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National audience; Les personnes nées en Afrique subsaharienne constituent en France l’une des populations les plus touchées par l’hépatite B et par l’infection VIH. Pour ajuster les stratégies de santé publique aux besoins propres de ces migrants, il est nécessaire de mieux comprendre ce qui accroît leur vulnérabilité face à ces infections, en particulier les expériences de précarité qui peuvent accompagner l’installation en France. Si la précarité des migrants est souvent évoquée, celle-ci est en réalité relativement mal mesurée ; en particulier la fréquence des précarités et leur place dans la trajectoire individuelle sont mal connues. Afin d’étudier comment les trajectoires de santé, les trajectoires sociales, familiales, migratoires et administratives s’entrecroisent et se construisent les unes par rapport aux autres parmi les Africains vivant en France, une enquête a été menée en 2012-2013 en Île-de-France, l’enquête Parcours pour « Parcours de vie, VIH et hépatite B chez les migrants subsahariens vivant en Île-de-France ». Cette enquête biographique, réalisée dans 70 services de santé, est la première en France à utiliser la méthode de collecte biographique démographique pour des recherches dans le champ de la santé, en impliquant des professionnels de santé. Nous présentons ici la méthodologie et la collecte de l’enquête Parcours et nous discutons des leçons tirées de cette expérience d’une enquête biographique en structures de santé et auprès de migrants. Puis nous présentons comment deux types de précarité vécues en France, la précarité résidentielle et la précarité administrative, ont été caractérisées sur l’ensemble des trajectoires biographiques. Enfin nous estimons le niveau de ces précarités lors de l’arrivée en France, leur évolution au long du séjour en France et leurs déterminants.

National audience

Dans le contexte international des Objectifs pour le développement durable, de plus en plus de pays se lancent dans des politiques visant à les aider à se diriger vers la couverture universelle en santé (CUS). Les chemins pour y parvenir sont évidemment très nombreux et de plus en plus de bailleurs de fonds soutiennent les pays dans leurs choix politiques spécifiques. De même, de plus en plus de recherches tentent de comprendre ces processus. C'est ainsi que profitant de deux programmes de recherches démarrant dans quelques pays du Sahel, nous avons décidé de réaliser un état des lieux de la CSU au Mali et au Sénégal. Ce document présente donc le contexte spécifique de ces deux pays, les politiques de santé mises en place depuis les années 1980 ainsi que la situation contemporaine concernant la CSU et les stratégies qu'ils entendent mettre en oeuvre.

International audience; Background: The universal test-and-treat strategy (UTT) aims to maximize the proportion of all people living with HIV (PLWHIV) on antiretroviral treatment (ART) and virally suppressed in a community, i.e. to reach population viral suppression (PVS). The ANRS 12249 TasP trial did not demonstrate an impact of universal ART on HIV incidence at population level (Lancet HIV 2017). Here, we investigated whether PVS improved during the course of the trial: differentially by arm, according to trial interventions or contextual changes.Methods: The TasP cluster-randomized trial (2012-2016) implemented six-monthly repeated home-based HIV counselling and testing (RHBCT) and referral of PLWHIV to local HIV clinics in 2×11 clusters opened sequentially. ART was initiated according to national guidelines in control clusters vs. regardless of CD4 count in intervention clusters.Test results, clinic visits, ART prescriptions, viral loads, CD4 counts, migrations and deaths were used to produce information on residency status, HIV status and HIV care status for each participant. PVS was computed daily and per cluster among all resident PLWHIV (≥16, including those not in care). We used a mixed linear model to explore the relation between PVS with calendar time, time since cluster opening, trial arm and interaction between arm and time since cluster opening, adjusting on sociodemographic changes at cluster level.Results: 8,646 PLWHIV were observed. Between January 1st, 2013 and January 1st, 2016, PVS increased significantly in both arms (intervention: 29.0% to 46.2%, +17.2, p< 0.001; control: 32.4% to 44.6%, +12.2, p < 0.001), but difference in temporal variation (+5.0%) was not significant (p=0.175).According to adjusted model (figure) this increase was mainly attributable to RHBCT (measured by time since cluster opening). They were also some effect due to contextual changes (measured by calendar time). The effect attributable to universal ART (interaction term) was limited.Conclusions: Although suboptimal, the UTT strategy implemented in TasP trial improved PVS over time. As it was mainly due to RHBCT rather than universal ART, it did not induce differences between arms, explaining the null effect observed on cumulative incidence, the main trial finding. Changes in ART initiation guidelines alone are not enough to significantly increase PVS.

National audience

International audience; IntroductionThe universal test-and-treat strategy (UTT) was developed to maximize the proportion of all HIV-positive individuals on antiretroviral and virally suppressed, assuming that it leads to reduction in HIV incidence. The evolution over time of the cross-sectional population HIV care cascade is determined by longitudinal individual trajectories through the HIV care continuum and the underlying HIV population dynamics. This structural effect could dilute the impact observed at population level of a UTT strategy RT: either add impact on what (incidence) or delete sentence. The purpose of this paper is to quantify the contribution of each component of population change on the population HIV care cascade in the context of UTT.SampleWe used prospective individual-level longitudinal data from the ANRS 12249 cluster-randomized trial which was implemented in rural KwaZulu-Natal, South Africa between 2012 and 2016 to test such an approach.MethodsHIV tests results and information on clinic visits, ART prescription, viral load and CD4 count, migration and deaths were used to calculate residency status, HIV status and HIV care status for each individual on a daily basis. Position within the HIV care continuum was considered as a score ranging from 0 (undiagnosed) to 4 (virally suppressed). We compared the cascade score of each individual joining or leaving the HIV population with the average score of their cluster at the time of entry or exit. Then, we computed the contribution of each event on the average cascade score and the annualised total contribution of all events, considering 5 components of HIV population change: aging into the cohort, HIV seroconversions, in-migrations, out-migrations, and permanent exits (including deaths).ResultsWhile the average cascade score increased over time in all clusters, that increase was limited due to population dynamics, the total contribution of all population entries and exits being negative. Permanent exits and individuals already infected when reaching the age of 16 had a marginal effect. Although migrants had a lower position than the rest of the population, their overall impact on the cross-sectional population cascade remained limited as in- and out-migration compensated each other.ConclusionsIn a context of high HIV incidence, the continuous flow of newly infected individuals slows down the efforts to increase ART coverage and population viral suppression.

L'approche biographique en démographie permet de prendre en compte non pas la situation à un moment donné mais bien les trajectoires de vie dans leur ensemble ; l'objectif de cette étude est d'étudier les conséquences sur l'activité, le couple et le bien-être perçu d'un diagnostic de VIH dans les trajectoires de vies des immigrés subsahariens. Pour ce faire, une démarche méthodologique originale est proposée, à l'articulation entre des méthodes biographiques 'classiques' qui s'intéressent à des transitions précises d'un état à un autre dans la trajectoire des individus et des méthodes dites holistes, qui prennent la trajectoire comme unité d'analyse. Les analyses reposent sur les données de l'enquête biographique Parcours, menée en 2012-2013 auprès de 926 immigrés subsahariens atteints de VIH/sida en Île-de-France. La combinaison de l'analyse de séquences et de modèles logistiques à temps discret à risques répétés permet de donner des résultats originaux sur l'impact du diagnostic dans des vies marquées par la migration. Pour la plupart des immigrés subsahariens, c'est la migration qui a un impact majeur sur les dimensions factuelles comme l'activité et la vie conjugale, et non le diagnostic. En revanche, le diagnostic entraîne une détérioration importante du bien-être perçu.

International audience; ContexteBien que les travailleuses du sexe (TS) constituent une population particulièrement à risque du VIH, la compréhension du fardeau du VIH reste limitée dans cette population en Afrique subsaharienne. Le projet PrEP-CI ANRS 12361 comportait une estimation de l’incidence de l’infection VIH chez des TS en Côte d’Ivoire à l’aide de tests d’infection récente.MéthodesL’étude a été conduite entre septembre 2016 et mars 2017 auprès de TS âgées de 18 ans et plus à Abidjan et à San Pedro, en mobilisant une méthodologie mixte :(i) des entretiens qualitatifs individuels et des focus groupes auprès de 60 TS,(ii) un questionnaire sociodémographique standardisé ainsi qu’un dépistage du VIH par deux tests rapides (Determine®, Alere et Vikia®, bio Mérieux) administrés par des paires éducatrices sur les sites prostitutionnels auprès de 1000 TS. En cas de positivité, un prélèvement sur DBS a été réalisé pour déterminer la fenêtre d’infection à l’aide d’un test d’infection récente (EIA-RI) adapté au contexte ivoirien.Résultats1000 TS (400 à San Pedro, 600 à Abidjan) avec un âge médian de 25 ans [Intervalle Interquartile = 21-29] ont été incluses dans l’étude et ont été dépistées pour le VIH. Parmi elles, 39 ont été diagnostiquées VIH+, dont 7 infectées récemment (durée moyenne de la durée d’infection de 113 jours), correspondant à une incidence du VIH de 2,2%.L’incidence est plus élevée à San Pedro (3,2%) qu’à Abidjan (1,5%). Ces résultats sont à mettre en regard des données qualitatives : les TS de San Pedro ont témoigné de difficultés (distance, horaires, coûts …) à accéder aux soins de santé et aux moyens de prévention, notamment le préservatif. L’infection à VIH est également associée à la vulnérabilité : l’incidence est plus élevée chez celles qui pratiquent des passes ≤ 2000 CFA (3,1% vs. 0,7%) ; chez celles qui exercent sur les trottoirs (5,1%) et dans les hôtels (3,8%) ; et chez celles qui ne travaillent qu’une fois par semaine (2,9% vs. 0 cas incident observé chez celles qui travaillent tous les jours). Les TS travaillant occasionnellement sont plus difficilement identifiées par les paires éducatrices et ont moins accès à la prévention. Enfin, les TS de moins de 25 ans sont plus à risque d’infection (2,6%) que celles de plus âgées (1,6%) et l’incidence du VIH est associée aux autres IST (2,3% chez celles ayant eu ≥1 IST au cours des 12 derniers mois vs 1,8%).ConclusionCette étude est l’une des premières à estimer l’incidence du VIH en Côte d’Ivoire chez les TS. Cette population est beaucoup plus exposée que le reste de la population générale (2,2% vs. 0,06% estimé par l’Onusida). Les nouvelles infections se concentrent chez les TS plus jeunes, en situation précaire et travaillant dans des zones reculées, en particulier dans la région de San Pedro. Ces sous-groupes vulnérables doivent donc être visés en priorité par les programmes de prévention et devraient se voir proposer une prophylaxie préexposition (PrEP) selon les recommandations de l’OMS.

