveillance, behavioural surveillance provides data allowing for a more precise definition of HIV/STI prevention strategies. In 2008, mapping of behavioural surveillance in EU/EFTA countries was performed on behalf of the European Centre for Disease prevention and Control.
Method
Nine questionnaires were sent to all 31 member States and EEE/EFTA countries requesting data on the overall behavioural and second generation surveillance system and on surveillance in the general population, youth, men having sex with men (MSM), injecting drug users (IDU), sex workers (SW), migrants, people living with HIV/AIDS (PLWHA), and sexually transmitted infection (STI) clinics patients. Requested data included information on system organisation (e.g. sustainability, funding, institutionalisation), topics covered in surveys and main indicators.
Results
Twenty-eight of the 31 countries contacted supplied data. Sixteen countries reported an established behavioural surveillance system, and 13 a second generation surveillance system (combination of biological surveillance of HIV/AIDS and STI with behavioural surveillance). There were wide differences as regards the year of survey initiation, number of populations surveyed, data collection methods used, organisation of surveillance and coordination with biological surveillance. The populations most regularly surveyed are the general population, youth, MSM and IDU. SW, patients of STI clinics and PLWHA are surveyed less regularly and in only a small number of countries, and few countries have undertaken behavioural surveys among migrant or ethnic minorities populations. In many cases, the identification of populations with risk behaviour and the selection of populations to be included in a BS system have not been formally conducted, or are incomplete. Topics most frequently covered are similar across countries, although many different indicators are used. In most countries, sustainability of surveillance systems is not assured.
Conclusion
Although many European countries have established behavioural surveillance systems, there is little harmonisation as regards the methods and indicators adopted. The main challenge now faced is to build and maintain organised and functional behavioural and second generation surveillance systems across Europe, to increase collaboration, to promote robust, sustainable and cost-effective data collection methods, and to harmonise indicators.
doi:10.1186/1471-2334-10-290
PMCID: PMC2959062  PMID: 20920339
13.  No variability across centers in adherence and response to HAART in French hospitals: results from the ANRS-EN12-VESPA study 
Objective
Because a centre effect can sometimes exist in HIV treatment, we sought to measure the heterogeneity of French hospital departments delivering HIV care and to test the presence of such an effect on adherence and response to HAART.
Methods
The ANRS-EN12-VESPA study is a nationally representative two-stage cross-sectional survey conducted in France in 2003 and covering 102 hospital departments providing HIV care. Each department described its HIV care activities and care provision. Analyses of adherence and four indicators of treatment outcome were restricted to the 699 patients diagnosed from 1996 onwards and treated with HAART for at least 6 months. The variability between departments was assessed with random-effect models for binary outcomes.
Results
The departments delivering HIV care proved to be somewhat heterogeneous in numerous respects, including their size and their onsite provision of consultancies and other services, as well as the characteristics of their patient population. Mean observed adherence was 63.3%, and the means of the different treatment failure indicators ranged from 6.1% to 59.8%. The departments showed some variability for these outcomes, but no significant centre effect was detected.
Conclusions
Despite the heterogeneity of the specific types of medical services offered by the hospitals providing HIV care, the nationwide treatment results appear homogeneous. This homogeneity could be attributed to the widespread and consistent application of therapeutic guidelines, which are regularly updated by consensus.
doi:10.1097/QAI.0b013e3181b26eb9
PMCID: PMC2936575  PMID: 19668085
Adult; Anti-HIV Agents; therapeutic use; Antiretroviral Therapy, Highly Active; Cross-Sectional Studies; Delivery of Health Care; Female; France; HIV Infections; drug therapy; Hospitals; Humans; Male; Medication Adherence; Middle Aged; Treatment Failure; HIV infection; HAART; Treatment failure; Service provision; Centre effect; France
14.  Routine testing to reduce late HIV diagnosis in France 
BMJ : British Medical Journal  2007;334(7608):1354-1356.
Although around half the French population has had an HIV test, many people are still not diagnosed until the disease is advanced. Cyrille Delpierre and colleagues believe the answer is to expand routine testing
doi:10.1136/bmj.39225.458218.94
PMCID: PMC1906674  PMID: 17600025
15.  Social vulnerability and unmet preventive care needs in outpatients of two French public hospitals 
Background
Outpatients attending consultations at public hospitals may have unmet needs for preventive medical care. The present study aimed to identify and assess the association between these needs, social vulnerability, and mode of healthcare use.
