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BMC Infectious Diseases

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Which adults in the Paris metropolitan area have never been tested for HIV? A 2010 multilevel, cross-sectional, population-based study

  • Véronique Massari1Email author,
  • Annabelle Lapostolle1,
  • Marie-Catherine Grupposo1,
  • Rosemary Dray-Spira1,
  • Dominique Costagliola2 and
  • Pierre Chauvin1
BMC Infectious Diseases201515:278

https://doi.org/10.1186/s12879-015-1006-9

Received: 2 April 2015

Accepted: 1 July 2015

Published: 22 July 2015

Abstract

Background

Despite the widespread offer of free HIV testing in France, the proportion of people who have never been tested remains high. The objective of this study was to identify, in men and women separately, the various factors independently associated with no lifetime HIV testing.

Methods

We used multilevel logistic regression models on data from the SIRS cohort, which included 3006 French-speaking adults as a representative sample of the adult population in the Paris metropolitan area in 2010. The lifetime absence of any HIV testing was studied in relation to individual demographic and socioeconomic factors, psychosocial characteristics, sexual biographies, HIV prevention behaviors, attitudes towards people living with HIV/AIDS (PLWHA), and certain neighborhood characteristics.

Results

In 2010, in the Paris area, men were less likely to have been tested for HIV at least once during their lifetime than women. In multivariate analysis, in both sexes, never having been tested was significantly associated with an age younger or older than the middle-age group (30–44 years), a low education level, a low self-perception of HIV risk, not knowing any PLWHA, a low lifetime number of couple relationships, and the absence of any history of STIs. In women, other associated factors were not having a child <20 years of age, not having additional health insurance, having had no or only one sexual partner in the previous 5 years, living in a cohabiting couple or having no relationship at the time of the survey, and a feeling of belonging to a community. Men with specific health insurance for low-income individuals were less likely to have never been tested, and those with a high stigma score towards PLWHA were more likely to be never-testers.

Our study also found neighborhood differences in the likelihood of men never having been tested, which was, at least partially, explained by the neighborhood proportion of immigrants. In contrast, in women, no contextual variable was significantly associated with never-testing for HIV after adjustment for individual characteristics.

Conclusions

Studies such as this one can help target people who have never been tested in the context of recommendations for universal HIV screening in primary care.

Keywords

HIVSexual behaviorPreventionGenderMultilevelCross-sectional studiesSocial inequalitiesImmigration statusNeighborhood

Background

In high-income countries, publications on the barriers to and/or the facilitators of HIV testing remain scarce [1, 2], especially those focusing on the situation of their immigrant populations [37]. In France, because of the legal restrictions on collecting and processing data on ethnicity, religion and immigration status, there are few studies on the social and migrational determinants of HIV testing [810].

Despite universal access to HIV screening and treatment and one of the highest annual HIV testing rates in Europe (103 per 1,000 inhabitants) [11], the Paris region is characterized by a high proportion of HIV-positive tests (4.5 per 1,000 tests) and a large number of people who are unaware of their HIV infection (estimated at around 13,000 in a regional population of 11.9 million people) [12, 13]. In this context, new screening strategies have been considered, which consist not only in promoting regular testing of high-risk individuals, but also in increasing the uptake of HIV screening by people who have never been tested. Indeed, in the past 5 years, the percentage of never-testers has decreased significantly but is still significant in this region. In 2010, a regional KABP survey found that 33.9 % of men and 21.5 % of women aged 18–54 years had never been tested during their lifetime (these proportions were 47.0 % and 33.6 % in 2004, respectively) [11]. The regional incidence of AIDS is estimated to be approximately 1,500 cases each year. In 2010, 60 % of them were unaware of their HIV status at the time of diagnosis, and 40 % had never been tested [14].

Our objectives were to collect certain socioeconomic status indicators, origin, sexual biographies, attitudes and behaviors regarding HIV testing and prevention, and neighborhood characteristics, in a representative sample of the adult, French-speaking population in the Paris metropolitan area and to determine those associated with no lifetime uptake of HIV testing.

Methods

The SIRS (a French acronym for health, inequalities and social ruptures) cohort is the first large, representative, population-based cohort created to study the social determinants of health and health-care utilization in the field of social epidemiology in France [15, 16]. In 2005, at inclusion, our study population was a multistage random sample of the adult French-speaking population living in the Paris metropolitan area (also called “Greater Paris”, consisting of the City of Paris and its three adjacent départements, which constitute the core area of the entire Paris region, with 6.6 million inhabitants). The primary sampling units were census blocks including about 2000 inhabitants each. Fifty of them were randomly selected from the 2595 eligible census blocks according to their socioeconomic type. Subsequently, 60 households in each census block were chosen at random. Lastly, one adult in each household was randomly selected by the next-birthday method and interviewed at home.

In 2010, 47.2 % of the 3006 participants included in 2005 were reinterviewed (2.6 % were deceased, 1.8 % were too sick to answer our questions, 13.9 % had moved out of the 50 surveyed IRISs, 2.7 % were absent during the survey period, 18.4 % declined to participate, and 13.4 % were lost to follow-up). Their sex ratio and mean age were similar to those of the individuals who were not reinterviewed. The individuals lost to follow-up were younger and better off than the others, but neither their health status nor the socioeconomic type of their census block of residence was different. Those absent during the survey period had a lower socioeconomic status and were mostly immigrants. In each census block, the individuals who were not reinterviewed in 2010 were replaced by means of a random procedure similar to the one used in 2005, up to a final sample size of 60 adults interviewed per census block. The refusal rate among the newly contacted individuals was 29 % (the same as in 2005).

