Hiv testing in minorities and women 1999


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Hiv testing in minorities and women 1999

  1. 1. HIV TESTING, KNOWLEDGE, ATTITUDES, BELIEFS, AND PRACTICES AMONGMINORrTIES: PREGNANT WOMEN OF NORTH-AFRICAN ORIGIN IN SOUTHEASTERN FRANCE Antoine Messiah, MD, PhD, Dominique Rey, MD, Yolande Obadia, MD, Michel Rotily, MD, and Jean-Paul Moatfi, PhD Marseille, France Since 1991, the French public health ministry has recommended that human immunod- eficiency virus (HIV) testing be offered to all pregnant women. This study was undertaken to determine whether this recommendation is followed independently of a womans ethnicity. It is based on a 1992 survey regarding knowledge, attitudes, beliefs, and practices on HIV infection and testing among pregnant women in southeastern France. Survey results revealed that North-African women (n=207) were more likely to have a low socioeconomic and educational level, receive their health care at public health institu- tions, and be less knowledgeable about HIV transmission than French women (n=2234). They were also more likely to have been tested for HIV without their knowing it and less like- ly to perceive themselves as being at risk. Consent to undergo HIV testing during pregnancy was dependent on their North-African origin after controlling for significant covariates. These results indicate that routine prenatal screening appears insufficient to ensure ade- quate HIV testing and counseling of women of ethnic minorities. The development of HIV pre- vention programs that are cultural-specific and that aim at increasing physicians compliance with the official recommendation is needed. (J Nati Med Assoc. 1 998;90:87-92.) Key words: * human immunodeficiency virus ate for general policies of human immunodeficiency (HIV) * HIV transmission * minorities virus (HIV) screening and counseling to reach all women.2 This is especially true in France, where the In France, as in most other industrialized countries, public social insurance system guarantees universalthe proportion of women among the total number of health coverage for all pregnant women living in theregistered acquired immunodeficiency syndrome country. Since the early 1970s, a minimum of four(AIDS) cases has increased steadily since the begin- free-of-charge prenatal care medical consultationsning of the epidemic (from 13.9% in 1987 to 20.4% in (including testing for syphilis, rubella, and toxoplas-1995.1 Prenatal care is viewed as especially appropri- mosis at the first visit) have been mandatory. It is wide- ly accepted that this legislation greatly contributed toFrom the South-Eastern French Center for Disease Control and the recent progress in prenatal care and prevention of pre-Institut Paoli-Calmettes, Marseille, France. This study was supported term births and childrens handicaps.3by the French Agency for Aids Research. Requests for reprints In December 1991, the French Ministry of Healthshould be addressed to Dr Antoine Messiah, INSERM U-379, Institut issued an official recommendation that general practi-Paoli Calmettes, 232 bd Sainte Marguerite, BP 156, 13273 tioners, gynecologists, and obstetricians systematicallyMarseille Cedex 09, France. offer, an HIV test to all pregnant women consultingJOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 90, NO. 2 87
  2. 2. HIV TESTING AMONG MINORITIES foreigners; among them, 35% come from North Table 1. Sociodemographic Data and Conditions Africa.6 Evidence from other countries strongly sug- of Pregnancy, by Ethnic Group gests that HIV prevention programs have specific dif- % North- ficulties in reaching women from ethnic minorities African % French and emphasizes the need for culturally adapted mes- Women Women sages and interventions.79 It is therefore important to (n=207) (n=2234) P Value know, if despite the official recommendation, there Age (years) are differences in access to HIV testing and counsel- <25 26 21 ing between members and nonmembers of these 25 to 34 60 67 NS minorities and to determine to which factors these dif- ,35 14 12 ferences are related. Matrimonial status A survey on HIV screening among pregnant Married 71 64 women conducted in southeastern France in 1992, Unmarried but living with a partner 13 28 <.001 the Prevagest survey,011 included North-African and Living alone 16 7 French women. The survey examined sociodemo- Level of education graphic characteristics, pregnancy conditions, HIV University