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The French contribution to global public health over the past two centuries has been marked by a fundamental tension between two approaches: State-provided universal free health care and what we propose to call State humanitarian verticalism. Both approaches have historical roots in French colonialism and have led to successes and failures that continue until the present day. In this paper, the second in The Lancet's Series on France, we look at how this tension has evolved. During the French colonial period (1890s to 1950s), the Indigenous Medical Assistance structure was supposed to bring metropolitan France's model of universal and free public health care to the colonies, and French State imperial humanitarianism crystallised in vertical programmes inspired by Louis Pasteur, while vying with early private humanitarian activism in health represented by Albert Schweitzer. From decolonisation to the end of the Cold War (1960–99), French assistance to newly independent states was affected by sans frontièrisme, Health for All, and the AIDS pandemic. Since 2000, France has had an active role in development of global health initiatives and favoured multilateral action for health assistance. Today, with adoption of the 2030 Sustainable Development Goals and the challenges of non-communicable diseases, economic inequality, and climate change, French international health assistance needs new direction. In the context of current debate over global health as a universal goal, understanding and acknowledging France's history could help strengthen advocacy in favour of universal health coverage and contribute to advancing global equity through income redistribution, from healthy populations to people who are sick and from wealthy individuals to those who are poor.

Background Although treatment adherence is a major challenge in sub-Saharan Africa, it is still unknown which longitudinal patterns of adherence are the most detrimental to long-term virological response to non-nucleoside reverse transcriptase inhibitor (NNRTI) regimens. This analysis aimed to study the influence of different time patterns of adherence on virological failure after 24 months of treatment in Cameroon.Methods Antiretroviral therapy (ART) adherence data were collected using face-to-face questionnaires administered at months 1, 3, 6, 12, 18 and 24. Virological failure was defined as viral load >40 copies/ml at month 18 and/or 24. Two combined indicators of early adherence (months 1, 3 and 6) and adherence during the maintenance phase (months 12, 18 and 24) were designed to classify patients as always adherent during the early or maintenance phase, non-adherent at least once and having interrupted ART for >2 days at least once at any visit during either of these two phases.Results Virological failure occurred in 107 (42%) of the 254 patients included in the analysis. In the early and maintenance phases, 84% and 76%, respectively, were always adherent, 5% and 5% were non-adherent and 11% and 20% experienced =1 treatment interruption. Early non-adherence was independently associated with virological failure (adjusted OR 7.2 [95% CI 1.5, 34.6]), while only treatment interruptions had a significant impact on virological failure during the maintenance phase (adjusted OR 2.1 [95% CI 1.1, 4.4]).Conclusions ART NNRTI-regimens used in sub-Saharan Africa seem to ‘forgive’ deviations from good adherence during the maintenance phase. Optimizing adherence in the early months of treatment remains crucial, especially in a setting of poor health care infrastructure and resources.

It is well established that high adherence to HIV-infected patients on highly active antiretroviral treatment (HAART) is a major determinant of virological and immunologic success. Furthermore, psychosocial research has identified a wide range of adherence factors including patients’ subjective beliefs about the effectiveness of HAART. Current statistical approaches, mainly based on the separate identification either of factors associated with treatment effectiveness or of those associated with adherence, fail to properly explore the true relationship between adherence and treatment effectiveness. Adherence behavior may be influenced not only by perceived benefits—which are usually the focus of related studies—but also by objective treatment benefits reflected in biological outcomes.

Background Good knowledge in HIV care among physicians is a necessary prerequisite to effective antiretroviral therapy (ART) scaling-up in Sub-Saharan Africa.Methods Between September 2006 and March 2007, a 27-item knowledge questionnaire was proposed to all HIV physicians working in 27 hospitals throughout six provinces of Cameroon. Physicians’ responses were compared between the three levels of decentralization of the Cameroonian healthcare delivery system (?2and Fisher tests). Correct responses were summed to build a knowledge score. Factors significantly associated with a higher score were identified using linear regression.Results In total, 93 physicians filled in the questionnaire. Level of knowledge was globally good (median score 23), with no significant difference between the three levels of decentralization. Gaps in knowledge were observed regarding the use of cotrimoxazole and the follow-up of ART-treated patients. Main factors independently associated with a higher knowledge score included training, involvement in therapeutic committees, satisfactory collaboration with other practitioners and establishment of strong relationships between patients and patients’ associations.Conclusions Overall knowledge in HIV care is good among HIV physicians working at all three levels of decentralization of healthcare in Cameroon. However, a national training policy should be set up to improve knowledge and practices in both ART follow-up and specific situations such as paediatric HIV. Collaboration between caregivers and external resources involved in HIV care should also be encouraged.