International audience; ContexteY compris en Afrique sub-saharienne, les hommes ayant des rapports sexuels avec d‘autres hommes (HSH) sont plus à risque de s’infecter par le VIH que la population générale. Dans ce groupe, les bisexuels sont souvent perçus comme plus « à risque » que les homosexuels exclusifs et pouvant constituer une « passerelle épidémique » avec la population générale, sur la base de l’hypothèse selon laquelle les bisexuels seraient moins susceptibles de se conformer aux normes préventives que les homosexuels exclusifs.ObjectifProposer une synthèse des connaissances sur les différentes catégories d’homo-bisexuels dans les enquêtes épidémiologiques réalisées en Afrique sub-saharienne depuis 2004 et sur leur exposition au VIH.MéthodesÀ partir d’une revue de la littérature, nous avons retenu les publications présentant des estimations quantifiées de la bisexualité, mesurée en fonction des enquêtes selon trois dimensions : le pôle d’activité sexuelle (sexe des partenaires sexuels sur une période donnée), l’identité déclarée et l’attirance sexuelle. Nous avons examiné : (i) les taux de bisexualité calculés selon ces trois dimensions ; (ii) les taux de prévalence du VIH par groupe (et les odds-ratio correspondants) et (iii) des indicateurs de comportements selon l’orientation sexuelle.RésultatsLes taux de bisexualité varient fortement d’une étude à l’autre (de 12 à 94%) et selon l’indicateur retenu. Globalement, les taux observés en Afrique de l’Ouest sont sensiblement plus élevés que ceux d’Afrique australe, l’Afrique centrale et de l’Est étant dans une situation intermédiaire.À l’exception de deux études, la prévalence du VIH observée parmi les bisexuels est inférieure à celle des homosexuels exclusifs, quelle que soit la dimension considérée pour définir ces deux groupes (voir figure). Les différences de prévalence selon l’identité déclarée sont plus marquées que selon le pôle d’activité sexuelle.La majorité des études n’ont pas relevé de différence d’utilisation du préservatif entre bisexuels et homosexuels exclusifs. Les bisexuels ont parfois une fréquence de rapports sexuels moindre et systématiquement moins de rapports anaux réceptifs que les homosexuels exclusifs. Ils ont commencé leur vie sexuelle avec les hommes plus tardivement et ont eu moins de partenaires masculins au cours de leur vie. Par contre, ils sont moins nombreux à avoir déjà fait un test de dépistage du VIH.Conclusion et recommandationsLa bisexualité est multiforme en Afrique sub-saharienne : les bisexuels ne constituent pas un groupe homogène et les identités sexuelles sont si diverses qu’une simple opposition homosexuels vs. bisexuels est réductrice. Toutefois, selon les enquêtes disponibles et quelle que soit la dimension considérée pour mesurer la bisexualité, les bisexuels sont moins exposés au VIH que les homosexuels exclusifs. S’il reste important que les programmes de prévention et de traitement prennent en compte les bisexuels, les homosexuels exclusifs doivent rester une cible prioritaire pour l’accès aux nouveaux outils de la prévention et du soin.

Depuis le milieu des années 1990, de nombreuses études ont été réalisées sur la migration indépendante des mineur-e-s ; elles portent essentiellement sur le contexte des pays d’accueil, notamment l’espace européen, et se struc-turent autour de trois aspects principaux : le statut juridique et le traitement légal de cette catégorie de migrants au plan international et national, le profil des mineur-e-s migrant-e-s arrivant en Europe et les raisons de leur migra-tion ; ce dernier volet est encore peu exploré, y compris concernant les mineur-e-s d’origine asiatique ou africaine, très présent-e-s en Europe. Ce Working Paper déplace l’observation dans les lieux de transit, là où se nouent et se dénouent les contraintes et les dangers de la migration L’objectif est de rendre compte des risques et des opportuni-tés autour desquels se construit l’expérience migratoire des mineur-e-s. Ici, cette question est abordée sous l’angle des mineur-e-s en transit dans la zone sahélo-saharienne, dont l’objectif est de rejoindre l’Union européenne. D’un point de vue méthodologique, la carte, objet de la géographie, et l’analyse statistique textuelle, saisie par les sciences mathématiques, sont mobilisées comme « opérateurs de découverte ». Ce dialogue entre les disciplines et les méthodes permet d’explorer le rapport que les mineur-e-s entretiennent avec les mots ; ce contenu « caché » donne à voir des alliages d’objets et de sujets inattendus, articulés à un réseau très enchevêtré d’incertitudes et d’opportunités. Ces réalités nouvelles invitent à considérer la mobilité des mineur-e-s sous un paradigme nouveau et quelque peu insolite entre territoires multisitués et pluriparentalité.

BackgroundUniversal antiretroviral therapy (ART), as per the 2015 WHO recommendations, might reduce population HIV incidence. We investigated the effect of universal test and treat on HIV acquisition at population level in a high prevalence rural region of South Africa.MethodsWe did a phase 4, open-label, cluster randomised trial of 22 communities in rural KwaZulu-Natal, South Africa. We included individuals residing in the communities who were aged 16 years or older. The clusters were composed of aggregated local areas (neighbourhoods) that had been identified in a previous study in the Hlabisa subdistrict. The study statisticians randomly assigned clusters (1:1) with MapInfo Pro (version 11.0) to either the control or intervention communities, stratified on the basis of antenatal HIV prevalence. We offered residents repeated rapid HIV testing during home-based visits every 6 months for about 4 years in four clusters, 3 years in six clusters, and 2 years in 12 clusters (58 cluster-years) and referred HIV-positive participants to trial clinics for ART (fixed-dose combination of tenofovir, emtricitabine, and efavirenz) regardless of CD4 cell count (intervention) or according to national guidelines (initially ≤350 cells per μL and FindingsBetween March 9, 2012, and June 30, 2016, we contacted 26 518 (93%) of 28 419 eligible individuals. Of 17 808 (67%) individuals with a first negative dried blood spot test, 14 223 (80%) had subsequent dried blood spot tests, of whom 503 seroconverted after follow-up of 22 891 person-years. Estimated HIV incidence was 2·11 per 100 person-years (95% CI 1·84–2·39) in the intervention group and 2·27 per 100 person-years (2·00–2·54) in the control group (adjusted hazard ratio 1·01, 95% CI 0·87–1·17; p=0·89). We documented one case of suicidal attempt in a woman following HIV seroconversion. 128 patients on ART had 189 life-threatening or grade 4 clinical events: 69 (4%) of 1652 in the control group and 59 (4%) of 1367 in the intervention group (p=0·83).InterpretationThe absence of a lowering of HIV incidence in universal test and treat clusters most likely resulted from poor linkage to care. Policy change to HIV universal test and treat without innovation to improve health access is unlikely to reduce HIV incidence.FundingANRS, GiZ, and 3ie.