graduate 15 52 testing experience, risk situation and risk perception, Secondcary school and knowledge and beliefs about HIV transmission. graduate 44 37 <.001 Lower level of METHODS education 41 11 Population Occupational status The Prevagest survey is described elsewhere.0"1 It Employed 27 70 <.00 1 consists of three subsurveys directed at pregnant Unemployed 73 30 women and the health-care institutions caring for Level of income ,6000 francs 58 14 <.001 them. The first subsurvey is an unlinked anonymous >6000 francs 42 86 HIV seroprevalence survey. The second subsurvey, Religion which is analyzed in this article, is a survey on the None or not knowledge, beliefs, attitudes, and practices of the practicing 30 64 <.001 women. Through the data collected by the third sub- Practicing 70 36 survey, directed at the institution, we could determine Prenatal care whether the women were in a ward conducting sys- delivered by tematic testing; the accuracy of this information was Private ambulatory checked by direct observation at each site. In south- physicians 44 76 <.001 eastern France, 77 wards attend pregnant women for Public prenatal delivery. Seventy-one wards agreed to participate in institutions 56 24 No. of prenatal the study during April 1992. A total of 3148 women consultations were cared for during the study period; of these, 114 <4 2 1 (4%) neither spoke nor read French and 209 (7%) 4 6 1 <.001 refused to participate. The remaining 2825 women I,< 4 92 98 included North Africans (n=207), French metropoli- Abbreviations: NS=not significant. tans (born in continental France) (n=2234), French Caribbeans (n=37), Europeans (n=207), sub-Saharan Africans (n=35), other (n=63), and unknown (n=42). For the purpose of this article, the first two groupsfor prenatal care, provided the women gave informed were compared.consent and could decline the offer. In this context,screening appears as a universal policy, expected to be Data Collection and Analysisequal for everyone, but it assumes that preventive A self-administered anonymous questionnaire wascounseling targeted at the general population is able to proposed by a nurse to all the hospitalized womenreach all subgroups, including cultural minorities.45 within 3 days after childbirth. Topics included Of the entire population living in France, 6.3% are detailed sociodemographic information, the womans88 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 90, NO. 2
  3. 3. HIV TESTING AMONG MINORITIESexperience with prenatal care and HIV testing duringher pregnancy, HIV-related individual risk behaviors Table 2. Risk Behavior and Individual Riskand perception, and knowledge concerning horizon- Perception, by Ethnic Grouptal and vertical HIV transmission. For the institutions % North-whose policy was systematic testing, a womans African % Frenchanswers to the question, "Were you offered an HIV Risk Women Womentest here?" allowed us to determine whether she had Behavior (n=207) (n=2234) P Valuebeen tested with or without her knowledge. Multiple sexual partners in the past 2 years Univariate comparisons between ethnic groups Yes 5 7 NSwere performed with the chi-squared test (qualitative No 95 93data) and Students t-test (quantitative data).2 All sig- Intravenous drug use (at least once)nificant variables (P<.05) were introduced into a Yes 1 1 NSlogistic regression model,3 with a womans declara- No 99 99 HIV-positive sexual partner (at least once)tion of having been tested (versus not) during her Yes 0 0 NSpregnancy as the dependent variable. The final No 100 100model consisted of variables with P<.10. Calculations Intravenous drug user sexual partner (at least once)were done using SPSS software. Yes 0 2 NS No 100 98RESULTS DeclaredSociodemographic Data and Conditions of At least one ofPregnancy the above 6 8 NS Regarding age, North-African women were similar None ofto French metropolitan women (Table 1). North- the above 94 92African women were more likely to live alone, to be Declared higher or average risk of being infected, in comparison with overall womens populationunemployed and less educated, to have a low Yes 7 20 <.001income, to practice a religion, and to have their pre- No 93 80natal care delivered by public institutions. Frenchmetropolitan women were more likely to have more Abbreviations: NS=not significant and HIV=humanthan four prenatal consultations. immunodeficiency virus.HIV Testing Experience, Risk Situation and RiskPerception, Knowledge, and