Background The aim of this study was to assess the cost-effectiveness of HIV treatment alternatives – with and without highly active antiretroviral therapy (HAART) – within alternative strata based on the CD4+T-cell count at the initiation of treatment in a low-resource setting.Methods A retrospective observational study was conducted following 286 HIV-positive individuals admitted to the principal teaching hospital in Casablanca, Morocco, between 1995 and 2002. Patients were stratified by CD4+T-cell count and regression models were fitted to determine risk of opportunistic infection. Data on healthcare resource use were derived from patient records and were evaluated from the hospital perspective.Results HAART led to a significant reduction in the number of HIV-related opportunistic infections (P<0.0001), extended survival (61.3 versus 55.2 months; P<0.0001) and reduced hospital stays (P<0.0001) in comparison with care in the absence of HAART. When medical care and drug costs were considered together, HAART was more costly than providing treatment for opportunistic infections. The incremental cost-effectiveness ratio was lower than gross domestic product (GDP) per capita for patients starting HAART with a CD4+T-cell count <200 cells/mm3, but this increased to nearly three times GDP per capita when HAART was initiated at CD4+T-cell counts above this threshold.Conclusions HAART is more cost-effective than treating HIV-related opportunistic infections and, contrary to conclusions drawn in developed countries, HAART is more cost-effective when the CD4+T-cell count drops to <200 cells/mm3.

La révolution génétique est-elle en marche ? Et ce, au niveau technologique et conceptuel, avec le passage d’un paradigme anatomique et histologique vers un paradigme moléculaire ? On peut imaginer un recours aux tests génétiques à toutes les étapes de la prise en charge médicale, une même personne bénéficiant de différents tests à différents moments. Par exemple, des tests constitutionnels peuvent permettre d’identifier les individus à risque élevé de développer certains cancers ; ceux-ci peuvent se voir proposer des tests génétiques de dépistage de ce cancer et, en cas de diagnostic de cancer, les analyses génétiques de la tumeur peuvent orienter le traitement. Pour autant, il n’est pas toujours de l’intérêt du patient, de celui du clinicien ou de la société defaire forcément tout ce qui est techniquement possible. La diffusion des tests génétiques en cancérologie ne peut donc pas être abandonnée à la seule logique du progrès technique et médical,ni à celle des intérêts des firmes de biotechnologie qui interviennent légitimement dans cesecteur. Il est urgent que s’instaure un véritable débat public et interdisciplinaire sur le sujet, afinqu’il en ressorte des mécanismes de régulation socialement acceptables et acceptés.

Until now, the economic implications of nonadherence to drug therapies have been mostly assessed in a cost perspective and understood as the impact of nonadherence behaviours on the cost-effectiveness ratios of particular therapies. In HIV disease, some modelling approaches have suggested that high adherence levels might improve the cost-effectiveness of highly active antiretroviral treatment regimens. However, there is an urgent need for research directly observing and measuring the costs of nonadherence behaviours. In addition to this cost perspective, the authors argue that the economic impact of nonadherence should also be studied in a microeconomic – patient-oriented – perspective. Major implications of this microeconomic perspective are drawn. First, the microeconomic approach highlights that nonadherence may often be a rational choice of the patient, thus suggesting new ways for improving adherence. Second, it implies that the adherence behaviour can be interpreted as an indicator of patients’ subjective valuation of highly active antiretroviral treatment therapies; in particular, higher levels of adherence are associated with higher patient well-being. Third, it shows that the adherence behaviour cannot be regarded as an exogenous variable when the impact of adherence on health outcome or on cost-effectiveness ratios is studied, thus requiring the use of specific statistical or econometric methods.