Methods
In a multicentre epidemiological study, a group of socially vulnerable outpatients was compared with a non-vulnerable group in a sample of 1316 outpatients selected in hospital consultations, using a validated tool for detection of social vulnerability. Before the patient was seen by medical staff, investigators collected data on social characteristics, healthcare use and preventive medical care received (interventions and advice).
Results
More than 75% of outpatients stated that they were regularly followed by a physician, usually a general practitioner, but fewer vulnerable than non-vulnerable outpatients were followed (77% vs 89%, p<10−3). For the majority of preventive interventions (vaccinations, screening for cardiovascular risk factors and gynaecological cancers), vulnerable outpatients presented a more marked shortage than non-vulnerable patients, but there was an overall shortage in both groups. When recommended preventive interventions had not been delivered, they had rarely been offered in either group. After adjustment for mode of healthcare use, the differences in preventive care received persisted to the disadvantage of vulnerable outpatients with regard to technical preventive interventions, but there was no difference between the two groups regarding advice received to reduce risk behaviours.
Conclusion
Unmet needs for preventive care primarily resulted from social inequalities in secondary access to such care. It may be necessary to set up specific interventions targeting vulnerable patients within hospital consultations.
doi:10.1093/eurpub/ckp033
PMCID: PMC2873303  PMID: 19307244
Adult; Ambulatory Care; Cross-Sectional Studies; Female; France; Health Services Needs and Demand; Healthcare Disparities; Hospitals, Public; Humans; Male; Middle Aged; Preventive Health Services; Retrospective Studies; Social Class; Vulnerable Populations; Young Adult; health inequalities; prevention; social vulnerability; healthcare use
16.  Living with HIV, antiretroviral treatment experience and tobacco smoking: results from a multisite cross-sectional study 
Antiviral Therapy  2008;13(3):389-397.
Objective
To assess prevalence of, and factors associated with tobacco smoking and dependence in HIV patients.
Design
A one-day cross-sectional national survey.
Methods
727 consecutive outpatients from a representative sample of 82 French units specialized in HIV-infected patient care were asked to complete a self-administered questionnaire, assessing smoking habits, dependence, cessation motivation, other substance abuse, socio-cultural characteristics, life with HIV and its treatment. Smoking prevalence and dependence were assessed and compared with a representative sample of the general French population; associated factors were determined.
Results
593 (82%) patients completed the questionnaire, 12% were active or ex-intravenous drug users, 37% were homosexual men; 43% were active smokers (31% in the French population). Fifty-six percent of smokers were classified as moderately or highly dependent, 14% of smokers were highly motivated and free of other substance abuse and of depressive symptoms. Smoking was independently associated with male sex (OR=2.38; 95% CI: 0.99–1.11), BMI (OR=1.08; 95% CI: 1.14-1.03), smoking environment (OR=4.75; 95% CI: 3.02–7.49), excessive alcohol consumption (OR=2.50; 95% CI: 1.20–5.23), illicit drug use (OR=2.43; 95% CI: 1.41–4.19), HIV status disclosure to family (OR=1.81; 95% CI: 1.16–2.85) and experience of rejection due to disclosure (OR=1.90; 95% CI: 1.14–3.17). Disclosure and drug substitutes’ usage were associated with high tobacco dependence.
Conclusions
Tobacco smoking is frequent and associated with other substance use and HIV disclosure. The rate of smokers who would be good candidates for a standard tobacco cessation program appears very low. Tobacco reduction or cessation strategies should be adapted to this population.
PMCID: PMC2652638  PMID: 18572752
Adaptation; Psychological; Adult; Africa South of the Sahara; Africa; Northern; Aged; Alcohol Drinking; epidemiology; Anti-Retroviral Agents; therapeutic use; Body Mass Index; Cross-Sectional Studies; Europe; Female; HIV Infections; drug therapy; epidemiology; psychology; Homosexuality; Male; statistics & numerical data; Humans; Male; Middle Aged; Motivation; Odds Ratio; Prejudice; Prevalence; Questionnaires; Risk Assessment; Risk Factors; Sex Factors; Smoking; epidemiology; prevention & control; psychology; Smoking Cessation; psychology; Substance-Related Disorders; epidemiology; Tobacco Use Disorder; epidemiology; psychology; therapy; Truth Disclosure; Tobacco; HIV; dependence; motivation; associated factors
17.  Factors correlated with disclosure of HIV infection in the French Antilles and French Guiana: results from the ANRS-EN13-VESPA-DFA Study 
AIDS (London, England)  2007;21 Suppl 1:S89-S94.
