hiv testing in minorities and women 1999

HIV TESTING, KNOWLEDGE, ATTITUDES,BELIEFS, AND PRACTICES AMONG

MINORrTIES: PREGNANT WOMEN OF NORTH-AFRICAN ORIGIN IN SOUTHEASTERN FRANCE

Antoine Messiah, MD, PhD, Dominique Rey, MD, Yolande Obadia, MD, Michel Rotily, MD,and Jean-Paul Moatfi, PhD

Marseille, France

Since 1991, the French public health ministry has recommended that human immunod-eficiency virus (HIV) testing be offered to all pregnant women. This study was undertaken todetermine whether this recommendation is followed independently of a woman's ethnicity. Itis based on a 1992 survey regarding knowledge, attitudes, beliefs, and practices on HIVinfection and testing among pregnant women in southeastern France.

Survey results revealed that North-African women (n=207) were more likely to have alow socioeconomic and educational level, receive their health care at public health institu-tions, and be less knowledgeable about HIV transmission than French women (n=2234).They were also more likely to have been tested for HIV without their knowing it and less like-ly to perceive themselves as being at risk. Consent to undergo HIV testing during pregnancywas dependent on their North-African origin after controlling for significant covariates.

These results indicate that routine prenatal screening appears insufficient to ensure ade-quate HIV testing and counseling of women of ethnic minorities. The development of HIV pre-vention programs that are cultural-specific and that aim at increasing physicians' compliancewith the official recommendation is needed. (J Nati Med Assoc. 1 998;90:87-92.)

Key words: * human immunodeficiency virus(HIV) * HIV transmission * minorities

In France, as in most other industrialized countries,the proportion of women among the total number ofregistered acquired immunodeficiency syndrome(AIDS) cases has increased steadily since the begin-ning of the epidemic (from 13.9% in 1987 to 20.4% in1995.1 Prenatal care is viewed as especially appropri-

From the South-Eastern French Center for Disease Control and theInstitut Paoli-Calmettes, Marseille, France. This study was supportedby the French Agency for Aids Research. Requests for reprintsshould be addressed to Dr Antoine Messiah, INSERM U-379, InstitutPaoli Calmettes, 232 bd Sainte Marguerite, BP 156, 13273Marseille Cedex 09, France.

ate for general policies of human immunodeficiencyvirus (HIV) screening and counseling to reach allwomen.2 This is especially true in France, where thepublic social insurance system guarantees universalhealth coverage for all pregnant women living in thecountry. Since the early 1970s, a minimum of fourfree-of-charge prenatal care medical consultations(including testing for syphilis, rubella, and toxoplas-mosis at the first visit) have been mandatory. It is wide-ly accepted that this legislation greatly contributed torecent progress in prenatal care and prevention of pre-term births and children's handicaps.3

In December 1991, the French Ministry of Healthissued an official recommendation that general practi-tioners, gynecologists, and obstetricians systematicallyoffer, an HIV test to all pregnant women consulting

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 90, NO. 2 87

HIV TESTING AMONG MINORITIES

Table 1. Sociodemographic Data and Conditionsof Pregnancy, by Ethnic Group

% North-African % FrenchWomen Women(n=207) (n=2234) P Value

Age (years)<25 26 2125 to 34 60 67 NS,35 14 12

Matrimonial statusMarried 71 64Unmarried but living

with a partner 13 28 <.001Living alone 16 7

Level of educationUniversity graduate 15 52Secondcary school

graduate 44 37 <.001Lower level of

education 41 11Occupational statusEmployed 27 70 <.00 1Unemployed 73 30

Level of income,6000 francs 58 14 <.001>6000 francs 42 86

ReligionNone or not

practicing 30 64 <.001Practicing 70 36

Prenatal caredelivered byPrivate ambulatory

physicians 44 76 <.001Public prenatal

institutions 56 24No. of prenatalconsultations<4 2 14 6 1 <.001I,<4 92 98

Abbreviations: NS=not significant.

for prenatal care, provided the women gave informedconsent and could decline the offer. In this context,screening appears as a universal policy, expected to beequal for everyone, but it assumes that preventivecounseling targeted at the general population is able toreach all subgroups, including cultural minorities.4'5