International audience; “We need to do our utmost so that the benefits of the new treatments can reach those poorest people in Africa and in the rest of the world” said Jacques Chirac, former French President, at the tenth International Conference on AIDS and STIs in Africa (ICASA), held in December, 1997, in Abidjan, Cote d'Ivoire. 20 years on, Abidjan is again hosting ICASA, with one aim: “Africa: ending AIDS—delivering differently”.In two decades, new funding mechanisms have been developed and antiretroviral therapy (ART) has been scaled up exponentially. ART has been proven efficient in reducing mortality and morbidity, HIV transmission,1and HIV acquisition.2Social science contributed to show that access to ART was feasible, efficient, and acceptable in Africa.3Modelling research suggested that a universal test-and-treat strategy could potentially stop HIV transmission and end AIDS4—the goal of UNAIDS's 90-90-90 target for 2020.However, we are still facing major gaps. Biomedical innovations will be crucial, but not sufficient alone. Innovations in terms of intervention implementation, delivery models, and public health policies are urgently required. Such challenges are not just operational, logistic, or politic. Beyond effectiveness, we need empirical and theoretical knowledge about implementation.5We also need social science research, both fundamental and operational, to analyse social, cultural, political, and structural processes that still limit access to prevention and care.Long-term perspective is needed to understand present limitations of HIV services, despite the huge funding devoted to HIV response by global institutions. How global health policies could jeopardise local response in some areas? Why perceived stigma is still a major barrier to care and services as it was 20 years ago? This issue is particularly true for western and central Africa, which received historically less attention than eastern and southern Africa6and where gaps are more pronounced: among people living with HIV in 2016, only 42% knew their status, 35% were on treatment, and 25% were virally suppressed in western and central Africa, versus 76%, 60%, and 50%, respectively, in eastern and southern Africa.7These issues were raised at the Social Science and HIV/AIDS in Sub-Saharan Africa conference, hosted in Abidjan in December, 2016. To fully play their part, social and implementation sciences must embrace the key questions raised by contemporary epidemics and that cannot be solved by biomedical science alone, including stigma, therapeutic failure, people-centred approaches, ageing of people living with HIV, integration of HIV services, governance and funding, and implementation of universal health coverage. Dedicated funding for coordination, research networks, and both operational and fundamental social science research is essential.We, scientists in social and implementation science, on behalf of the Abidjan 2016 conference scientific committee, would like to reaffirm the importance of multifaceted and plural social sciences and to keep such research on the international scientific agenda, in particular for western and central Africa. We hope that the 2017 ICASA conference held in Abidjan this week will provide a forum to discuss such matters.We declare no competing interests. We are members of the Social Science and

International audience; Dans une approche interdisciplinaire anthropo-communicationnelle, la notion d’identité est interrogée par l’étude du processus collectif de commémoration d’un héros dans la communication numérique. Quelles sont les modalités de fabrication du héros ? Que nous dit le corpus des rapports de force qui président à la fabrication de ce héros ? Une étude des traits héroïques de Mano Dayak, leader de la rébellion touarègue des années 90, est conduite sur un corpus constitué d’une discussion WhatsApp ayant eu lieu pendant un mois, à l’occasion des vingt ans de son décès. Si la commémoration actualise et transforme la figure du leader en héros de la rébellion actuelle, elle masque également toutes les autres morts dont les Touaregs par coutume ne peuvent parler.

Summary Background In resource-limited settings, people with disabilities have been left behind in the response to HIV. In the HandiVIH study, we estimate and compare HIV prevalence and associated risk factors between people with and without disabilities. Methods In this cross-sectional, population-based, observational study, we used two-phase random sampling to recruit adults with disabilities and a control group matched for age, sex, and residential location from households of the general population. We used the Washington Group Short Set of Questions on Disability to identify people with disabilities. We administered an HIV test and a life-course history interview to participants. The primary outcome was the prevalence of HIV among participants with and without disabilities. Findings Between Oct 2, 2014, and Nov 30, 2015, we recruited 807 people with disabilities and 807 participants without disabilities from Yaounde, Cameroon. 28 of 716 people in the control population had a positive HIV test result (crude prevalence 3·9%, 95% CI 2·9–5·3) compared with 50 of 739 people with disabilities (6·8%, 5·0–8·6; conditional odds ratio [OR] 1·7; p=0·04). Women with disabilities were more often involved in paid sexual relationships than were women without disabilities (2·5% vs 0·5%, p=0·05). People with disabilities were also at increased risk of sexual violence than were women without disabilities (11·0% vs 7·5%, OR 1·5; p=0·01). Sexual violence and sex work were strongly associated with increased risk of HIV infection among participants with disabilities but not among controls (OR 3·0, 95% CI 1·6–5·6 for sexual violence and 12·3, 4·4–34·6 for sex work). Analyses were done in men and women. Interpretation The higher prevalence of HIV infection in people with disabilities than people without disabilities reflects a higher exposure to HIV infection as well as the presence of disability-associated HIV infection. The susceptibility of people with disabilities to HIV infection seems to be shaped by social and environmental factors. Research is needed to inform firm recommendations on how to protect this vulnerable population. Funding Agence nationale de recherches sur le sida et les hepatites virales (ANRS-Inserm) and the 5% Initiative.

International audience; Naît-on fille ou garçon ou le devient-on ? Comment se constituent les différences sexuées en matière d’éducation, de jeux, de droits, de représentations ? Quel regard portent les enfants sur leur condition de fille ou de garçon, comment sont-ils acteurs des dynamiques à l’oeuvre à l’école, à la maison, au travail ? L’ouvrage revisite l’enfance et l’adolescence en prenant en compte le genre dans les processus de construction sociale. En divers lieux, sur des terrains situés en Afrique et en Europe, les auteur-e-s croisent les regards, montrent comment se fabriquent les différences entre filles et garçons.Les questions de l’accès à l’instruction, des tâches domestiques, du travail des enfants, de leurs migrations, prennent toute leur mesure lorsqu’il s’agit de définir l’enfance comme une période de la vie, différemment construite et définie selon les cultures et les normes dans lesquelles elle prend place. Les expériences abordées ici montrent à quel point ces questions sont fondamentales pour comprendre le devenir des sociétés contemporaines.

International audience; Although “community conflicts” are a heated topic in Cameroon, not all of them are given equal attention. This article aims to analyze the forms and consequences of conflicts that remain understudied in the academic literature, namely those between farmers and herders in the Adamawa and East regions. Although these conflicts are not new, they have become more frequent and intense in recent years. By studying the range of factors that cause tensions between farmers and herders, I will show how conflicts over land and resource use are transformed into intercommunity issues, turning the conflicting parties into rival groups. The recurrence of these conflicts and their responses at various levels highlight the ongoing transformations in the Adamawa and East regions, as well as the reconfigurations and power issues at stake. By studying the strategies of national (representatives of the Mbororo community) and international stakeholders (NGOs), I will examine how these agropastoral tensions may be reconfigured and how they interact with an authoritarian context of a “stationary state.”

International audience; Depuis les années 2010, le Cameroun a vu se multiplier les interventions internationales visant à répondre aux déplacements forcés sur son territoire. Prenant l'exemple du secteur éducatif, cette étude interroge les liens et conséquences de ces interventions sur les acteurs et enjeux politiques, à différentes échelles. Le secteur préscolaire, tout d'abord, est réinvesti par les acteurs locaux grâce à des programmes d'aide d'urgence influençant la politique nationale de décentralisation ainsi que l'orientation des stratégies gouvernementales. L'étude de la crise anglophone souligne un processus d'humanitarisation de l'école primaire, visant à dépolitiser un conflit national en neutralisant les enjeux qui lui sont attachés. Enfin, l'exemple d'un projet de formation professionnelle permet d'analyser la manière dont acteurs étatiques, humanitaires et réfugiés s'accommodent d'un environnement politique et de ses contraintes.

We analyze the multitude of conflicts of interest to which all actors in the development chain are subject. Our aim is to reflect on how the findings of research and evaluations conducted on development interventions of all kinds can be biased as a result. This analysis rests on an inclusive definition of conflict of interest, which exists whenever an actor’s public stance is constrained by interests that put pressure on him or her to either express statements that contradict his or her own perceptions or knowledge, or to withhold criticism that he or she would otherwise be prepared to express. We illustrate the analysis with many cases based on our long experience in the field. Identifying problems encountered by a development intervention must be understood as a key step in formulating solutions adapted to local contexts. Nous analysons la multitude de conflits d’intérêts auxquels sont soumis tous les acteurs de la chaîne du développement. Nous nous intéressons à la façon dont les résultats des recherches et des évaluations menées sur les interventions de développement de toutes sortes peuvent être biaisés en raison de ces conflits d’intérêts. Cette étude repose sur une définition inclusive du conflit d’intérêts : ce dernier apparaît chaque fois que la position publique d’un acteur est contrainte par des intérêts, si bien qu’il est amené à faire une déclaration qui va à l’encontre de ses propres perceptions ou connaissances, ou qu’il se retient d’exprimer une critique. Notre analyse s’appuie sur de nombreux cas issus de notre longue expérience du terrain. Une étape clé dans la formulation de solutions adaptées aux contextes locaux est l’identification des problèmes rencontrés par une intervention de développement. Analizamos la multitud de conflictos de intereses a los que se ven confrontados todos los actores de la cadena del desarrollo. Nos interesamos a la manera en que los resultados de las investigaciones y evaluaciones llevadas a cabo por todo tipo de acciones de desarrollo pueden verse sesgadas a causa de estos conflictos de intereses. Este estudio se basa en una definición inclusiva del conflicto de intereses: este surge cada vez que la posición pública de un actor se ve afectada por intereses, ya sea porque se vea obligado a realizar una declaración que va contra sus propias percepciones o sus propios conocimientos, ya sea porque deba abstenerse de realizar una crítica. Nuestro análisis se fundamenta en numerosos casos procedentes de nuestra larga experiencia sobre el terreno. Una etapa crucial para la formulación de soluciones adaptadas a los contextos locales es la identificación de los problemas encontrados por una acción de desarrollo.

International audience; Appropriate costing and economic modeling are major factors for the successful scale-up of health interventions. Various cost functions are currently being used to estimate costs of health interventions at scale in low- and middle-income countries (LMICs) potentially resulting in disparate cost projections. The aim of this study is to gain understanding of current methods used and provide guidance to inform the use of cost functions that is fit for purpose. We reviewed seven databases covering the economic and global health literature to identify studies reporting a quantitative analysis of costs informing the projected scale-up of a health intervention in LMICs between 2003 and 2019. Of the 8725 articles identified, 40 met the inclusion criteria. We classified studies according to the type of cost functions applied-accounting or econometric-and described the intended use of cost projections. Based on these findings, we developed new mathematical notations and cost function frameworks for the analysis of healthcare costs at scale in LMICs setting. These notations estimate variable returns to scale in cost projection methods, which is currently ignored in most studies. The frameworks help to balance simplicity versus accuracy and increase the overall transparency in reporting of methods.