Objective To disentangle the impact of adherence from that of injecting drug status and depressive syndrome on HIV clinical progression in a cohort of highly active anti-retroviral therapy (HAART)-treated HIV patients infected through drug use.Design MANIF 2000 is a French cohort of HIV-infected drug users with scheduled medical visits every 6 months. Only patients enrolled in the MANIF 2000 cohort who had a CD4 cell count >200 cells/µl at HAART initiation were selected. The follow-up period included all post-HAART initiation visits.Methods HIV clinical progression was defined as either AIDS-related death or reaching a CD4 level <200 cells/µl. Adherence was assessed using a self-administered questionnaire and a structured face-to-face interview. Depressive symptoms were evaluated by a Center for Epidemiologic Studies Depression Scale (CES-D) score at each visit. Cox proportional hazards model was used to calculate crude and adjusted relative hazards and 95% confidence intervals and thus identify independent predictors of clinical progression.Results Of the 305 HAART-treated patients in the cohort, 243 had CD4 cell count >200 cells/µl at HAART initiation. At the first visit after HAART initiation, median CD4 cell count was 466 cells/µl and 45% had undetectable viral load. Injecting drug users accounted for 17% of the study group. Over the follow-up period, 32 patients experienced HIV clinical progression. Probable depression was encountered in 46% of patients and non-adherence in 31% of the sample. After adjustment on baseline CD4 cell count, predictors of clinical progression were: having a higher level of cumulative non-adherence over the follow-up period [HR (95% CI)=1.2 (1.1–1.3) per 10% increase] and having a high score of depressive symptoms following HAART initiation [HR (95% CI)=5.3 (2.21–3.0)]. Conclusions: Although depressive syndrome is known to influence non-adherence behaviours that are amongst the major reasons for clinical progression, it is also a predictor of clinical progression in HIV-infected intravenous drug users on HAART, independently of non-adherence behaviours. HIV care providers should be more sensitive to depressive symptoms in order to detect them early and supply HIV patients with specific care. Further research is needed to determine whether treating depressive symptoms may improve adherence and thus delay disease progression and mortality.

La localisation et l’identification de deux gènes de prédisposition au cancer du sein et/ou de l’ovaire, BRCA1 et BRCA2, ont permis l’introduction dans les nouvelles pratiques cliniques, de tests biologiques de prédisposition génétique destinés aux personnes supposées à haut risque. La diffusion de ces nouvelles pratiques médicales et biologiques se fait avec les difficultés traditionnelles de toute activité innovante, auxquelles peuvent s’ajouter de fortes incertitudes relatives à la revendication de droits de propriété sur les gènes et au financement des actes médicaux et biologiques. Dans ce contexte, l’évolution de l’offre de tests de prédisposition génétique est analysée à travers deux enquêtes réalisées pour décrire les profils d’activité en 1998 et en 2001 de l’ensemble des acteurs médicaux impliqués en France dans ces nouvelles pratiques : les médecins assurant les consultations d’oncologie génétique, les centres où ont lieu ces consultations spécialisées et les laboratoires associés réalisant les analyses de biologie moléculaire.

La fréquentation des services hospitaliers d’urgences connaît une croissance forte depuis plus de 10 ans. Cette étude cherche à identifier les profils de consommation de soins des personnes admises aux urgences et de les relier aux conditions sociales et économiques déclarées par ces derniers.

In 1999, the French Parliament established a “right to palliative care”, which reactivated public debate about euthanasia. In order to investigate jointly physicians’ attitude toward palliative care and euthanasia, we conducted a cross-sectional survey of a national sample of French GPs, oncologists, and neurologists. Overall, 917 physicians participated in the survey. Significant proportions of respondents, especially among GPs and neurologists, considered that palliative sedation and withdrawing life-sustaining treatments (WLST) were euthanasia. Multivariate analysis showed that the physicians who had special medical training in palliative care, and those who distinguish palliative sedation and WLST from euthanasia were more likely to oppose legalisation of euthanasia. Thus, French physicians’ attitude to the legalisation of euthanasia is strongly influenced by whether or not they distinguish palliative care from euthanasia. Improved palliative care requires better training of the entire medical profession, and clearer guidelines about which end-of-life care practices are legally and ethically acceptable.