Of the entire population living in France, 6.3% are

foreigners; among them, 35% come from NorthAfrica.6 Evidence from other countries strongly sug-gests that HIV prevention programs have specific dif-ficulties in reaching women from ethnic minoritiesand emphasizes the need for culturally adapted mes-sages and interventions.79 It is therefore important toknow, if despite the official recommendation, thereare differences in access to HIV testing and counsel-ing between members and nonmembers of theseminorities and to determine to which factors these dif-ferences are related.A survey on HIV screening among pregnant

women conducted in southeastern France in 1992,the Prevagest survey,'0'11 included North-African andFrench women. The survey examined sociodemo-graphic characteristics, pregnancy conditions, HIVtesting experience, risk situation and risk perception,and knowledge and beliefs about HIV transmission.

METHODSPopulation

The Prevagest survey is described elsewhere.'0"'1 Itconsists of three subsurveys directed at pregnantwomen and the health-care institutions caring forthem. The first subsurvey is an unlinked anonymousHIV seroprevalence survey. The second subsurvey,which is analyzed in this article, is a survey on theknowledge, beliefs, attitudes, and practices of thewomen. Through the data collected by the third sub-survey, directed at the institution, we could determinewhether the women were in a ward conducting sys-tematic testing; the accuracy of this information waschecked by direct observation at each site. In south-eastern France, 77 wards attend pregnant women fordelivery. Seventy-one wards agreed to participate inthe study during April 1992. A total of 3148 womenwere cared for during the study period; of these, 114(4%) neither spoke nor read French and 209 (7%)refused to participate. The remaining 2825 womenincluded North Africans (n=207), French metropoli-tans (born in continental France) (n=2234), FrenchCaribbeans (n=37), Europeans (n=207), sub-SaharanAfricans (n=35), other (n=63), and unknown (n=42).For the purpose of this article, the first two groupswere compared.

Data Collection and AnalysisA self-administered anonymous questionnaire was

proposed by a nurse to all the hospitalized womenwithin 3 days after childbirth. Topics includeddetailed sociodemographic information, the woman's

88 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 90, NO. 2


experience with prenatal care and HIV testing duringher pregnancy, HIV-related individual risk behaviorsand perception, and knowledge concerning horizon-tal and vertical HIV transmission. For the institutionswhose policy was systematic testing, a woman'sanswers to the question, "Were you offered an HIVtest here?" allowed us to determine whether she hadbeen tested with or without her knowledge.

Univariate comparisons between ethnic groupswere performed with the chi-squared test (qualitativedata) and Student's t-test (quantitative data).'2 All sig-nificant variables (P<.05) were introduced into alogistic regression model,'3 with a woman's declara-tion of having been tested (versus not) during herpregnancy as the dependent variable. The finalmodel consisted of variables with P<.10. Calculationswere done using SPSS software.

RESULTSSociodemographic Data and Conditions ofPregnancy

Regarding age, North-African women were similarto French metropolitan women (Table 1). North-African women were more likely to live alone, to beunemployed and less educated, to have a lowincome, to practice a religion, and to have their pre-natal care delivered by public institutions. Frenchmetropolitan women were more likely to have morethan four prenatal consultations.

HIV Testing Experience, Risk Situation and RiskPerception, Knowledge, and Beliefs About HIVTransmission

Declaration of prenatal HIV testing was signifi-cantly lower among North-African women (42%)than among French metropolitan women (65%;P<.001). Eighty-three percent of French metropolitanwomen declared that they had been tested at leastonce for HIV, including the ones who had a testbefore the pregnancy, versus 49% among North-African women (P<.001). Among the 907 womenwho said they had not been tested for HIV duringpregnancy, only a few (3.3% of North-African womenand 1.3% of French metropolitan women) hadrefused the test offered to them; this contrasts with68% of North-African women and 56% of Frenchmetropolitan women to whom the test had not beenproposed (P<.001). When the women's statementsand those of the medical ward attending them werepooled, it appeared that an additional 33% of North-African women versus only 8% of French metropoli-

Table 2. Risk Behavior and Individual RiskPerception, by Ethnic Group% North-African % French

Risk Women WomenBehavior (n=207) (n=2234) P ValueMultiple sexual partners in the past 2 yearsYes 5 7 NSNo 95 93