Beliefs About HIV tan women (P<.001) had had a routine HIV test with-Transmission out their being aware of it because of a lack or inade- Declaration of prenatal HIV testing was signifi- quacy of informed consent procedures. Thus, thecantly lower among North-African women (42%) actual frequency of prenatal HIV testing was similarthan among French metropolitan women (65%; between North-African women (75%) and FrenchP<.001). Eighty-three percent of French metropolitan metropolitan women (73%).women declared that they had been tested at least North-African women declared HIV-related riskonce for HIV, including the ones who had a test behaviors as frequently as French metropolitanbefore the pregnancy, versus 49% among North- women did (Table 2). However, they were less likelyAfrican women (P<.001). Among the 907 women to perceive themselves at higher or average risk.who said they had not been tested for HIV during Knowledge about the main routes of HIV trans-pregnancy, only a few (3.3% of North-African women mission was less accurate among North-Africanand 1.3% of French metropolitan women) had women; the difference was larger for horizontal thanrefused the test offered to them; this contrasts with for vertical transmission (Table 3). North-African68% of North-African women and 56% of French women more frequently believed in HIV transmis-metropolitan women to whom the test had not been sion through casual contact and mosquito bite.proposed (P<.001). When the womens statementsand those of the medical ward attending them were Multivariate Analysispooled, it appeared that an additional 33% of North- To determine how differences in HIV testing dur-African women versus only 8% of French metropoli- ing pregnancy were correlated with the variables dif-JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 90, NO. 2 89
  4. 4. HIV TESTING AMONG MINORITIES Table 3. Knowledge and Beliefs About HIV Horizontal and Vertical Transmissions, by Ethnic Group Knowledge % North-African % French & Beliefs Women (n=207) Women (n=2234) P Value Horizontal Transmission Correct answers to People can get AIDS from* Sexual intercourse (yes) 73 95 <.001 Intravenous drug use (yes) 73 91 <.001 Receiving blood (yes) 68 88 <.001 Donating blood (no) 31 55 <.001 Being admitted in the same hospital ward as a person with AIDS (no) 44 72 <.001 Using public lavatories (no) 32 60 <.001 Drinking in a glass used by a person with AIDS (no) 41 65 <.001 A mosquito bite (no) 33 57 <.001 Knowledge scoret m=4.3 m=5.9 <.001 SD=2.2 SD=1.7 Vertical Transmission Correct answers to "HIV can be transmitted from an infected mother to her baby"* During pregnancy (yes) 69 90 <.001 During delivery (yes) 19 37 <.001 Through breast-feeding (yes) 32 39 NS By taking care of the child after birth (no) 37 68 <.001 Knowledge scoret m=1.7 m=2.4 <.001 SD=1.1 SD=1.0 Abbreviations: HIV=human immunodeficiency virus, AIDS=acquired immunodeficiency virus, SD=standard deviation, and NS=not significant. *The correct answer is given in parentheses. tThe score (minimum=0, maximum=8) was built by counting each correct answer as 1 and summing them. $The score (minimum=0, maximum=4) was built by counting each correct answer as 1 and summing them.ferentiating North-African women from French met- nant women delivering in southeastern France wereropolitan women, logistic regression was performed surveyed during the study period, but not all could be(Table 4). It showed a positive correlation between reached because the study protocol was restricted toknowledge scores, risk perception, and the likeli- French-speaking women for practical reasons. It ishood of being tested (with the womans knowledge). likely, however, that if non-French speaking womenIt also showed that those women who were married, had been included, differences between migrants andhad a low educational level, and low income level nonmigrants would have been even larger. Southernwere significantly less likely to be tested. Finally, it France has historical links with North Africa and isshowed that even when these covariates were con- the focus for migration and travel to Europe; effec-trolled for, being a North-African women was still tively, non-French women in our sample were pri-significantly associated with a lower likelihood of marily from North Africa. Only small populationsbeing tested with informed consent. come from other non-European countries, which pre- vented their inclusion in this analysis. The situation ofDISCUSSION these other minorities may be quite different, but in- This survey was the first in France to compare depth analysis would require surveys in Frenchaccess to HIV screening and counseling between regions where they are better represented.migrant and metropolitan women. Most of the preg- The French public social insurance system guaran-90 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 90, NO. 2