OBJECTIVES
To determine the rate, patterns and predictors of HIV disclosure in a predominantly heterosexual population in the Caribbean region.
METHODS
A cross-sectional survey was carried out among a 15% random sample (n= 398) of the hospital caseload in all 9 hospitals providing HIV care in French Antilles and French Guiana. Information was obtained from a face-to-face questionnaire and from medical records. Determinants of disclosure to 1) steady partner and 2) other members of the social network were analysed using logistic regression.
RESULTS
From the time of diagnosis, 84.6% of those in a couple (n=173) disclosed their HIV+ status to their steady partner/spouse, 55.6% disclosed to other close relatives and friends and 30.3% did not tell their status to anyone. Disclosure within steady partnership was less likely among non-French individuals (Haitians: aOR 0.11 [95%CI 0.02–0.72], other nationalities: aOR 0.13 [0.02–0.68]), and among patients diagnosed since 1997 (aOR 0.21 [0.05–0.86]). Determinants of disclosure to the family, friend or religious network were found to be gender (women: aOR 2.04 [1.24–3.36]), age at diagnosis (>=50 years vs <30 years: aOR 0.42 [0.19–0.90]), nationality (Haitians vs French: aOR 0.39 [0.19–0.77]), transmission route (non-sexual vs sexual: aOR 3.38 [1.12–10.23]) and hospital inpatients (hospitalised vs non-hospitalised patients: aOR 1.98 [1.17–3.37]). A marginally significant association was found between eduction and disclosure: less educated people disclosed less often both to steady partner and to their social network. After disclosing, most persons living with HIV/AIDS received social and emotional support from their confidants. Discriminatory attitudes were infrequent.
CONCLUSIONS
In this study, almost one third of persons living with HIV/AIDS had not told anyone that they were HIV positive. Interventions targeting the general population and social institutions, and support of PLWHA by healthcare staff are needed to improve the situation.
doi:10.1097/01.aids.0000255091.29050.13
PMCID: PMC2504690  PMID: 17159594
Adult; Age Factors; Attitude to Health; Caribbean Region; epidemiology; Cross-Sectional Studies; Female; HIV Infections; ethnology; psychology; transmission; Humans; Male; Middle Aged; Prejudice; Sex Factors; Truth Disclosure
18.  Correlates of late HIV diagnosis: implications for testing policy 
To develop new strategies aimed to reduce the delay in seeking HIV diagnosis, we proposed to identify correlates of late diagnosis of HIV infection in France. Late testing was studied among the 1077 patients diagnosed from 1996 and enrolled in the ANRS-EN12-VESPA, a representative sample of the French HIV-infected population. Patients were defined as “late testers” if they had presented either clinical AIDS events or CD4 cell count <200/mm3 at diagnosis. 33.1% were classified as late testers, among whom 42.6% had discovered their HIV infection at the time of AIDS events. This proportion increased with age and was higher for heterosexual men and migrants. Among the non migrants heterosexual population, late diagnosis was more frequent among people in longstanding couple, with children and conversely was less likely among individuals with large number of sexual partners. Being on welfare benefit before diagnosis was associated with a lower risk of late diagnosis. Among migrants, lack of recent steady partnership was associated with an increased risk, as being diagnosed during the first year of stay in France.
Our results showed low risk factors of infection were risk factors of late testing. Public communication should aimed at improving the awareness of HIV risk in longstanding couples with stable employment, both among homosexual and heterosexual populations. Among migrants, HIV testing with informed consent short after entry should be improved, especially towards individuals not in couple.
doi:10.1258/095646207780749709
PMCID: PMC2486458  PMID: 17524190
Adult; CD4 Lymphocyte Count; Family Characteristics; Female; France; epidemiology; HIV Infections; diagnosis; epidemiology; prevention & control; Health Policy; Health Surveys; Heterosexuality; Homosexuality, Male; Humans; Male; Middle Aged; Patient Acceptance of Health Care; Risk-Taking; Sexual Partners; Time Factors; Transients and Migrants; HIV infection; Late diagnosis; France; Heterosexual longstanding couples; Migrants
19.  Disease severity, self-reported experience of workplace discrimination and employment loss during the course of chronic HIV disease: differences according to gender and education 
Objectives
Evidence for the existence of a harmful effect of chronic disease on employment status has been provided. Although this effect of chronic illness on employment has been reported to be higher among the groups with the lowest position on the labour market, the mechanisms of such inequalities are poorly understood. The present study aimed at investigating social inequalities in the chances of maintaining employment during the course of HIV infection and at examining the correlates of such inequalities.