HIV self-testing (HIVST) empowers individuals by allowing them to decide when and where to test and with whom to share their results. From 2019 to 2022, the ATLAS program distributed ≈ 400 000 HIVST kits in Côte d Ivoire, Mali, and Senegal. It prioritised key populations, including female sex workers and men who have sex with men, and encouraged secondary distribution of HIVST to their partners, peers and clients. To preserve the confidential nature of HIVST, use of kits and HIVST results were not systematically tracked. Therefore, an anonymous phone survey was conducted to estimate HIVST positivity rates and linkage to confirmatory testing and care. This two-step survey involved an initial recruitment phase from March to June 2021 where participants were encouraged via leaflets to call a free phone number and complete a sociobehavioural questionnaire. This was followed by a second phase in September and October 2021, where participants who reported a reactive HIVST result were re-contacted to complete a further questionnaire. Of the 2 615 participants recruited during the first phase, 89.7% reported consistent results (2 visible lines and result interpreted as reactive; one line and interpreted as non-reactive; or no/one line and interpreted as invalid). HIVST positivity rates varied between 2.4% to 9.1% based on calculation methods (i.e. self-interpreted result or reported number of lines, inclusion or exclusion of don t knows and refusals). The second phase saw 78 out of 126 eligible participants complete the questionnaire. Of the 27 who reported a consistent reactive result in the first phase, 15 (56%, 95%CI: 36 to 74%) underwent confirmatory HIV testing, with 12 (80%) confirmed as HIV-positive, all of whom began antiretroviral treatment. The confirmation rate of HIVST results was fast, with 53% doing so within a week and 91% within three months of self-testing. Two-thirds (65%) went to a general public facility, and one-third to a facility dedicated to key populations. The ATLAS HIVST distribution strategy reached people living with HIV in West Africa. Linkage to confirmatory testing remained sub-optimal in these first years of HIVST implementation. However, if confirmed HIV-positive, almost all initiated treatment. HIVST constitutes a relevant complementary tool to existing screening services.

La migration peut engendrer différentes situations de vulnérabilité et de précarités sociales et économiques. Si les migrants subsahariens viennent de pays où la consommation d'alcool est moins fréquente qu'en France, les difficultés sociales rencontrées à l'arrivée peuvent s'accompagner d'une consommation d'alcool à risque. Parallèlement, les migrants subsahariens vivant en France constituent une population à risque en ce qui concerne l'infection à VIH et au virus de l'hépatite B, maladies pour lesquelles la consommation abusive d'alcool peut compliquer la prise en charge médicale. Il est donc nécessaire de mieux connaître la consommation d'alcool et les déterminants de cette consommation chez ces migrants. Nous proposons de décrire la consommation d'alcool et en analyser les déterminants chez les migrants subsahariens vivants en Île-de-France, à partir de l'enquête ANRS-PARCOURS menée en 2012-2013 en Île-de-France. Cette enquête a permis de mesurer la consommation d'alcool au moment de l'enquête chez des migrants subsahariens suivis pour une infection à VIH ou une hépatite B chronique, ou n'ayant aucune de ces deux maladies, mais égale-ment de recueillir des informations sur leur parcours migratoire et leur situation sociale en France. Notre analyse montre que la consommation d'alcool et la consommation à risque d'alcool sont présentes au sein de cette population même si elles sont moins fréquentes comparées à ce qu'on observe dans la population générale française. Ces modes de consommation sont associées à certaines situations de vulnérabilité engendrées par le parcours migratoire.

International audience; Whether risk compensation could offset the preventive effect of early initiation of antiretroviral therapy (ART) on human immunodeficiency virus (HIV) transmission remains unknown. Using virological and behavioral data collected 12 months after inclusion in the TEMPRANO randomized trial of early ART (Abidjan, Côte d'Ivoire, 2009–2012), we estimated the risk of HIV transmission and compared it between the intervention (early ART; n = 490) and control (deferred ART; n = 467) groups. We then simulated increases in various sexual risk behaviors in the intervention group and estimated the resulting preventive effect. On the basis of reported values of sexual behaviors, we estimated that early ART had an 89% (95% confidence interval: 81, 95) preventive effect on the cumulative risk of HIV transmission over a 1-month period. This preventive effect remained significant for a wide range of parameter combinations and was offset (i.e., nonsignificant) only for dramatic increases in different sexual behaviors simulated simultaneously. For example, when considering a 2-fold increase in serodiscordance and the frequency of sexual intercourse together with a 33% decrease in condom use, the resulting preventive effect was 47% (95% confidence interval: −3, 74). An important reduction of HIV transmission may thus be expected from the scale-up of early ART, even in the context of behavioral change.

Background The 2015 WHO recommendation of antiretroviral therapy (ART) for all immediately following HIV diagnosis is partially based on the anticipated impact on HIV incidence in the surrounding population. We investigated this approach in a cluster-randomised trial in a high HIV prevalence setting in rural KwaZulu-Natal. We present findings from the first phase of the trial and report on uptake of home-based HIV testing, linkage to care, uptake of ART, and community attitudes about ART. Methods and Findings Between 9 March 2012 and 22 May 2014, five clusters in the intervention arm (immediate ART offered to all HIV-positive adults) and five clusters in the control arm (ART offered according to national guidelines, i.e., CD4 count ≤ 350 cells/μl) contributed to the first phase of the trial. Households were visited every 6 mo. Following informed consent and administration of a study questionnaire, each resident adult (≥16 y) was asked for a finger-prick blood sample, which was used to estimate HIV prevalence, and offered a rapid HIV test using a serial HIV testing algorithm. All HIV-positive adults were referred to the trial clinic in their cluster. Those not linked to care 3 mo after identification were contacted by a linkage-to-care team. Study procedures were not blinded. In all, 12,894 adults were registered as eligible for participation (5,790 in intervention arm; 7,104 in control arm), of whom 9,927 (77.0%) were contacted at least once during household visits. HIV status was ever ascertained for a total of 8,233/9,927 (82.9%), including 2,569 ascertained as HIV-positive (942 tested HIV-positive and 1,627 reported a known HIV-positive status). Of the 1,177 HIV-positive individuals not previously in care and followed for at least 6 mo in the trial, 559 (47.5%) visited their cluster trial clinic within 6 mo. In the intervention arm, 89% (194/218) initiated ART within 3 mo of their first clinic visit. In the control arm, 42.3% (83/196) had a CD4 count ≤ 350 cells/μl at first visit, of whom 92.8% initiated ART within 3 mo. Regarding attitudes about ART, 93% (8,802/9,460) of participants agreed with the statement that they would want to start ART as soon as possible if HIV-positive. Estimated baseline HIV prevalence was 30.5% (2,028/6,656) (95% CI 25.0%, 37.0%). HIV prevalence, uptake of home-based HIV testing, linkage to care within 6 mo, and initiation of ART within 3 mo in those with CD4 count ≤ 350 cells/μl did not differ significantly between the intervention and control clusters. Selection bias related to noncontact could not be entirely excluded. Conclusions Home-based HIV testing was well received in this rural population, although men were less easily contactable at home; immediate ART was acceptable, with good viral suppression and retention. However, only about half of HIV-positive people accessed care within 6 mo of being identified, with nearly two-thirds accessing care by 12 mo. The observed delay in linkage to care would limit the individual and public health ART benefits of universal testing and treatment in this population. Trial registration ClinicalTrials.gov NCT01509508, Collins Iwuji and colleagues report implementation indicators and early health outcomes from the first phase of a cluster-randomized trial of immediate antiretroviral therapy to all HIV-positive individuals in rural KwaZulu-Natal, South Africa., Author Summary Why Was This Study Done? A study in stable sexual partners in which one partner was HIV-positive and the other partner was HIV-negative (and both partners had disclosed to each other) showed that if the HIV-positive partner was on antiretroviral therapy, there was a 96% reduction in HIV transmission from the HIV-positive partner to the HIV-negative partner. However, we do not know if antiretroviral therapy prescribed to HIV-positive individuals in the general population—and where individuals might not disclose their HIV status to sexual partners—would have a similar impact on HIV transmission. It is important to determine whether prescribing antiretroviral therapy to all HIV-positive individuals is more effective at decreasing HIV transmission than starting individuals on antiretroviral therapy only once their HIV has progressed to the point at which local HIV treatment guidelines currently recommend that HIV-positive individuals start treatment. What Did the Researchers Do and Find? We designed an experiment to investigate whether antiretroviral therapy can reduce new HIV infections in the general population, and piloted the trial in ten communities in KwaZulu-Natal, South Africa, to check whether starting HIV-positive individuals on antiretroviral therapy directly after diagnosis is feasible and acceptable. We visited people in their homes, offered HIV rapid tests every six months to all individuals 16 years and older, and referred identified HIV-positive individuals to trial clinics, where they were offered antiretroviral therapy either regardless of their CD4 count (intervention group) or when they were treatment-eligible per current national guidelines (control group). During the two-year study, we contacted 9,927 (77%) of 12,894 eligible individuals and ascertained the HIV status of 80% of contacted women and 75% of contacted men. HIV-positive status was ascertained for 1,339 adults who were not previously in care; 1,177 were followed in the trial at least 6 mo after referral, of whom 559 (47.5%) engaged with care within this period. What Do These Findings Mean? Our findings show good acceptance of home-based HIV testing in rural South Africa but highlight the challenges in reaching adequate numbers of people to offer HIV tests to, especially among men. We also found that linkage to care was slower than expected, but amongst those who reached the clinics, uptake of antiretroviral therapy was high, with the majority of individuals achieving good control of the virus. Our study informs health care professionals, planners, and policy makers about the challenges that need to be addressed to achieve the UNAIDS target of 90% of people living with HIV aware of their HIV diagnosis, 90% on antiretroviral therapy, and 90% achieving good control of the virus, with testing and treatment offered to all.