Intravenous drug use (at least once)Yes 1 1 NSNo 99 99

HIV-positive sexual partner (at least once)Yes 0 0 NSNo 100 100

Intravenous drug user sexual partner (at least once)Yes 0 2 NSNo 100 98

DeclaredAt least one ofthe above 6 8 NS

None ofthe above 94 92

Declared higher or average risk of being infected,in comparison with overall women's populationYes 7 20 <.001No 93 80

Abbreviations: NS=not significant and HIV=humanimmunodeficiency virus.

tan women (P<.001) had had a routine HIV test with-out their being aware of it because of a lack or inade-quacy of informed consent procedures. Thus, theactual frequency of prenatal HIV testing was similarbetween North-African women (75%) and Frenchmetropolitan women (73%).

North-African women declared HIV-related riskbehaviors as frequently as French metropolitanwomen did (Table 2). However, they were less likelyto perceive themselves at higher or average risk.

Knowledge about the main routes of HIV trans-mission was less accurate among North-Africanwomen; the difference was larger for horizontal thanfor vertical transmission (Table 3). North-Africanwomen more frequently believed in HIV transmis-sion through casual contact and mosquito bite.

Multivariate AnalysisTo determine how differences in HIV testing dur-

ing pregnancy were correlated with the variables dif-



Table 3. Knowledge and Beliefs About HIV Horizontal and Vertical Transmissions, by Ethnic Group

Knowledge % North-African % French& Beliefs Women (n=207) Women (n=2234) P Value

Horizontal TransmissionCorrect answers to 'People can get AIDS from'*Sexual intercourse (yes) 73 95 <.001Intravenous drug use (yes) 73 91 <.001Receiving blood (yes) 68 88 <.001Donating blood (no) 31 55 <.001Being admitted in the same hospital ward asa person with AIDS (no) 44 72 <.001

Using public lavatories (no) 32 60 <.001Drinking in a glass used by a person with AIDS (no) 41 65 <.001A mosquito bite (no) 33 57 <.001Knowledge scoret m=4.3 m=5.9 <.001

SD=2.2 SD=1.7Vertical TransmissionCorrect answers to "HIV can be transmitted

from an infected mother to her baby"*During pregnancy (yes) 69 90 <.001During delivery (yes) 19 37 <.001Through breast-feeding (yes) 32 39 NSBy taking care of the child after birth (no) 37 68 <.001Knowledge scoret m=1.7 m=2.4 <.001

SD=1.1 SD=1.0Abbreviations: HIV=human immunodeficiency virus, AIDS=acquired immunodeficiency virus, SD=standard deviation,and NS=not significant.*The correct answer is given in parentheses.tThe score (minimum=0, maximum=8) was built by counting each correct answer as 1 and summing them.$The score (minimum=0, maximum=4) was built by counting each correct answer as 1 and summing them.

ferentiating North-African women from French met-ropolitan women, logistic regression was performed(Table 4). It showed a positive correlation betweenknowledge scores, risk perception, and the likeli-hood of being tested (with the woman's knowledge).It also showed that those women who were married,had a low educational level, and low income levelwere significantly less likely to be tested. Finally, itshowed that even when these covariates were con-trolled for, being a North-African women was stillsignificantly associated with a lower likelihood ofbeing tested with informed consent.

DISCUSSIONThis survey was the first in France to compare

access to HIV screening and counseling betweenmigrant and metropolitan women. Most of the preg-

nant women delivering in southeastern France weresurveyed during the study period, but not all could bereached because the study protocol was restricted toFrench-speaking women for practical reasons. It islikely, however, that if non-French speaking womenhad been included, differences between migrants andnonmigrants would have been even larger. SouthernFrance has historical links with North Africa and isthe focus for migration and travel to Europe; effec-tively, non-French women in our sample were pri-marily from North Africa. Only small populationscome from other non-European countries, which pre-vented their inclusion in this analysis. The situation ofthese other minorities may be quite different, but in-depth analysis would require surveys in Frenchregions where they are better represented.