Objective To assess the impact of different patterns of adherence to highly active antiretroviral therapy (HAART), in particular, the relative impact of early and late adherence, on long-term immuno-virological response in HIV-infected individuals started on a protease inhibitor-containing regimen.Design Clinical, immuno-virological and self-reported adherence data were collected at 4 (M4), 12 (M12), 20 (M20), 28 (M28) and 36 (M36) months after HAART initiation in the French APROCO cohort.Methods A standardized self-administered questionnaire classified patients as non-adherent, moderately or highly adherent at each visit. Stable viral suppression at both M28 to M36, and a CD4 cell increase >200 between M0 and M36 were used as outcome measures.Results Of the 582 patients followed regularly through M36, 360 patients had complete adherence data. Although 59.2% were highly adherent at M4, only 25.8% maintained consistent high adherence throughout the follow-up. High adherence at M4 was independently associated with both stable viral suppression at M28–M36 [OR (95% CI): 2.8 (1.4–5.5)] and a CD4 cell increase >200 during the same period [OR (95% CI): 3.9 (1.7–9.7)]. However, ‘moderately adherent’ patients between M12 and M36 had the same likelihood [OR (95% CI): 1.9 (1.1–3.2)] as patients who were always high adherent [OR (95% CI): 1.9 (1.1–3.2)] of achieving stable viral load suppression, relative to those who reported non-adherence episodes.Conclusion Optimizing adherence in the early months of treatment is crucial to ensure long-term immuno-virological success. Moderate deviations from high adherence during follow-up have a less negative impact. Priority should be given to interventions aimed to improve adherence in the early months of HAART.

Cet article présente une synthèse des principaux aspects traités par la littérature internationale de sciences humaines et sociales (SHS) depuis l’apparition des multithérapies antirétrovirales en 1996. Initialement sollicitées pour contribuer à l’observance de ces traitements, les SHS ont permis de dépasser l’approche «prédictive», jusque là dominante dans les disciplines biomédicales, qui visait à identifier sur la base d’un nombre limité de caractéristiques a prioriles patients censés présenter un «haut risque» de non-observance. Elles ont montré que l’observance est un processus d’apprentissage dynamique qui dépend avant tout de l’expérience subjective vécue par les patients. La «chronicisation » de la maladie VIH a conduit les SHS à s’intéresser à l’impact des traitements sur tous les aspects de la vie quotidienne (de l’insertion professionnelle à la sexualité), en même temps qu’elles soulignent la contradiction entre les espoirs suscités par des multithérapies économiquement coût-efficaces d’une part, et la précarité sociale d’une proportion croissante de personnes atteintes, d’autre part. Ces recherches débouchent sur des recommandations visant à adapter les politiques publiques de lutte contre l’épidémie de sida tout en préservant le potentiel d’innovations qu’elles ont favorisé dans les systèmes de santé et de protection sociale, ainsi que dans les relations médecin/malade.

Some screening programs have very high costs per life-year saved and require large financial support. Public policies decision-makers need criteria to appreciate the costs and benefices of such programs. The safety of blood transfusions is a specific example of such a situation, in which the decision to reduce residual risks could be a highly debatable use of resources when the additional effectiveness is small. This article analyzes various economic evaluations of hepatitis C virus screening strategies and discusses the results. The screening of blood donations for hepatitis C virus antibodies is cost-effective and enzyme-linked immunoblot assay testing appears to be the most efficient and reliable test for daily processing of a large number of samples in a large blood bank. In contrast, new tests proposed to increase safety in blood donations, such as the adjunction of polymerase chain reaction testing, do not compare favorably with socially-acceptable threshold in health economics.