International audience; Based on social indicators collected within the TEMPRANO-ANRS12136 trial, we assessed the social consequences of early antiretroviral therapy (ART) initiation in west Africa. We did not observe any significant differences in the levels or the time trends of various social indicators, including union status, HIV disclosure and HIV-related discrimination, between early and deferred ART initiation. Early ART does not carry detectable adverse social consequences that could impair its clinical and preventive benefits.

The French associative landscape against HIV/AIDS sees at the end of the 1990s the emergence of a set of immigrant organizations, especially led by persons born in sub-Saharan Africa. Heavily affected by the epidemic and long forgotten by the programs to combat the epidemic, immigrant women became a priority target of the health authorities and now occupy a particular position within immigrant organizations. The objective of this thesis is to shed light on the specific role played by women born in sub-Saharan Africa in the fight against HIV/AIDS in France and to analyze the consequences of such an associative commitment on various spheres of their lives. A socio-ethnographic survey was conducted in the Ile-de-France region, between 2011 and 2013, from the observation of the daily lives, actions and events of six organizations. Eighty-six interviews were conducted among women met in twelve organizations, in order to reconstruct their biographical trajectory. Twenty-six doctors, nurses and hospital social workers were interviewed in order to seize their representations of these associative players. Theories of care and agency form the analytical framework emerging from the empirical materials. The survey shows that the associative projects led by women born in sub-Saharan Africa respond sensitively to the needs of the most vulnerable immigrants but also to the needs of the social and health professionals. Predominantly female, these groups fit into an associative grammar of care based on self-support and the meeting between two profiles: the female users in a liminal position and the caregivers with diverse resources. The female users draw on these spaces the necessary supports to get out of the liminal status, while the caregivers develop a field expertise which allows them to fit into HIV/AIDS policies and professional spheres. The analyses point out the agency process of the women engaged within these organizations. The female users negotiate the mode of their social integration in France tactically resorting to the associations they frequent. The caregivers rely on the fight against HIV/AIDS to exceed the position traditionally assigned to immigrants in France and to have access to the public space. Furthermore, the specific positioning of women within immigrant organizations offers them a special opportunity to strategically appropriate the gender norms integrated over their socialization. However, HIV/AIDS social issues linked to the social position of women in the migration context hamper the different voice/way which seems to be open to them in the fight against the epidemic in France.; Le paysage associatif français de lutte contre le VIH/sida voit émerger dès la fin des années 1990 un ensemble d'associations d’immigrant-e-s, en particulier porté par des personnes nées en Afrique Subsaharienne. Lourdement affectées par l’épidémie et longtemps oubliées des programmes de lutte contre l’épidémie, les femmes immigrantes devenues une cible prioritaire des autorités sanitaires y occupent une position particulière. L'objectif de cette thèse est d'éclairer le rôle spécifique joué par les femmes nées en Afrique Subsaharienne dans la lutte contre le VIH/sida en France et d'analyser les conséquences d'un tel engagement associatif sur les différentes sphères de leur vie. Une enquête socio-ethnographique a été réalisée en Ile-de-France, entre 2011 et 2013, à partir de l'observation du quotidien de six associations, d'actions et événements associatifs divers. Quatre-vingt-six entretiens ont été conduits auprès de femmes rencontrées dans douze associations, afin de reconstituer leur trajectoire biographique, et auprès de médecins et assistantes sociales hospitalières pour saisir leurs représentations de ces actrices associatives. Le care et l'agency forment le cadre analytique émergeant des matériaux empiriques. L'enquête montre que les projets associatifs menés par les femmes nées en Afrique Subsaharienne répondent de manière sensible aux besoins des immigrant-e-s les plus vulnérables mais également aux besoins de soutien des professionnel-le-s de l'action sociale et de santé. Majoritairement féminins, ces collectifs s'inscrivent dans une grammaire associative du care reposant sur l’auto-support et la rencontre entre deux profils : les usagères en situation de liminalité et les aidantes aux ressources diverses. Les usagères puisent dans ces espaces les supports nécessaires à la sortie du statut liminal, tandis que les aidantes développent une expertise du terrain qui leur permet de s’insérer dans les sphères professionnelles et politiques du VIH/sida. Les analyses pointent le processus d’agency des femmes engagées au sein de ces associations. Les usagères négocient les modalités de leur insertion sociale en France en recourant de manière tactique aux associations qu'elles fréquentent. Les aidantes s'appuient sur la lutte contre le VIH/sida pour dépasser la place traditionnellement réservée aux immigrant-e-s en France et accéder à l'espace public. De plus, le positionnement spécifique des femmes au sein des associations d'immigrant-e-s leur offre une opportunité particulière de s’approprier stratégiquement les normes de genre intégrées au fil de leur socialisation. Cependant, les enjeux sociaux de la lutte contre le VIH/sida articulés à la position sociale de ces femmes dans le contexte migratoire freinent la voix/e différente qui semble leur être ouverte par la lutte contre l’épidémie en France.

International audience; Reunion Island is a French overseas department and Ultra Peripheral European Region. Its demographic, social and economic characteristics match with the territory’s geography, as well as its physical features. Several elements (such as the distance separating the island from France and Europe, its exposure to seven of the eight major environmental hazards, the strong contrast between the coastal and the inland regions of the island) are to be considered when it comes to analysing key indicators like poverty rate, unemployment, and social inequality, which are amongst the highest in France. Therefore, the rapid ageing population on the island and the care for the elderly are challenges the public institutions have to tackle. However they are also an opportunity to promote innovative approaches, deeply rooted in territorial dynamics, and mindset. This communication therefore focuses on analysing these movements of constraints, as well as social and demographic opportunities, and the way it interacts within the territory with a view to enhancing institutional innovation.; L’île de La Réunion est un département d’outre-mer français et une région ultra périphérique européenne dont les caractéristiques démographiques, sociales et économiques sont en forte résonance avec les caractéristiques géographiques et physiques du territoire. L’éloignement de la métropole et du continent européen, l’exposition à sept des huit risques majeurs, la dichotomie entre les espaces côtiers et montagneux, sont ainsi à mettre en relation avec des taux de pauvreté, de chômage et d’inégalités parmi les plus élevés de France. Dans ce contexte, le vieillissement très rapide de la population réunionnaise et la prise en charge des personnes âgées en perte d’autonomie sont des défis pour les pouvoirs publics, mais aussi une occasion de promouvoir des approches originales fortement ancrées dans la dynamique territoriale. Cette communication s’intéresse donc à analyser ce mouvement de contraintes et d’opportunités sociales et démographiques et la manière dont il interagit avec le territoire pour en faire un lieu d’innovation institutionnelle.

International audience; Al firmar el convenio 169 de la Organización Internacional del Trabajo, al adoptar la Ley e implementar el reglamento de Consulta Previa, el Estado peruano otorga derechos colectivos especiales a pueblos indígenas u originarios. Este reconocimiento de la diversidad cultural dentro de la sociedad no solamente lleva consigo nuevos desafíos para la política y las instituciones, en busca de encontrar caminos para incluir voces históricamente marginadas e interactuar más cercanamente con la ciudadanía; sino que también genera nuevas oportunidades para el desarrollo nacional, la cultura institucional y las culturas diversas presentes en la sociedad peruana.Este trabajo estudia estos desafíos y oportunidades en cuanto al ámbito educativo, preguntándose específicamente cómo repercuten en las políticas de Educación Intercultural Bilingüe. Basado en el análisis de documentos oficiales, extractos de prensa así como entrevistas con actores implicados directamente o indirectamente en el proceso de consulta previa del Plan Nacional de Educación Intercultural Bilingüe, estudiamos los cambios que emergen de este diálogo entre el Estado y la ciudadanía. Demostramos así la importancia de la consulta previa como espacio político, de construcción y aprendizaje institucional y social, en el que se discuten la necesidad y las posibilidades para adaptar el modelo educativo republicano a la realidad socio-política y cultural de la sociedad peruana.

International audience; Les mutations sociales contemporaines constituent de nouveaux défis pour la sociolinguistique et suscitent le renouvellement d’outils méthodologiques et conceptuels permettant de repenser les rapports entre langage et société. Cet ouvrage réunit des textes qui contribuent à relever ce défi en apportant des éléments de compréhension relatifs aux situations sociolinguistiques contemporaines et à leurs dynamiques plurilingues en lien avec la ville, la migration et l’école. Tous contribuent à revisiter les pratiques, les mobilités et l’éducation plurilingues, rendant ainsi un hommage aux travaux du professeur Caroline Juillard.

