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L'enquête Parcours réalisée en 2012-2013 dans des établissements de santé en Île-de-France permet d'étudier les violences sexuelles que les femmes immigrées originaires d'Afrique subsaharienne ont subies après leur migration et d'examiner le contexte social de leur survenue. L'insécurité résidentielle et administrative accroît ces violences sexuelles. Un tiers des femmes séropositives pour le VIH a été infecté après la migration, et rapporte quatre fois plus souvent avoir été victime de rapports sexuels forcés que les femmes non infectées.

Objective Recent studies highlighted that many HIV-positive migrants in Europe acquired their infections post-migration. However, the timing of these infections is not always known. This study aims to estimate the timing of post-migration HIV acquisition among sub-Saharan migrants in France and to understand the correlates of post-migration infection. Methods Within the PARCOURS retrospective survey conducted in 2012-2013 in 74 healthcare facilities in the Paris region, life-event data were collected among a random sample of 926 patients living with HIV in HIV services and 763 patients undiagnosed with HIV in primary care centres born in sub-Saharan Africa (reference group). Based on previous analysis, we considered the first 6 years in France after migration as a settlement period. Among the persons who acquired HIV after migration, we estimated the proportion of persons infected during settlement (0-6 years after migration) and after settlement (>6 years after migration) by using an algorithm that combines life-event data and a modelisation of CD4(+) T-cell count decline. We then assessed the determinants of HIV acquisition during settlement and after settlement using bivariate logistic regression models. Results Overall, 58% of sub-Saharan migrants who acquired HIV after migration were infected during the first 6 years in France. HIV acquisition during settlement was found to be linked to short/transactional partnerships and lack of a resident permit. 42% of migrants had contracted HIV after settlement. After settlement, HIV acquisition was associated with short/transactional but also with concurrent partnerships and not with social hardship. Conclusion Two profiles of HIV post-migration acquisition emerged. The majority of HIV post-migration acquisition occurs during the settlement period: comprehensive combination prevention programmes among recently arrived migrants are needed. However, long-term migrants are also at risk for HIV through multiple partnerships. Prevention programmes should address the different profiles of migrants at risk for post-migration HIV acquisition.

Migration can affect reproductive outcomes due to different socioeconomic and cultural contexts before and after migration, to changes in the affective and conjugal status of women and to their life conditions. The aim of this study is to investigate the association between international migration and abortion. The data came from a retrospective life-event survey from sub-Saharan African women living in ile-de-France. Differences in abortion distribution before and after migration were assessed using the Pearson chi-square test, and the association between the predictor and the outcome was investigated using Generalized Estimating Equations. A total of 363 women and 1377 pregnancies were investigated. Among these pregnancies, 15.6% that occurred before and 11.0% that occurred after migration was reported as ended in abortion (p = 0.011). The odds of reporting having had an abortion was lower after migration (OR 0.59, 95% CI 0.42-0.84), even after adjustment. However, after including intendedness of pregnancy in the model, this association lost its significance. The difference in induced abortion occurrence between before and after migration is almost entirely due to a change in the intendedness of pregnancy. Thus, socioeconomic and cultural issues have a greater weight in the decision to abort than the legal interdiction of this practice.

Migrants from sub-Saharan Africa (SSA) are often diagnosed at an advanced stage of HIV, and many of them have harsh living conditions. We aimed to evaluate the entry into care after HIV diagnosis and examine the related social determinants. The ANRS PARCOURS study is a life-event survey conducted in 2012-2013 in the Paris region among. Time between HIV diagnosis of SSA migrants living diagnosed HIV positive in France and HIV care and the determinants was assessed yearly by using mixed-effects logistic regression models. Among a total of 792 participants, 94.2% engaged in HIV care within the year of HIV diagnosis, 4.3% in the following year and 2.5% beyond the second year after diagnosis. The participants were more likely to engage in HIV care during years when they were effectively covered by health insurance and if the HIV test was carried out at the initiative of the doctor. Immigration for economic reasons or owing to threats in his/her country of origin was associated with delayed engagement in HIV care. Additionally, 4.3% of treated participants discontinued HIV care at least once at the time of the survey and more often if diagnosed at an advanced HIV disease stage and financially dependent.

