30%

7%

33%

1%

3%

26%

Belgium

Europe excl. Bel.

Subsaharan Africa

North Africa

Other: Amer., Asia

Unknown

Ep

idem

iolo

gy

Provider Initiated HIV-Testing and Counseling among Sub-Saharan African Migrants in Flanders

Lazare Manirankunda, Jasna Loos & Christiana Nöstlinger

HIV-SAM Project, Department of Public Health, Institute of Tropical Medicine (ITM), Antwerp

Lmaniran@itg.be

jloos@itg.becnoestlinger@itg.bewww.hivsam.be

References[1] Sasse A et al. (2010) Epidemiologie van AIDS en HIV-infectie in België. Toestand op 31 december 2009 [2] Burns FM et al. (2001) Africans in London continue to present with advanced HIV disease in the era of highly active antiretroviral therapy. Aids 15:2453-5.[3] Sadler KE et al. (2007) Sexual behaviour and HIV infection in black-Africans in England: results from the Mayisha II survey of sexual attitudes and lifestyles. Sexually Transmitted Infections 83:523-9.

[4] Hamers FF et al. (2006) HIV/AIDS in Europe: trends and EU-wide priorities. Eurosurveillance 11(47). [5] Manirankunda et al. (2009) “It’s better not to know”: perceived barriers to HIV voluntary counseling and testing among sub-Saharan African migrants in Belgium. AIDS Education and Prevention, 21(6), 582–593.[6] Manirankunda at al. “It’s not easy”: Challenges for the promotion of provider initiated HIV testing and counseling among Sub-Saharan African migrants in Flanders. Submitted to AIDS patient care and STDs

The promotion of HIV-testing among SAM is a public health priority [4]

SAM are more likely to be diagnosed late [2]

Origin of patients presenting late for HIV diagnose, ARC-ITM *diagnose at advanced stage of infection; ** late hiv-diagnose (as defined by Anrinori et al. 2010)

Year Origin N (% total HIV-patients ITM) <200CD4cell/µl * <350CD4cells/µl**

2009 SAM 530 (28.7%) 47.5% 80.4%

Belgian 1037 (56.2%) 33.2% 69.1%

2010 SAM 567 (28,3%) 48.1% 81.5%

Belgian 964 (52.5%) 32.3% 69.9%

Prefer ignorance: “It’s better not to know”

� HIV = death and ‘slim’

� HIV = stigma and social exclusion

� HIV = fear of deportation

Lack of information

� Leads to misinformation and boosts existing stigma

� Increases doubts about entitlement to care and rights

� Maintains practical barriers

Distribution of HIV-patients in Belgium, since 1985 (SIPH, 2009)

Fin

din

gs

Current HIV testing practices

Patient initiated or on indication

WHO/ UNAIDS VCT guidelines are not respected

� Pre-test counseling: Little information provided

� Diagnostic testing

� “Everybody knows what HIV is”

� “Don’t want to scare the patient”

� No HIV exceptionalism: "When you test for cancer,

you don't give extensive counseling either"

� Post-test counseling

� HIV+: Result communication and referral to ARC

� HIV-: Strict result communication (over the phone)

Missed opportunity for prevention

Barriers to PITC

Lack of information on medical relevance

No policy prescribing PITC for SAM

Caution not to create the impression of xenophobia by targeting SAM

Questionable provision of care for non-resident migrants:

� Who will pay?

� Is follow-up assured?

“I don’t want to test, if they will be deported tomorrow”

“After an emergency visit, migrants often disappear again”

Reluctance to provide intensive counseling:

� Time consuming

� Lack of cultural competence to discuss sensitive sexual issues

� Prevention is not the role of the physician

� Language barriers

Provider initiated HIV testing and counseling (PITC) face many barriersA qualitative study assessing 20 physicians’

practices and barriers towards PITC for SAM [6] Fin

din

gs

because mutually re-enforcing barriers of SAM and physicians are facilitating late HIV-diagnosis

Reco

mm

en

dati

on

s Need for increased efforts to promote HIV-testing and counseling

Health care level: Promotion of PITC

Epidemiological factsheet: medical relevance

Counseling guidelines:

Clarify counseling steps

+ Background on cultural aspects

+ Practical tips

Currently implemented and systematically

evaluated in GP practices in Flanders

Community level: Promotion of HIV-testing

Outreach HIV-testing

Sensitization by community leaders

In Belgium, 1 in 3 HIV-patients are Sub-Saharan African Migrants (SAM) [1]

HIV-positive SAM are more likely to be unaware of their status [3]

Culture of sheer emergency seeking behaviour, enforced by

precarious migrant situation, limits preventive medicine

Low perceived susceptibility to HIV: “I didn’t run any risks”

Financial incapability

Lack of opportunity: “My doctor knows best and he didn’t

propose the test to me”

A qualitative study assessing the barriers of 70 SAM towards HIV testing [5]

SAM are in favour of HIV-testing, but the barriers outweigh the advantages

SAM suggest provider initiated HIV-testing and counseling