International audience; In Jordan, between censorship, repression and election rigging, political activism is limited –despite the democratic opening glimpsed in 1989. Pénélope Larzillière charts the path of longstanding activists in Jordan and shows how opposition movements there have shifted from the underground to a heavily controlled public sphere. Activists discuss their motivation and commitment and the consequences their activism has had throughout their lives. Not only do these accounts highlight the general conditions for political activism in a repressive regime, they also unpack the meaning individuals attach to their political journey and chosen ideology, whether communist, nationalist, Islamist or otherwise.

International audience; Based on the analysis of autobiographic stories told by Peruvian domestic workers in Lima, the present article discusses the conditions for these women to stand up and speak out for their rights. Studying the speakers' use of the two verba dicendi (“verbs of speaking”) decir and hablar, it reconstructs the communicative competence these marginalised actors themselves define as necessary for their active participation in society. The analysis allows for discussing the conditions for women in Latin America to participate in the struggle against social inequalities, as well as the role and responsibility of the ethnographic research process with regard to this competence.; Apoyándose en narraciones autobiográficas de trabajadoras del hogar peruanas en Lima, el presente artículo estudia las condiciones de la participación activa de esas mujeres en los debates públicos acerca de sus derechos. Concentrándose en el uso que hacen las narradoras de los dos verba dicendi (verbos de actos de habla) hablar y decir, el análisis muestra la construcción por ellas mismas de una competencia comunicativa desde la perspectiva socialmente marginada. El análisis permite discutir las condiciones de la participación de mujeres en Latinoamérica en la lucha contra las desigualdades sociales, así como el papel y la responsabilidad del proceso etnográfico de investigación en miras de esta competencia.

International audience

Settlement is a key moment in migrant trajectories in a new country. Although the field of migration studies has placed great emphasis on the causes of migration and its consequences, relatively much less is known about the moment of settlement. One of the reasons for this lies in the scarcity of longitudinal data that allow for an analysis of the settlement process. Drawing on Amartya Sen's concept of capabilities, this study aims at understanding Sub-Saharan migrant settlement in France and its potential interaction with HIV/AIDS and chronic hepatitis B which particularly affect this population. Using the PARCOURS life-event history survey led in 2012-2013 in Paris area which collected 2468 trajectories of migrants affected or not by HIV/AIDS or hepatitis B, we analyse the dynamics and factors of obtaining a personal dwelling, a residence permit and financial autonomy. We show that Sub-Saharan migrants take 6 to 9 years in median to obtain a minimal stability (dwelling, papers, resource) whatever their HIV or hepatitis B statuses are. They are then exposed to social difficulties during a long period. The sequence of settlement is gendered : men first access an activity whereas women first access personal dwelling. Being educated for men, and having a stable partner in France upon arrival both for men and women accelerate settlement.

International audience; Introduction: We aimed to quantify and identify associated factors of linkage to HIV care following home-based HIV counselling and testing (HBHCT) in the ongoing ANRS 12249 treatment-as-prevention (TasP) cluster-randomized trial in rural KwaZulu-Natal, South Africa. Methods: Individuals ]16 years were offered HBHCT; those who were identified HIV positive were referred to cluster-based TasP clinics and offered antiretroviral treatment (ART) immediately (five clusters) or according to national guidelines (five clusters). HIV care was also available in the local Department of Health (DoH) clinics. Linkage to HIV care was defined as TasP or DoH clinic attendance within three months of referral among adults not in HIV care at referral. Associated factors were identified using multivariable logistic regression adjusted for trial arm. Results: Overall, 1323 HIV-positive adults (72.9% women) not in HIV care at referral were included, of whom 36.9% (n 0488) linked to care B3 months of referral (similar by sex). In adjusted analyses (n 01222), individuals who had never been in HIV care before referral were significantly less likely to link to care than those who had previously been in care (B33% vs. !42%, p B0.001). Linkage to care was lower in students (adjusted odds-ratio [aOR] 00.47; 95% confidence interval [CI] 0.24Á0.92) than in employed adults, in adults who completed secondary school (aOR 00.68; CI 0.49Á0.96) or at least some secondary school (aOR 00.59; CI 0.41Á0.84) versus 5 primary school, in those who lived at 1 to 2 km (aOR 00.58; CI 0.44Á0.78) or 2Á5 km from the nearest TasP clinic (aOR 00.57; CI 0.41Á0.77) versus B1 km, and in those who were referred to clinic after ]2 contacts (aOR 00.75; CI 0.58Á0.97) versus those referred at the first contact. Linkage to care was higher in adults who reported knowing an HIV-positive family member (aOR 01.45; CI 1.12Á1.86) versus not, and in those who said that they would take ART as soon as possible if they were diagnosed HIV positive (aOR 02.16; CI 1.13Á4.10) versus not. Conclusions: Fewer than 40% of HIV-positive adults not in care at referral were linked to HIV care within three months of HBHCT in the TasP trial. Achieving universal test and treat coverage will require innovative interventions to support linkage to HIV care. Keywords: HIV/AIDS; home-based HIV counselling and testing; linkage to care; universal test and treat; South Africa.

This essay drafts a new interdisciplinary agenda for research on population and development. Starting from Kingsley Davis's 1963 formulation of change and response, Davis's analytical categories are broadened to include inertia as well as change and to encompass both demographic and non-demographic responses at the micro, meso, and macro levels. On that basis the essay proposes what can be called a comprehensive demography, an approach drawing principally on micro-level methodologies like those employed in anthropological demography. Like anthropological demography, comprehensive demography questions the rationality of actors, emphasizes cultural infuences, and stops short of the postmodernist extremes of anthropology. But it also takes explicit account of higher-level social, economic, and political factors bearing on demographic behavior and outcomes. The conclusion raises some epistemological issues. Illustrative examples are offered throughout to demonstrate the feasibility of the approach, mainly referring to sub-Saharan africa and the Caribbean and often drawn from the authors' own fieldwork.

International audience; The first step in preventing mother-to-child HIV transmission (PMTCT) programmes is offering HIV counselling and testing to pregnant women. In developing countries where HIV testing remains rare, it represents a unique opportunity for many women to learn their HIV status. This prenatal HIV testing is not only the entry point to prevention of mother-to-child HIV transmission, but also an occasion for women to sensitize their male partner to sexual risks. Here we explore if these women, HIV-tested as mothers, apply the prevention recommendations they also receive as women. In the Ditrame Plus PMTCT program in Abidjan, Côte d'Ivoire, two cohorts of women (475 HIV-infected women and 400 HIV-negative women) were followed up two years after the pregnancy when they were offered prenatal HIV testing. In each cohort, we compared the proportion of women who communicated with their regular partner on sexual risks, prior to and after prenatal HIV testing. We analysed socio-demographic factors related to this communication. We measured two potential conjugal outcomes of women HIV testing: the level of condom use at sex resumption after delivery and the risk of union break-up. Prenatal HIV testing increased conjugal communication regarding sexual risks, whatever the woman's serostatus. This communication was less frequent for women in a polygamous union or not residing with their partner. Around 30% of women systematically used condoms at sex resumption. Among HIV infected ones, conjugal talk on sexual risks was related to improved condom use. After HIV testing, more HIV-infected women separated from their partners than HIV-uninfected women, despite very few negative reactions from the notified partners. In conclusion, offering prenatal HIV counselling and testing is an efficient tool for sensitizing women and their partners to HIV prevention. But sexual prevention in a conjugal context remains difficult and need to be specifically addressed.

International audience; In Sub-Saharan Africa, prevention of HIV pediatric infection due to breastfeeding requires turning to alternatives to prolonged breastfeeding: artificial feeding or exclusive breastfeeding with early weaning. Choosing a preventive option and applying it does not only depend upon the mother but also on the father and more specifically on couple interactions. To date, not enough studies have considered this question. In Abidjan, Ivory Coast, HIV-positive women and their infants were followed over two years in Ditrame Plus, a prevention of mother-to-child transmission (PMTCT) project. Using data from this project and from interviews conducted with couples and women, we analyzed the construction of decisions and practices concerning the application of preventive infant feeding options. Differences may be found between women and men in discourses regarding their attitudes, which are in part related to their conceptions of motherhood and fatherhood. We found that when men know their wife is HIV positive and are involved in the PMTCT project, they play an active role in applying the advice received. However, women do not always need the support of their spouse to undertake preventative behaviour. The project team also plays an important role in the adoption of such by women and men. The implementation of preventive options is a complex process in which three groups of actors (women, men and the project team) interact. In order to optimize PMTCT programs for couples, it is essential that this dynamic be taken into account.

International audience; Les travaux sur les comportements bisexuels en Afrique sont rares. En 2004, une étude au Sénégal auprès de 463 hommes ayant des rapports sexuels avec des hommes révèle que 74 % ont eu des partenaires féminines dans l’année. En 2007, une nouvelle enquête a été complétée par un volet qualitatif consacré aux comportements bisexuels. De 12 entretiens auprès d’hommes ayant des rapports sexuels avec des hommes et des femmes et 12 auprès de partenaires féminines se dégagent différents types de partenaires et un lien complexe entre notion de partenaire féminine, sexualité et rapport à l’homosexualité. Le type de relation entre ces hommes et les femmes dépend de leurs représentations de l’homosexualité et de leurs relations avec d’autres hommes.