L’intérêt des approches économiques dans le domaine de la santé réside dans la possibilité de hiérarchiser, sur la base de deux critères (efficacité médicale et coûts), les programmes médicaux susceptibles d’être menés, et d’aider à fixer des objectifs de santé publique, à moyen ou à long terme, compatibles avec les ressources disponibles. Cet article présente une revue de la littérature spécifique des principaux travaux d’évaluation économique qui se sont efforcés de contribuer à la définition de politiques optimales en matière de dépistage et de traitement de l’hépatite C. Les résultats de ces évaluations économiques montrent d’une part, que, malgré un coût économique immédiat important, le dépistage de certaines populations à risque est source à long terme d’économies par rapport à l’absence de dépistage, et suggèrent, d’autre part, que les traitements, y compris les plus coûteux et performants, aboutissent à sauver des années de vie pour des rapports qui ne sont jamais supérieurs à ceux généralement admis comme limite pour les interventions dans le domaine de la santé.

The authors investigated the acceptability to women of the preventive strategies available for dealing with hereditary breast/ovarian carcinoma in France, the United Kingdom, and Canada, countries selected because of their cultural differences. The authors aimed to discover the existence of specific factors that may affect acceptability of these preventative measures. A cross-sectional, multicenter survey was conducted in Marseilles, France (n = 141), in Manchester, England (n = 130), and in Montreal, Quebec (n = 84). All of the women attending cancer genetic clinics for the first time because of a family history of breast-ovarian carcinoma completed a self-administered questionnaire before their clinic consultation. Variations in responses to different preventative options presented on the questionnaire were seen within the sample of patients considered as a whole. The highest levels of acceptability were obtained for mammographic screening (87%) and chemoprevention (58%). In contrast, prophylactic oophorectomy and prophylactic mastectomy were thought to be acceptable at an early age (before 35 years), an age associated with the highest prophylactic efficacy, by only 19% and 16% of the respondents, respectively. After multivariate adjustment, the statistical data showed that the British respondents were more in favor of oophorectomy (P &lt; 0.0001) and more in favor of chemoprevention than the French (P &lt; 0.001) and the Canadian respondents (P &lt; 0.001). The British (overall adjusted response [ORadj] = 3.9; P &lt; 0.001) and Canadian respondents (ORadj = 3; P &lt; 0.01) were more in favor of prophylactic mastectomy than the French. The cumulated acceptability of mammography before the age of 40 years was found to be greater in the French (ORadj = 2.8; P &lt; 0.01) and Canadian (ORadj = 3.1; P &lt; 0.05) samples than in the British sample. These results demonstrated the existence of international variations in the acceptability of the preventive strategies available for women at risk for hereditary breast/ovarian carcinoma. Therefore, these results suggested that when establishing medical recommendations or planning public health interventions, physicians must integrate the population's perception of advantages and drawbacks with the patient's individual decision making. Cancer 2001;92:959–68. © 2001 American Cancer Society.

AbstractObjectives:The aim of this study was to determine what medical specialists knew about recent findings in the genetics of breast/ovarian cancer, according to their speciality and the methods they used to keep themselves up to date. Methods:A national random sample of 1,169 surgeons and gynaeco-obstetricians was surveyed using a mailed questionnaire, to which 700 of those contacted responded (60%). Results:Two years after it had been identified, BRCA1 was known by only 54% of the practitioners, whereas BRCA2 was known by 49.1% 1 year after it was first identified. The lifetime breast cancer risk of women in the general population was estimated by 37.6% of the participants to be between 6 and 10%, and 35.7% rated the penetrance of a breast cancer mutated gene at between 70 and 90%. After multivariate adjustment, the overall score for knowledge of hereditary breast/ovarian cancer was mainly determined as follows: by the speciality (p < 0.001), since the gynaeco-obstetricians scored the highest and the general surgeons the lowest; by the size of practice (p < 0.001), since a larger practice was associated with a higher score, and by whether or not the participants were accustomed to reading the international literature (p < 0.01). Conclusions:These results show the need for physicians who are not geneticists to acquire further knowledge about cancer genetics. We discuss the role of international reviews in communicating the latest knowledge available in genetics to specialists working in other medical fields.Copyright © 2000 S. Karger AG, Basel