Background: Sub-Saharan and Caribbean immigrants are particularly affected by HIV in Europe, and recent evidence shows that a large portion of them acquired HIV after arrival. There is a need for efficient interventions that can reduce immigrants' exposure to HIV. We describe the pilot phase of a community-based empowerment outreach intervention among sub-Saharan and Caribbean immigrants in the greater Paris area aimed at 1) constructing the intervention, 2) assessing its feasibility, and 3) assessing the feasibility of its evaluation based on a stepped-wedge approach. Methods: 1) To develop the intervention, a literature review was conducted on existing interventions and participatory approaches developed, including the constitution of peer groups. 2) To assess the intervention's feasibility, a pilot was conducted between April 2018 and December 2018. A daily register was used to collect data on sociodemographic characteristics of all persons who visited the mobile team to assess eligibility and acceptability. 3) To assess the feasibility of performing a stepped-wedge trial to evaluate the intervention, we compared eligibility, enrolment and retention at 3 months in two arms (immediate vs deferred). Chi-squared tests were used to compare reach and retention between the two arms. Results: Intervention development. The Makasi intervention was designed as an outreach intervention that starts with the persons' capacities and helps them appropriate existing resources and information and obtain knowledge about sexual health, based upon motivational interviewing techniques. Intervention Feasibility. Between April 2018 and December 2018, a total of 485 persons were identified as eligible. Participation in the intervention was proposed to 79% of eligible persons. When proposed, the persons enrolled in the intervention with a response rate of 69%. Some were lost to follow-up, and 188 persons were finally included. Evaluation Feasibility. The proportions of eligible (45 and 42%) individuals and of enrolled individuals (65 and 74%) were similar and not significantly different in the immediate and deferred arms, respectively. Conclusions: A community-based outreach intervention aimed at improving sub-Saharan and Caribbean immigrants' empowerment in sexual health is feasible. The pilot phase was key to identifying challenges, designing a relevant intervention and validating the stepped-wedge protocol for evaluation.

Background: This study aimed to estimate the frequency of renunciation of health care among people living with HIV (PLHIV) in France, including health care unrelated to HIV, and to characterize associated socioeconomic and psychosocial risk factors.Methods: The cross-sectional ANRS-VESPA2 survey was conducted on adult PLHIV attending French hospitals in 2011. Correlates of health-care renunciation in the 12 months before the survey were assessed through logistic modelling. Results: Among the 3,020 PLHIV included in the sample, 17% declared health-care renunciation during the preceding year and 42% had a high level of social insecurity. During the previous 2 years, 8% and 11%, respectively, were discriminated against by medical staff and family. In multivariate analysis, positive associations were found between health-care renunciation and a high level of social insecurity (adjusted odds ratio [95% CI] 3.44 [2.54, 4.65]; P

Background: In this study, we aim to measure and compare the frequency of reported denial of care in subSaharan African migrants living in the Paris area, according to their HIV and HBV status and social and migration characteristics. Methods: The ANRS-PARCOURS study is a life-event survey conducted in 2012-13 in healthcare facilities in the Paris area, among three groups of sub-Saharan migrants recruited in primary care centres (N= 760; reference group), in dedicated centres for HIV care (N= 922; HIV group) and in centres for chronic hepatitis B care (N= 777; CHB group). Characteristics associated with refusal of care since arrival in France were identified using a logistic regression model. Results: Compared to the reference group (6%, P < 0.001), the reported refusal of care was twice as high in the HIV group (12%) and the CHB group (10%). In the multivariate analysis, men and women living with HIV were at greater risk of being denied care (aOR = 2.20[ 1.14-4.25] and 2.24[ 1.25-4.01]). Women covered by the specific health insurance (HI) for precarious or undocumented migrants were also at higher risk (aOR = 2.07[ 1.10-3.89] and 2.69[ 1.18-6.10], respectively). The risk was also increased in men who remained for at least one year without permit of residence or without HI and among those who were threatened in their country. Conclusion: Refusals to provide healthcare are frequent and deleterious situations especially for migrants living with HIV. Health decision makers, public insurance bodies and health professional councils must address this issue to improve equity in the healthcare system.