International audience; IntroductionHIV epidemics in Western and Central Africa (WCA) remain concentrated among key populations, who are often unaware of their status. HIV self-testing (HIVST) and its secondary distribution among key populations, and their partners and relatives, could reduce gaps in diagnosis coverage.We aimed to document and understand secondary HIVST distribution practices by men who have sex with men (MSM), female sex workers (FSW), people who use drugs (PWUD); and the use of HIVST by their networks in Côte d’Ivoire, Mali, and Senegal.MethodsA qualitative study was conducted in 2021 involving (a) face-to-face interviews with MSM, FSW, and PWUD who received HIVST kits from peer educators (primary users) and (b) telephone interviews with people who received kits from primary contacts (secondary users). These individual interviews were audio-recorded, transcribed, and coded using Dedoose software. Thematic analysis was performed.ResultsA total of 89 participants, including 65 primary users and 24 secondary users were interviewed. Results showed that HIVST were effectively redistributed through peers and key populations networks. The main reported motivations for HIVST distribution included allowing others to access testing and protecting oneself by verifying the status of partners/clients. The main barrier to distribution was the fear of sexual partners’ reactions. Findings suggest that members of key populations raised awareness of HIVST and referred those in need of HIVST to peer educators. One FSW reported physical abuse.Secondary users generally completed HIVST within two days of receiving the kit. The test was used half the times in the physical presence of another person, partly for psychological support need. Users who reported a reactive test sought confirmatory testing and were linked to care. Some participants mentioned difficulties in collecting the biological sample (2 participants) and interpreting the result (4 participants).ConclusionThe redistribution of HIVST was common among key populations, with minor negative attitudes. Users encountered few difficulties using the kits. Reactive test cases were generally confirmed. These secondary distribution practices support the deployment of HIVST to key populations, their partners, and other relatives. In similar WCA countries, members of key populations can assist in the distribution of HIVST, contributing to closing HIV diagnosis gaps.

International audience; Introduction: In sub-Saharan Africa, as in the rest of the world, men who have sex with men (MSM) are at greater risk of HIV infection than the general population. Bisexuals are often perceived to be more at risk than exclusive gay men.Purpose of research: We propose a review of epidemiological surveys conducted in sub-Saharan Africa since 2005 to provide an overview of knowledge on HIV exposure among gay/bisexual men.Results: We reviewed 355 publications and identified 62 measures of the association between bisexuality and HIV prevalence and 8 measures of the association between bisexuality and incidence. Except for 4 of 62 measures, the HIV prevalence observed among bisexuals was equal to or lower than that observed among exclusive gay men. In terms of incidence, all but one of the identified studies observed lower or equal HIV incidence among bisexuals. From a behavioural perspective, most studies found no difference in condom use. Bisexuals may have less frequent sex and consistently less receptive anal sex. They mainly started their sexual lives with men later, had fewer partners, and were less likely to know their HIV status.Conclusions: Bisexuals are less likely to be at risk of HIV than exclusive gay men, partly because of behavioural differences. Prevention and treatment programs for MSM must take the specificities of bisexuals into account and design differentiated services.; Introduction : En Afrique subsaharienne, comme dans le reste du monde, les hommes ayant des rapports sexuels avec des hommes (HSH) sont plus exposés à l’infection par le virus de l’immunodéficience humaine (VIH) que la population générale. Les bisexuels sont souvent perçus comme plus à risque que les homosexuels exclusifs.But de l’étude : Nous proposons une synthèse des connaissances sur l’exposition au VIH des homo-bisexuels à partir d’une revue des enquêtes épidémiologiques réalisées en Afrique subsaharienne depuis 2005.Résultats : Nous avons étudié 355 publications et avons identifié 62 mesures de l’association entre bisexualité et prévalence du VIH et 8 mesures de l’association entre bisexualité et incidence. À l’exception de 4 mesures sur 62, la prévalence du VIH observée parmi les bisexuels était inférieure ou égale à celle des homosexuels exclusifs. En matière d’incidence, toutes les études identifiées sauf une observent une incidence du VIH plus faible ou égale parmi les bisexuels. Du point de vue comportemental, la majorité des études n’ont pas relevé de différence d’utilisation du préservatif. Les bisexuels ont parfois une fréquence de rapports sexuels moindre et systématiquement moins de rapports anaux réceptifs. Ils ont commencé leur vie homosexuelle plus tardivement, ont eu moins de partenaires et sont moins nombreux à connaître leur statut VIH.Conclusions : Les bisexuels sont moins exposés au VIH que les homosexuels exclusifs, notamment en raison de différences comportementales. Il importe que les programmes de prévention et de traitement à destination des HSH prennent en compte les spécificités des bisexuels et conçoivent des offres différenciées.

Background Although caesarean section (CS) rates have increased rapidly in Thailand, the upward trend is not supported by significant maternal or perinatal health benefits. The appropriate use of CS through QUALIty DECision-making by women and providers (QUALI-DEC project) aims to design and implement a strategy to optimize the use of CS through non-clinical interventions. This study aimed to explore the factors influencing women’s and health professionals’ preferences for CS delivery in Thailand. Methods We conducted a formative qualitative study by using semi-structured in-depth interviews with pregnant and postpartum women, and healthcare staff. Purposive sampling was used to recruit participants from eight hospitals across four regions of Thailand. Content analysis was used to develop the main themes. Results There were 78 participants, including 27 pregnant and 25 postpartum women, 8 administrators, 13 obstetricians, and 5 interns. We identified three main themes and seven sub-themes of women and healthcare providers’ perceptions on CS: (1) avoiding the negative experiences from vaginal birth (the pain of labor and childbirth, uncertainty during the labor period); (2) CS is a safer mode of birth (guarantees the baby’s safety, a protective shield for doctors); and (3) CS facilitates time management (baby’s destiny at an auspicious time, family’s management, manage my work/time). Conclusions Women mentioned negative experiences and beliefs about vaginal delivery, labor pain, and uncertain delivery outcomes as important factors influencing CS preferences. On the other hand, CS is safer for babies and facilitates multiple tasks in women’s lives. From health professionals’ perspectives, CS is the easier and safer method for patients and them. Interventions to reduce unnecessary CS, including QUALI-DEC, should be designed and implemented, taking into consideration the perceptions of both women and healthcare providers.

The analysis of hospital resilience is essential in understanding how health services prepared for and responded to sudden shocks and unexpected challenges in the COVID-19 health crisis. This study aimed to analyze the resilience of a referral hospital in the state of Pernambuco, Brazil, in the context of the COVID-19 pandemic. The main theoretical approach based on resilience is the system's capacity to maintain essential functions and to absorb, adapt, and transform in the face of unprecedented or unexpected changes. A single case study approach was used to identify the strengths and weaknesses of this response capacity. Data triangulation was employed. Data were collected from April (beginning of case discharges) to October 2020 (decrease in the moving average of cases in 2020). A content analysis was then conducted. Data were analyzed in relation to context, effects, strategies, and impacts in facing the disruptions caused by the pandemic. The results indicated the occurrence of four configurations mostly favorable to hospital resilience during the study period. Among the main strengths were: injection of financial resources; implementation of new hospital protocols; formation of a support network; equipping and continuing education of professionals; and proactive leadership. Weaknesses found in the analysis included: initial insufficiency of personal protective equipment and confirmatory tests; difficulties in restructuring work schedules; increasing illness among professionals; stress generated by constant changes and work overload; sense of discrimination for being a health professional; lack of knowledge about the clinical management of the disease; and the reduction of non-COVID assistance services.

Introduction A key component of achieving respectful maternal and newborn care is labor companionship. Despite important health benefits for the woman and baby, there are critical gaps in implementing labor companionship for all women globally. The paper aims to present the perceptions and experiences of pregnant women, postpartum women, and health care providers regarding companionship during labor and childbirth, and to identify barriers and facilitating factors to the implementation of labor companionship in Burkina Faso. Methods This is a formative study to inform the “Appropriate use of cesarean section through QUALIty DECision-making by women and providers” (QUALI-DEC) study, to design, adapt and implement a strategy to optimize the use of the cesarean section, including labor companionship. We use in-depth interviews (women, potential companions, and health workers) and health facility readiness assessments in eight hospitals across Burkina Faso. We use a thematic analysis approach for interviews, and narrative summaries to describe facility readiness assessment. Results In all, 77 qualitative interviews and eight readiness assessments are included in this analysis. The findings showed that all participants acknowledged an existing traditional companionship model, which allowed companions to support women only in the hospital waiting room and post-natal room. Despite recognizing clear benefits, participants were not familiar with companionship during labor and childbirth in the hospital as recommended by WHO. Key barriers to implementing companionship throughout labor and birth include limited space in labor and delivery wards, no private rooms for women, hospital rules preventing companionship, and social norms preventing the choice of a companion by the woman. Conclusion Labor companionship was considered highly acceptable in Burkina Faso, but more work is needed to adapt to the hospital environment. Revisions to hospital policies to allow companions during labor and childbirth are needed as well as changes to provide private space for women. Training potential companions about their roles and encouraging women’s rights to choose their companions may help to facilitate effective implementation.