This paper challenges traditional views which oppose health economics and medical ethics by arguing that economic assessment is a necessary complement to medical ethics and can help to improve public participation and democratic processes in choices about resource allocation for health care technologies. In support of this argument, four points are emphasized: (1) Most current biomedical ethical debates implicitly deal with economic issues of resource allocation. (2) Clinical decisions, which usually respect the Hippocratic code of ethics, are nevertheless influenced by economic incentives and constraints. (3) Economic assessment is concerned with both efficiency and equity and potential trade-offs between the two, which means that ethical judgements are always embedded in welfare economics. (4) The real debate is not between economics on the one side and medical ethics on the other. Rather it is between different ethical conceptions of social justice and the contrasting approaches they entail to reconciling individual interests and preferences with collective goods and welfare.

Worldwide ethical considerations have led to banning markets for human organs and to promoting supply of organs for transplantation strictly on a donor noncommercial basis. In most industrialized countries, including France, there is a shortage of organs available for transplantation. Following on the earlier debate between Titmuss and Arrow over banning the market for blood supply, this presentation first challenges the conventional economic view that the ban is necessarily responsible for these critical shortages. It will argue that it is the obstacles to adequate exhortation (i.e., the efforts to inform and persuade participants in the donor system who cannot be paid for what they supply) rather than the inefficiency per se of appeals to donor altruism that are the cause of a shortage. The paper will then discuss the way a market for non-human organs may be an efficient alternative to a donor system by supplying a substitute good. Data from a survey in a random sample of the French general population (?18 years of age in June 1997; response rate 62.0; n 1,011 ) show that less than half of the respondents (42.4) agreed that xenotransplantations should be developed. Support for xenotransplantation was higher (50.6 vs. 38.2 in the rest of the sample, p< 0.001) among respondents who declare that in case of an accidental death of a family member, they would accept the use of his organs for transplantation, among those with the highest level of knowledge about transplantation (48.6 vs. 39.4, p< 0.005), and among blood donors (45.9 vs. 38.3, p< 0.02). Supply of non-human organs should remain under the control of the public sector in order to be consonant with current donor systems for human organs. Recommendations for adequate regulation of the R&D process of non-human alternatives for organ transplantations will be made.

Using the example of substitution of peripheral blood stem cell (PBSC) collection to bone marrow harvest for autologous transplantation in cancer patients, our study attempts to illustrate how economic assessment, starting at an early stage of medical innovation, can influence the development and diffusion process of a new technological procedure whose optimal design has not yet been established. Two cost minimization studies comparing costs for obtaining a clinically reinfusable graft using bone marrow harvest or alternatively various protocols of PBSC collection contributed to a change in the French clinical standard for this procedure.

A prospective economic analysis of autologous peripheral blood progenitor-cell transplantation (PBPCT) versus autologous bone marrow transplantation (BMT) was performed as part of a randomised clinical trial in 129 patients (adults and children) receiving high-dosage antineoplastic therapy for non-leukaemic malignant disease. The clinical assessment criteria of the study were the duration of thrombocytopenia(<30 × 109/Land<50 × 109/L)and of granulocytopenia (<0.5 × 109/L).The cost of medical resources used was the primary economic end-point. We also calculated the cost of reaching 2 specified haematological end-points: platelet recovery (≥30 × 109/L) and granulocyte recovery (≥0.5 × 109/L). Economic analysis was based on the French hospital perspective. Haematological recovery was significantly quicker in the PBPCT groups (adults and children) compared with the BMT groups. Economic study revealed that the PBPCT groups were clearly less expensive with regard to costs up to discharge (17% decrease of the average cost for adults and 29% for children) and those associated with specified haematological end-points. The global costs of PBPCT were lower than those of BMT for these adult and paediatric populations. Economic arguments can clearly be added to clinical ones in favour of substitution of autologous PBPCT for autologous BMT. International comparisons of diffusion of PBPCT could be of great interest for further economic research into medical innovation.

Objective To evaluate the impact of the 1993 French National Policy which made it mandatory to offer screening for the presence of human immunodeficiency virus (HIV) to all pregnant women who planned to give birth, although women remained free to refuse the test.