  5. 5. HIV TESTING AMONG MINORITIES Table 4. Logistic Regression Analysis of Womens Declaration of Having Had an HIV Prenatal Test (Yes Versus No)* OR 95% Cl P Value Matrimonial status Married 0.59 0.39-0.88 .010 Unmarried but living with a partner 0.83 0.55-1.27 .398 Living alone* 1 .00 Level of education University graduate* 1.00 Secondary school graduate 0.59 0.49-0.73 <.001 Lower level of education 0.53 0.39-0.71 <.001 Level of income <6000 francs 0.75 0.57-1.00 .050 >6000 francs* 1.00 Individual risk perception of being HIV infected when compared with average risk among women Higher or average risk 1.25 0.99-1.58 .066 Lower or no risk, or no evaluation* 1.00 Knowledge scores (numeric variables) Of horizontal HIV transmissiont .027 Of vertical HIV transmissiont .019 Ethnic group North-African women 0.61 0.44-0.90 .007 French women* 1.00 Abbreviations: OR=adjusted odds ratio and CI=95% confidence interval. *Category of reference. tOR=1.06 per point of score. tOR=1 .12 per point of score.tees universal coverage for all pregnant women living HIV transmission through casual contact and mos-in the country, and the legislation recommends that quito bite, as found in other ethnic minorities.89 Suchall pregnant women be offered HIV screening, pro- cultural beliefs create specific challenges for HIV pre-vided they give informed consent. Screening policy vention.4"5 In addition, married women were lesstherefore is expected to be equal for everyone. Our likely to have been tested for HIV, contrasting withsurvey shows that if all HIV tests taken with or with- unmarried women living with their partner. This sug-out the womans knowledge are considered, the fre- gests that marriage restrains women of ethnic minori-quency of prenatal HIV testing is similar between ties from being tested. Until now, North Africa wasgroups independently of ethnic origin. However, the relatively unaffected by the epidemic; most HIV-survey also shows that equality is not achieved in positive women were infected by their husbands.6practice. It reveals a dramatic difference in applica- In France, only 3% of cumulated AIDS patients intion of the testing policy: North-African women were 1993 were born in North Africa." It often is arguedmore frequently tested without their knowledge and that the traditional cultural norms of North-Africanless likely to have been proposed a test by the physi- women have a protective effect against HIV infec-cian, suggesting a lack of adequate preventive coun- tion.18 Some of the HIV-related beliefs of theseseling associated with testing for these women. This is women are closely linked to the Islamic religion, eg,especially unfortunate because, as the survey shows, risk of vertical contamination through breast-feed-North-African women lack knowledge about AIDS ing and, more generally, risk of transmissiontransmission and are less likely to feel at risk although through contact with body fluids.they declared at risk behaviors as frequently as Numerous aspects differentiating North-AfricanFrench women did. women from French women, including lower North-African women more frequently believed in socioeconomic and educational levels, couldJOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 90, NO. 2 91
  6. 6. HIV TESTING AMONG MINORITIESexplain the lesser tendency of North-African women Naitre en France, dix ans divolution. Paris, France: Doin-INSERM; 1984.of knowing that they had a test. Even when these 4. Steffen M. France: social solidarity and scientific exper-parameters were controlled for, being of North- tise. In: Kirp DL, Bayer R eds. AIDS in the IndustrializedAfrican origin was still correlated with this tendency. Democracies. Passions, Politics and Policies. New Brunswick, NJ:This suggests that institutional factors might be at Rutgers University Press; with these women. Such factors include the 5. MoattiJ, Dab W, Loundou A, Quenel P, Beltzer N, Ames A, et al. Impact on the general public of media campaigns againstwards screening policy toward these women and AIDS: a French evaluation. Health Policy. 