Background Ensuring access to healthcare services is a key element to achieving the Sustainable Development Goal 3 of “promoting healthy lives and well-being for all” through Universal Health Coverage (UHC). However, in the context of low- and middle-income countries, most studies focused on financial protection measured through catastrophic health expenditures (CHE), or on health services utilization among specific populations exhibiting health needs (such as pregnancy or recent sickness). Methods This study aims at building an individual score of perceived barriers to medical care (PBMC) in order to predict primary care utilization (or non-utilization). We estimate the score on six items: (1) knowing where to go, (2) getting permission, (3) having money, (4) distance to the facility, (5) finding transport, and (6) not wanting to go alone, using individual data from 1787 adult participants living in rural Senegal. We build the score via a stepwise descendent explanatory factor analysis (EFA), and assess its internal consistency. Finally, we assess the construct validity of the factor-based score by testing its association (univariate regressions) with a wide range of variables on determinants of healthcare-seeking, and evaluate its predictive validity for primary care utilization. Results EFA yields a one-dimensional score combining four items with a 0.7 Cronbach’s alpha indicating good internal consistency. The score is strongly associated—p-values significant at the 5% level—with determinants of healthcare-seeking (including, but not limited to, sex, education, marital status, poverty, and distance to the health facility). Additionally, the score can predict non-utilization of primary care at the household level, utilization and non-utilization of primary care following an individual’s episode of illness, and utilization of primary care during pregnancy and birth. These results are robust to the use of a different dataset. Conclusion As a valid, sensitive, and easily documented individual-level indicator, the PBMC score can be a complement to regional or national level health services coverage to measure health services access and predict utilization. At the individual or household level, the PBMC score can also be combined with conventional metrics of financial risk protection such as CHE to comprehensively document deficits in, and progress towards UHC.

International audience; Objectives: To estimate the proportion of users of the TousAntiCovid app(lication) and identify factors associated with its non-use for contact tracing. Methods: We conducted an online survey of a quota sample of French adults between 8 and 18 January 2021. Three categories of TousAntiCovid use were considered: contact tracing, other or temporary usage, and no use. A weighted multiple logistic regression was performed to analyze the factors associated with these different uses. Results: Among the 1 000 respondents, 63.3% declared they had never downloaded the TousAntiCovid app, 23.5% used it for contact tracing. The remaining 13.2% did not enable contact tracing, mainly because of excessive battery consumption and fear of misuse of personal data. Trust in political representatives, financial deprivation and other factors were associated with never downloading the app. Conclusion: This study confirms the previously suggested links between trust in political representatives, financial deprivation and the use of contact tracing apps in France.

International audience

The community homes are social child day-care centres, co-managed by the Colombian State and the community, which operate since the 1980s in the vulnerable neighbourhoods of the big Colombian cities. The woman of the house cares for about fifteen children and thus becomes a community mother. The resources provided by the State are managed by associations which gather about twenty community homes. This research studies both the evolution of the community homes on the public scene, and the daily life of the members of an association of beneficiaries of the programme. The author combines the study of a legal corpus which regulates the operation of the community homes and an ethnography conducted in an underprivileged neighbourhood in the southern periphery of Bogotá. With the support of the social regulation theory, the analysis sheds light on the central role played by the community homes in the process of construction of the Colombian nation : within a society burdened by an internal war, child protection is presented as the cornerstone of national integration, a supreme moral value and a lever of social development. The translation into domestic law of the principle of the child's best interest, taken from international legislation, facilitates the institutionalisation of such values. Yet, in the name of these values, the fundamental rights of the community mothers, who have a status of volunteers, and not of employees, are neglected by the State : the community mothers mobilise in order to claim their rights and obtain conclusive results. The mechanisms by which these women are empowered, around their daily child care activities, are exposed. The values associated to child protection thus appear as the bedrock and the driving force of the empowerment of two antagonist social actors : the Colombian State and the community mothers. The light shed on this mechanism, as well as its global anchorage, is intended as a contribution to contemporary anthropology and sociology of childhood. This research also nourishes the juridical debates on the principle of the best interest of the child.; Los hogares comunitarios son guarderías gestionadas por el Estado colombiano y por la comunidad, que funcionan en casas de familia en los barrios vulnerables de las grandes ciudades de Colombia desde los años 1980. El ama de casa cuida de una quincena de niños y se convierte así en madre comunitaria, y los recursos puestos a disposición por el Estado son gestionados por asociaciones que agrupan alrededor de veinte hogares comunitarios. Esta tesis estudia a la vez la evolución de los hogares comunitarios en la escena pública, y la vida cotidiana de los miembros de una asociación de beneficiarios del programa. La autora combina el estudio de un corpus de normas jurídicas que regulan el funcionamiento de los hogares comunitarios y una etnografía realizada en un barrio desfavorecido de la periferia sur de Bogotá. Con el apoyo de la teoría de la regulación social, el análisis pone en evidencia el lugar central ocupado por los hogares comunitarios en el proceso de construcción de la nación colombiana: en una sociedad atravesada por una guerra intestina, la protección de la infancia es erigida en motor de la integración nacional, en valor moral supremo y en palanca para el desarrollo social. La traducción en derecho interno del principio del interés superior del niño, que tiene su origen en el derecho internacional, facilita la institucionalización de dichos valores. Ahora bien, en nombre de estos últimos, los derechos fundamentales de la madres comunitarias, que tienen un estatus de benévolas y no de empleadas, son desatendidos por el Estado : las madres comunitarias se movilizan para reivindicar sus derechos y obtienen resultados contundentes. Se exponen los mecanismos de empoderamiento de estas mujeres alrededor de las actividades cotidianas de cuidado de los niños, al igual que los efectos imprevistos del programa en campo. Los valores asociados a la protección del niño aparecen así como base y como motor del empoderamiento de dos actores sociales antagónicos : el Estado colombiano y las madres comunitarias. La descripción de ese dispositivo y de su anclaje global constituye una contribución metodológica a la antropología y a la sociología de la infancia contemporáneas. La tesis alimenta también los debates jurídicos alrededor del principio del interés superior del niño.; Les foyers communautaires sont des crèches cogérées par l'État colombien et par la communauté, fonctionnant au sein de maisons de famille dans les quartiers vulnérables des grandes villes colombiennes depuis les années 1980. La maîtresse de maison prend en charge une quinzaine d'enfants et devient ainsi mère communautaire, et les ressources mises à disposition par l'État sont gérées par des associations regroupant une vingtaine de foyers communautaires. Cette thèse étudie à la fois l'évolution des foyers communautaires sur la scène publique et la vie quotidienne des membres d'une association de bénéficiaires du programme. L'auteure combine l'étude d'un corpus de normes juridiques régissant le fonctionnement des foyers communautaires et une ethnographie menée dans un quartier défavorisé de la périphérie sud de Bogotá. À l'aide de la théorie de la régulation sociale, l'analyse met en lumière la place centrale qu'ont occupé les foyers communautaires dans le processus de construction de la nation colombienne : au sein d'une société traversée par une guerre intestine, la protection de l'enfance est érigée en moteur d'intégration nationale, en valeur morale suprême et en levier de développement social. La traduction en droit interne du principe de l'intérêt supérieur de l'enfant, issu du droit international, facilite l'institutionnalisation de ces valeurs. Or, au nom de ces derniers, les droits fondamentaux des mères communautaires, qui ont un statut de bénévoles et non pas d'employées, sont négligés par l'État : les mères communautaires se mobilisent afin de revendiquer leurs droits et obtiennent des résultats probants. Les mécanismes de l'empowerment de ces femmes autour des activités quotidiennes de prise en charge des enfants, ainsi que les effets imprévus du programme sur le terrain, sont mis en lumière. Les valeurs associées à la protection de l'enfant apparaissent ainsi comme étant le socle et le moteur de l'empowerment de deux acteurs sociaux antagonistes : l'État colombien et les mères communautaires. La mise en évidence de ce dispositif, ainsi que de son ancrage global, se veut une contribution méthodologique à l'anthropologie et à la sociologie de l'enfance contemporaines. La thèse nourrit également les débats au sein du champ juridique autour du principe de l'intérêt supérieur de l'enfant.

Réf interne : 15085En ligne sur http://www.afd.fr/webdav/site/afd/shared/Notes%20techniques/08-notes-techniques.pdf; Cette publication dresse de manière inédite un état des lieux analytique de la recherche sur l'éducation dans les pays du Sud, depuis la France, à travers les dimensions suivantes : une « cartographie » des capacités de recherche en France consacrées à ce champ (équipes et/ou chercheurs concernés, programmes en cours), la recension de toutes les thèses soutenues en France depuis 1990 et celles en cours en 1993, la production scientifique sur la période 1990-2013. Viennent en complément un inventaire des formations de master en éducation en France qui intègrent une dimension internationale ou de développement, et une recension des structures françaises, hors du monde académique et scientifique, productrices de connaissances sur l'éducation au sud. En regard de l'importance accordée à l'éducation, ce travail met avant tout en lumière une recherche française qui, bien que productive, demeure peu développée, faiblement structurée, une insuffisance des offres de formation de niveau master et une faiblesse des relations entre monde de la recherche et celui et l'action.

Cette présentation fait le point sur l'émergence, l'opérationnalisation et les premiers résultats disponibles de la stratégie de santé publique communément appelée « dépistage et traitement universel ». Plusieurs grands essais sont en cours et des modèles mathématiques permettent d'espérer l'élimination de l'épidémie de VIH, mais à certaines conditions. En outre, entre la théorie et sa mise en oeuvre, par exemple en Afrique australe, la situation est tout autre. Quels sont les défis à relever et quelles conséquences possibles pour les populations ?

International audience

International audience