Background : Sub-Saharan African migrant women are a key population at risk of HIV infection in Europe. Using data from the ANRS-PARCOURS study, we aimed to assess the prevalence of forced sex after migration and its association with post-migration acquisition of HIV as well as the circumstances of forced sex after migration, including housing and administrative insecurity, among sub-Saharan African migrant women living in the Paris Region, France. Methods The ANRS-PARCOURS study was a retrospective life-event survey done between February, 2012, and May, 2013, in health-care facilities in the Paris region of France. Women were eligible if they were born in sub-Saharan Africa, aged between 18 and 59 years, and had been diagnosed with HIV infection at least 3 months earlier for women receiving HIV care or not diagnosed with HIV. In this analysis, we used ANRS-PARCOURS study data to compare the incidence of forced sex after migration in three groups of sub-Saharan African migrant women: those who acquired HIV after migrating, those who acquired HIV before migrating, and those without HIV. We assessed the associations between forced sex, sexual partnerships, and living conditions after migration with mixed-effects logistic regression and generalised structural equation models. The study is registered with ClinicalTrials.gov, number NCT02566148. Findings We obtained data from 980 eligible individuals who participated in the ANRS-PARCOURS study (407 without HIV and 573 HIV-positive) from 54 randomly selected health-care facilities. We excluded 20 women whose HIV infection could not be dated and eight women with missing data from the analyses, for a total of 405 women in the reference group (without HIV) and 547 women in the HIV group (156 with post-migration HIV acquisition, 391 with pre-migration HIV). Women who acquired HIV after migration experienced forced sex after migration more frequently than women without HIV (24 [15%] vs 18 [4%]; p=0.001). Forced sex after migration was associated with being hosted by family or friends (beta=0.95, 95% CI 0.19-1.72) and lack of stable housing (beta=1.10, 0.17-2.03). Lack of a residence permit was also associated with forced sex after migration. Interpretation The social hardships faced by sub-Saharan African migrant women after migration, especially a lack of housing or lack of a residence permit, increases their exposure to sexual violence and to HIV infection.

With the increase in asylum-related immigration since 2015, understanding how immigrants settle in a new country is at the centre of social and political debate in European countries. The objective of this study is to determine whether the necessary time to settle for Sub-Saharan Africa immigrants in France depends more on pre-migratory characteristics or on the structural features of the host society. Taking a capability approach, we define settlement as the acquisition of three basic resources: a personal dwelling, a legal permit of a least 1year and paid work. We use data from the PARCOURS survey, a life-event history survey conducted from 2012 to 2013 that collected 513 life histories of Sub-Saharan African immigrants living in France. Situations regarding housing, legal status and activity were documented year by year since the arrival of the respondent. We use a Kaplan-Meier analysis and chronograms to describe the time needed for settlement, first for each resource (personal dwelling, legal permit and paid work) and then for the combined indicator of settlement. Discrete-time logistic regressions are used to model the determinants of this settlement process. Overall, women and men require 6 and 7years (medians), respectively, to acquire basic resources in France. This represents a strikingly long period of time in which immigrants lack basic security. The settlement process varies according to gender, but very few sociodemographic factors influence settlement dynamics. Therefore, the length of the settlement process may be due to structural features of the host society.