Methods
We used data from a national representative sample of persons living with HIV in France (ANRS-EN12-VESPA survey). Retrospective information on social trajectory and disease characteristics from the time of HIV diagnosis was available. The risk of employment loss associated with indicators of disease severity and HIV-related workplace discrimination was computed over time since HIV diagnosis according to sociodemographic and occupational factors, using Cox proportional hazards models.
Results
Among the 478 working-aged participants diagnosed as being HIV-infected in the era of multitherapies and employed at the time of HIV diagnosis, 149 experienced employment loss. After adjusting for sociodemographic and occupational factors, disease severity and self-reported HIV-related discrimination at work were significantly associated with the risk of employment loss in a socially-differentiated manner: advancement in HIV disease was associated with an increased risk of employment loss among women (HR 4.45, 95% CI [2.10–9.43]) but not among men; self-reported experience of HIV-related discrimination at work was associated with an increased risk of employment loss among individuals with a primary/secondary educational level (HR 8.85, 95%CI [3.68–21.30]) but not among those more educated.
Conclusions
Chronic HIV disease affects the chances of maintaining employment in a socially differentiated manner, resulting in increasing inequalities regarding workforce participation. Disease severity and workplace HIV-related discrimination, by weighing especially on employment status of those with the most disadvantaged socioeconomic position may play a major role.
doi:10.1136/oem.2007.034363
PMCID: PMC2259228  PMID: 17981911
Adult; Age Factors; Chronic Disease; Educational Status; Emigration and Immigration; Female; France; HIV Infections; psychology; HIV-1; Health Status; Health Surveys; Humans; Male; Middle Aged; Occupational Diseases; psychology; Odds Ratio; Prejudice; Risk; Sex Factors; Unemployment; Workplace; HIV infection; employment; social inequalities; workplace discrimination
20.  Antiretroviral HIV treatment and care for injecting drug users: an evidence-based overview 
AIDS-related mortality and the rate of progression to AIDS have dramatically decreased since the advent of highly-active antiretroviral treatment (HAART). The overall benefit from antiretroviral HIV treatment has, however, been lesser in HIV-infected IDUs than in other patient groups (e.g. men who have sex with men). Poorer outcomes in HIV-infected IDUs are related to a variety of factors, including increased rates of non-HIV related deaths, hepatitis C, delayed access to effective treatment, lower adherence to care and treatment regimens, continuation of illicit drug use, depression and negative life events. The available evidence strongly suggests the need for the large-scale implementation of comprehensive treatment and care strategies for IDUs that include both treatment of drug-dependence and HAART.
doi:10.1016/j.drugpo.2007.05.002
PMCID: PMC2020510  PMID: 17689373
21.  Buprenorphine substitution treatment in France: drug users' views of the doctor-user relationship 
Social Science & Medicine (1982)  2007;64(12):2578-2593.
The French system for drug substitution, or maintenance treatment, established in 1996, differs from the often strict conditions attached to methadone clinics in other countries. Because of the predominant role of general practitioners and the flexible prescription rules for Subutex® in France, the relationship between the physician and the drug user becomes a central element in the treatment. This article deals with the expectations that these users have of the physician, and their perception of his or her attitude towards them. In order to identify possible reasons for the absence of treatment compliance and of Subutex® misuse, it focuses on the users’ assessment of the physician’s response to the problems they report.
This study, based on a diversified sample of 28 persons in treatment, showed 4 patterns of relationships between physicians and users, which differed in their focus: a) dosage, b) compliance, c) the person and d) obtaining a prescription. In all four case types, users had difficulty reporting other drug use or intravenous Subutex® injection within this relationship in which the stigma attached to drug dependence seems to reappear. Moreover, the lack of clarity about the treatment objectives and time frame limits the users’ ability to integrate the treatment into their lives and to commit themselves to it. The heterogeneity and fragility of the users’ situations are elements related to dependence that, during contact with the physician, require regular assessment of the individual’s situation and of the treatment objectives. This constant reappraisal of the situation with the physician should help to optimize the treatment and avoid the hiatus that can generate or continue “misuse.”
doi:10.1016/j.socscimed.2007.02.049
PMCID: PMC1950347  PMID: 17442473

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