1992;21:233-247.the physicians perceptions of womens risk and 6. Labat J. La Population Etrangere. Recensement de latheir ability to deal with HIV prevention. They can- Population de 1990. Paris, France: INSEE Premiere; 1991.not be attributed to language barriers since women 7. OLeary A. Women at Risk: Issues in the Primary Preventionwho neither spoke nor understood French did not ofAIDS New York, NY: Plenum Press; 1995 8. Peruga A, Rivo M. Racial differences in AIDS knowledgeparticipate in the study. among adults. AIDS Educ Prev. 1992;4:52-60. Our survey strongly suggests that universal routine 9. Nyamathi A, Bennett C, Leake B, Lewis C, FlaskerudJ.prenatal HIV screening does not guarantee adequate AIDS-related knowledge, perceptions and behaviors amongcounseling, especially for women of ethnic minorities. impoverished minority women. AmJPublic Health. 1993;83:65-71.Additional studies on ethnic minorities other than 10. Obadia Y, Rey D, Moatti JP, Pradier C, Couturier E, Brossard Y, et al. HIV prenatal screening in South-EasternNorth-African women are necessary to confirm this France: differences in seroprevalences and screening policies byin the French context. pregnancy outcomes. AIDS Care. 1994;1:29-38. Zidovudine treatment of HIV-infected mothers, 11. Rey D, Moatti J, Obadia Y, Rotily M, Dellamonica P,which significantly reduces the risk of vertical trans- GilletJ, et al. Differences in HIV testing, knowledge and attitudesmission,1920 creates more incentives for the develop- in pregnant women who deliver and those who terminate: Prevagest 1992-France. AIDS Care. 1995;7:S39-S46.ment of systematic HIV prenatal screening. It 12. Armitage P, Berry G. Statistical Methods in Medicalunderscores the need for culturally sensitive pro- Research. 2nd ed. Oxford, England: Blackwell Scientificgrams for the medical community for these women Publications; benefit from the recent therapeutic advances in 13. Kleinbaum D, Kupper L, Morgenstern H. Epidemiologicprevention of vertical transmission, without contra- research principles and quantitative methods. New York, NY: Van Nostrand Reinhold; 1982.vening the ethical principle of patients individual 14. Ulin P. African women and AIDS: negotiating behavioralfreedom of choice. Additional prevention programs change. Soc Sci Med. 1992;34:63-73.therefore are needed, with some targeted at ethnic 15. Guerin A. Le modele culturel de la femme Africaine. Unminorities and others targeted at physicians and entretien avec Francoise Heritier-Auge. Le Journal du Sida.their institutions. 1994;64-65:33-34. 16. Maaroufi A, Chakib A, El Aouad R, Squalli M, Zahraoui M, Himmich H. Aspects Cliniques et Therapeutiques de linfection 2Acknowledgments VIH au Maroc. In: The Proceeding of the VIII International The authors thank Claire Julian-Reynier and Michel Morin Conference on AIDS in Africa, Marrakech 1993. Abstract.for help and advice during manuscript preparation, Colette 17. Lariven S, Bouvet E, Verdon R, Casalino E, Laporte A,Boirot and Fabienne Micollier for documentation, Anderson Vachon F. HIVInfection in Maghrebin Population in France. In: TheLoundou for computations, Carole Giovannini for typing the Proceeding of the VIII International Conference on AIDS inmanuscript, and Gary Burkhart for editing the text. Antoine Africa, Marrakech 1993. Abstract.Messiah is supported by a fellowship from the Fondation pour la 18. Moumen-Marcoux R. Migrants et Perception du Sida: LeRecherche Medicale. Maitre des Infideles. Paris, France: Lharmattan; 1993 19. Boyer P, Dillon M, Navaie M, Deveikis A, Keller M,Literature Cite ORourke S, et al. Factors predictive of maternal-fetal transmis- 1. Reseau National de Sante Publique. Surveillance du Sida sion of HIV-1: preliminary analysis of zidovudine given duringen France (situation au 31 Decembre 1995). Bulletin Epidemiologique pregnancy and/or delivery.JAAL4. 1994;271:1925-1930.Hebdomadaire. 1996;10:45-51. 20. Connor E, Sperling R, Gelber R, Kiselev P, Scott G, 2. Minkoff H, Holman S, Beller E, Delke I, Fishbone A, OSullivan M, et al. Reduction of maternal infant transmission ofLandesman SH. Routinely offered prenatal HIV testing. NEngIJ human immunodeficiency virus type 1 with zidovuline treatment.Med. 1988;319:1018. Letter. Pediatric AIDS Clinical Trial Group Protocol 076 Study Group. 3. Rumeau-Rouquette C, Du Mazaubrun C, Rabarison Y. NEnglJMed. 1994;331:1173-1180.92 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 90, NO. 2