Objectif : L'objectif de cette étude est d'analyser l'accès aux soins des personnes originaires d'Afrique subsaharienne (ASS) vivant avec une hépatite B chronique (HBC) en France. Méthodes : L'enquête ANRS-Parcours est une étude biographique réalisée en 2012-2013 auprès de personnes originaires d'ASS recrutées dans des services de prise en charge de l'HBC en Ile-de-France. Les données ont été recueillies en face-à-face à l'aide d'une grille biographique et d'un questionnaire standardisé. Résultats : Parmi les 619 participants, 96,4 % ont une couverture maladie de base dont 18,6 % la Couverture maladie universelle (CMU) et 23,4 % l'Aide médicale d'état (AME). Un tiers des bénéficiaires de l'Assurance maladie n'ont pas de complémentaire santé et 75,7 % sont couverts au titre d'une Affection longue durée. L'obtention d'une couverture maladie après l'arrivée en France a lieu en médiane la première année. Parmi les participants, 22,0 % rapportent avoir renoncé aux soins pour raisons financières depuis l'arrivée en France et 9,7 % avoir vécu un refus de soins le plus souvent par refus de la CMU ou l'AME. Une fois diagnostiqué, l'entrée en soins a lieu en médiane l'année-même du diagnostic. Le retard à l'entrée en soins est plus fréquent chez les personnes sans couverture maladie l'année du diagnostic. Les ruptures de suivi de plus de 12 mois sont rares. Conclusion : Les personnes originaires d'ASS vivant avec une HBC accèdent rapidement à une couverture maladie et aux soins. Cependant, des obstacles à l'accès aux soins persistent pour certaines du fait notamment de l'absence ou de l'incomplétude d'une couverture maladie et des refus de soins aux bénéficiaires de l'AME ou de la CMU.

Six à sept ans après leur arrivée en France, la moitié des migrants d'Afrique subsaharienne n'ont toujours pas les rois éléments d'installation que sont un titre de séjour d'au moins un an, un logement personnel, et un travail. Au bout de onze à douze ans, c'est encore le cas d'un quart d'entre eux. Cette longue période de précarité après l'arrivée en France tient plus aux conditions d'accueil (longueur du processus de régularisation, marché du travail segmenté, discriminations) qu'aux caractéristiques individuelles des arrivants. La situation des migrants subsahariens finit par se stabiliser, mais pour beaucoup d'entre eux, c'est au prix du passage par une longue période d'insécurité.

Objective HIV testing is an important tool in the management of the HIV epidemic among key populations. We aimed to explore the dynamic of first-time HIV testing in France for sub-Saharan migrants after their arrival. Methods ANRS-Parcours is a retrospective life-event survey conducted from 2012 to 2013 in health-care facilities in the Paris region, among 926 sub-Saharan HIV-infected migrants and 763 non-infected migrants. After describing the time to first HIV test in France and associated circumstances, we performed a discrete-time logistic regression to analyze the influence of socioeconomic position, contact with the healthcare system and sexual behaviors, on first-time HIV testing in France in migrants who arrived after 2000. Results Median first-time HIV testing occurred during the second year spent in France for noninfected men and women in both groups, and during the first year for men of the HIV group. The probability of testing increased with hospitalization and pregnancy for women of both groups. For non-infected men unemployment and absence of a residence permit were associated with an increased probability of HIV testing [respectively, OR = 2.2 (1.2-4.1) and OR = 2.0 (1.1-3.5)]. Unemployment was also associated with an increased probability of first-time HIV-testing for women of the HIV group [OR: 1.7 (1.0-2.7)]. Occasional and multiple sexual relationships were associated with an increased probability of first-time testing only for HIV-infected women [OR: 2.2 (1.2-4.0) and OR = 2.4 (1.3-4.6)]. Conclusion Access to first HIV testing in France is promoted by contact with the health care system and is facilitated for unemployed and undocumented migrants after arrival. However, testing should be offered more systematically and repeated in order to reduce time between HIV infection and diagnosis, especially for deprived people which are particularly vulnerable regarding HIV infection.