The French public social insurance system guaran-



Table 4. Logistic Regression Analysis of Women's Declaration of Having Had an HIV Prenatal Test (Yes Versus No)*OR 95% Cl P Value

Matrimonial statusMarried 0.59 0.39-0.88 .010Unmarried but living with a partner 0.83 0.55-1.27 .398Living alone* 1 .00

Level of educationUniversity graduate* 1.00Secondary school graduate 0.59 0.49-0.73 <.001Lower level of education 0.53 0.39-0.71 <.001

Level of income<6000 francs 0.75 0.57-1.00 .050>6000 francs* 1.00

Individual risk perception of being HIV infectedwhen compared with average risk among women

Higher or average risk 1.25 0.99-1.58 .066Lower or no risk, or no evaluation* 1.00

Knowledge scores (numeric variables)Of horizontal HIV transmissiont .027Of vertical HIV transmissiont .019

Ethnic groupNorth-African women 0.61 0.44-0.90 .007French women* 1.00

Abbreviations: OR=adjusted odds ratio and CI=95% confidence interval.*Category of reference.tOR=1.06 per point of score.tOR=1 .12 per point of score.

tees universal coverage for all pregnant women livingin the country, and the legislation recommends thatall pregnant women be offered HIV screening, pro-vided they give informed consent. Screening policytherefore is expected to be equal for everyone. Oursurvey shows that if all HIV tests taken with or with-out the woman's knowledge are considered, the fre-quency of prenatal HIV testing is similar betweengroups independently of ethnic origin. However, thesurvey also shows that equality is not achieved inpractice. It reveals a dramatic difference in applica-tion of the testing policy: North-African women weremore frequently tested without their knowledge andless likely to have been proposed a test by the physi-cian, suggesting a lack of adequate preventive coun-seling associated with testing for these women. This isespecially unfortunate because, as the survey shows,North-African women lack knowledge about AIDStransmission and are less likely to feel at risk althoughthey declared at risk behaviors as frequently asFrench women did.

North-African women more frequently believed in

HIV transmission through casual contact and mos-quito bite, as found in other ethnic minorities.8'9 Suchcultural beliefs create specific challenges for HIV pre-vention.'4"5 In addition, married women were lesslikely to have been tested for HIV, contrasting withunmarried women living with their partner. This sug-gests that marriage restrains women of ethnic minori-ties from being tested. Until now, North Africa wasrelatively unaffected by the epidemic; most HIV-positive women were infected by their husbands.'6In France, only 3% of cumulated AIDS patients in1993 were born in North Africa." It often is arguedthat the traditional cultural norms of North-Africanwomen have a protective effect against HIV infec-tion.18 Some of the HIV-related beliefs of thesewomen are closely linked to the Islamic religion, eg,risk of vertical contamination through breast-feed-ing and, more generally, risk of transmissionthrough contact with body fluids.

Numerous aspects differentiating North-Africanwomen from French women, including lowersocioeconomic and educational levels, could



explain the lesser tendency of North-African womenof knowing that they had a test. Even when theseparameters were controlled for, being of North-African origin was still correlated with this tendency.This suggests that institutional factors might be atplay with these women. Such factors include thewards' screening policy toward these women andthe physicians' perceptions of women's risk andtheir ability to deal with HIV prevention. They can-not be attributed to language barriers since womenwho neither spoke nor understood French did notparticipate in the study.

Our survey strongly suggests that universal routineprenatal HIV screening does not guarantee adequatecounseling, especially for women of ethnic minorities.Additional studies on ethnic minorities other thanNorth-African women are necessary to confirm thisin the French context.

Zidovudine treatment of HIV-infected mothers,which significantly reduces the risk of vertical trans-mission,19'20 creates more incentives for the develop-ment of systematic HIV prenatal screening. Itunderscores the need for culturally sensitive pro-grams for the medical community for these womento benefit from the recent therapeutic advances inprevention of vertical transmission, without contra-vening the ethical principle of patients' individualfreedom of choice. Additional prevention programstherefore are needed, with some targeted at ethnicminorities and others targeted at physicians andtheir institutions.

AcknowledgmentsThe authors thank Claire Julian-Reynier and Michel Morin

for help and advice during manuscript preparation, ColetteBoirot and Fabienne Micollier for documentation, AndersonLoundou for computations, Carole Giovannini for typing themanuscript, and Gary Burkhart for editing the text. AntoineMessiah is supported by a fellowship from the Fondation pour laRecherche Medicale.

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