En France, les migrants originaires d'Afrique subsaharienne sont particulièrement touchés par l'hépatite B chronique. Cependant, les caractéristiques des personnes originaires d'Afrique subsaharienne porteuses d'une hépatite B chronique et leurs spécificités sur le plan sociodémographique, épidémiologique et clinique ne sont pas bien connues. Cet article décrit les caractéristiques des personnes originaires de cette région suivies pour une hépatite B chronique en Île-de-France à partir des données de l'enquête ANRS-Parcours, menée en 2012-2013 auprès d'un échantillon aléatoire de 778 consultants dans 20 structures de soins. Les résultats indiquent que les personnes originaires d'Afrique subsaharienne suivies pour une hépatite B chronique constituent une population relativement jeune (âge médian : 39 ans), installée en France de façon durable (depuis 10 ans en médiane). Les situations de précarité sociale et/ou administrative sont fréquentes (12,1% de personnes sans logement stable, 32,1% sans emploi, 25,8% sans couverture santé ou couvertes par l'aide médicale d'État), tout particulièrement parmi les femmes et les personnes suivies dans d'autres structures que les services experts en hépatologie. Le maintien du secret sur le statut VHB vis-à-vis de l'entourage est fréquent, en particulier chez les hommes (23,9%). Le diagnostic d'hépatite B chronique n'a été établi qu'après l'arrivée en France dans l'immense majorité des cas, après un délai de 3 ans en médiane et dans des circonstances variées. Si le dépistage systématique occupe une place prépondérante parmi les femmes, il n'est à l'origine que de moins d'un tiers des diagnostics chez les hommes, parmi lesquels le diagnostic survient dans un délai plus long après l'arrivée en France et plus souvent lors d'une phase active de la maladie. Les caractéristiques de l'hépatite B chronique et de sa prise en charge n'apparaissent pas différentes selon que les personnes sont suivies dans des services experts en hépatologie ou dans d'autres structures de soins. Ces résultats fournissent des informations utiles pour contribuer à améliorer le dépistage, la prévention de la transmission et la prise en charge de l'hépatite B parmi les personnes originaires d'Afrique subsaharienne.

Contexte : les données épidémiologiques disponibles suggèrent qu'une part non négligeable des migrants d'Afrique subsaharienne qui vivent avec le VIH en Europe ont été infectés après leur arrivée, sans que cette proportion soit précisément connue. Matériel et méthodes : nous avons estimé la proportion de migrants subsahariens qui ont acquis le VIH après leur arrivée en France, en combinant les données biographiques et cliniques recueillies au sein d'un échantillon représentatif de patients nés en Afrique subsaharienne et suivis pour une infection à VIH dans les hôpitaux d'Ile-de-France. L'infection était considérée comme acquise en France si l'un des critères biographiques suivants était rempli : 1) une durée de séjour en France avant le diagnostic d'au moins 11 ans, 2) un test VIH négatif après l'arrivée en France, 3) le premier rapport sexuel après l'arrivée en France. Lorsqu'aucun de ces critères n'était rempli, nous avons estimé la durée depuis la contamination à partir de la première mesure des CD4 en utilisant un modèle statistique de déclin des CD4. Cette durée a été estimée 500 fois pour chaque enquêté. Nous avons considéré que la contamination était survenue en France si au moins 50% (en scénario médian) ou au moins 95% (en scénario conservateur) des 500 durées estimées étaient inférieures à la durée de vie en France. Résultats : parmi 898 adultes infectés par le VIH nés dans un pays d'Afrique subsaharienne, nous avons estimé que 49% [IC95%:45-53] d'entre eux en scénario médian et 35% [31-39] en scénario conservateur ont acquis le VIH après leur arrivée en France. Cette proportion était plus basse pour les femmes que pour les hommes (30% [25-35] vs. 44% [37-51] dans le scénario conservateur) et augmentait avec la durée du séjour en France. Conclusion : au vu de cette proportion importante de migrants d'Afrique subsaharienne infectés par le VIH après la migration, il apparaît nécessaire d'améliorer la prévention dans ce groupe de population et, pour cela, de mieux comprendre les déterminants de ces infections survenues en France.