In this paper, data collected in 2010 were examined cross-sectionally. The independent variables were selected from the SIRS dataset for the relevance of their association with HIV testing [17] or, more generally, with preventive health-care activities [18]. The analyses were limited to the 2621 subjects under 70 years of age to avoid a possible memory bias in the older individuals and to compare our data with those from other French studies.

Ethics

This cohort study had received legal authorization from two national authorities for non-biomedical research [19]: the Comité consultatif sur le traitement de l’information en matière de recherche dans le domaine de la santé (CCTIRS) (authorization number 904251) and the Commission nationale de l’informatique et des libertés (CNIL) (authorization number 05-1024). The participants provide their verbal informed consent. Written consent was not necessary because this survey did not fall into the category of biomedical research (as defined by French law) and did not collect any personal identification data.

Measures

Outcome

The outcome variable was no lifetime HIV testing.

Demographics

A first set of independent variables examined in this study consisted of demographics, which included age and ‘immigration status’. The latter was defined and categorized on the basis of both the individual’s and his/her parents’ nationality (at the time of the survey or of their death), distinguishing between French, born to two French parents; French, born to at least one foreign parent; and foreigners. Because HIV screening for all pregnant women had been widely offered since 1990 in France [20], having a child <20 years of age (or being pregnant at the time of the survey) was also considered.

Socioeconomic status

(SES)- Several characteristics related to the participants’ SES were taken into account: education level (none or primary school, secondary school, and postsecondary), employment status (actively employed vs. all others, including unemployed, retired, student and inactive), occupational category (coded as never having worked, blue-collar, tradespeople/salespeople/shopkeepers and intermediate occupation, lower white-collar, and upper white-collar), and monthly income per consumption unit (CU), as calculated according to the OECD scale [21].

Health care utilization status

This dimension was explored by examining two variables: health insurance status and having or not having a regular general practitioner.

HIV risk and stigma

The participants’ self-perception of HIV risk (ranked as low or high) and their knowing or not knowing people living with HIV/AIDS were taken into account. Five questions regarding attitudes towards PLWHA (namely, would accept to 1) work with them, 2) have a meal at their home, 3) go on vacation with them, 4) have protected sex with them, and 5) let them look after their children or grandchildren) were combined to calculate a stigma score, which ranged from 0 and 10 and increased with the level of negative attitude towards PLWHA. For each gender, this score was dichotomized into two categories (≤ or > 2, i.e., the mean score value for the entire population and also by gender).

Sexual biographies, attitudes and behaviors

The following variables were taken into account: self-reported sexual orientation (homosexual or bisexual, heterosexual, and not answered), the number of sexual partners of each sex, the number of sexual partnerships during the previous 5 years (one partnership, multiple partnerships or no partnerships), couple status at the time of the survey (no relationship, love affair, non-cohabiting couple or cohabiting couple), and the lifetime number of couple relationships. The interviewees were also asked about their STI history (with a single question: “Have you ever had an STI?”, with no further details).

Social integration

Certain characteristics pertaining to the participants’ social ties and social support were taken into consideration as well: a feeling of being supported (or of not being supported) by friends, relatives or neighbors (“social support” in the rest of this paper), living (or not) living alone, a sense of belonging to a community, and their religious affiliation and practice, if any (but not their religion per se, as this would not have been very acceptable in France).

Neighborhood characteristics

At the neighborhood level, four socioeconomic characteristics of the census blocks of residence were considered. The mean monthly household income was calculated using the 2007 income tax database (provided by French tax authorities) and divided into quartiles. The proportions of immigrants, unemployed residents, and people with a low education level (no education or primary school) were available in the 2007 population census data provided by the French National Institute of Statistics and Economic Studies.

Statistical analyses

The differences in characteristics among the participants who reported having been tested at least once for HIV and those who had not were investigated using χ2 analysis or the Fisher exact test. Since sexual biographies, attitudes and behaviors vary according to gender [22, 23], all the analyses were stratified by sex. All of the univariate statistical analyses were weighted to take into account the sampling method and the poststratification adjustment for age and gender according to the 2007 general population census data [16]. A two-sided p-value <0.05 was considered statistically significant.

To build the final model for each sex, we used the following modeling strategy. First, a null model was computed to estimate the area-level variations without any covariables. Second, we considered three groups of independent variables (1. demographics and SES; 2. the other individual variables, i.e., those concerning HIV risk and stigma toward PLWHA, sexual biographies, attitudes and behaviors, and social integration; and 3. the neighborhood variables) and performed a preselection of the independent variables associated with our outcome in each of these groups. To do this, all the variables associated with our dependant variable with a p-value <0.20 in univariate analysis (Table 1) were selected manually (using a backward-selection procedure based on the Hosmer & Lemeshow approach [24] with a threshold p < 0.10) and checking for multicollinearity. Third, in Model 1, only the preselected demographic and socioeconomic variables were included and further selected using the same procedure but with a threshold p < 0.05. Fourth, in Model 2, the other individual variables previously preselected were added to Model 1 and backward-selected with a threshold p < 0.05. Finally, all the contextual variables were added to Model 2 and selected in Model 3 in the same manner. Since no neighbourhood variable was found to be significantly associated in women, the final model was Model 2 (Table 3).
Table 1

Comparison of the characteristics of the HIV-tested and never-tested men (n = 1261) and women (n = 1360) in 2010

 

Overall (n = 2621)

%

Never-tested men (n = 537)

%

P-value (tested vs. never-tested)

Never-tested women (n = 451)

%

P-value (tested vs. never-tested)

Age

        

18–29 years

655

25.0

162/332

48.7

<.0001

133/323

41.3

<.0001

30–44 years

959

36.6

144/455

31.6

 

78/504

15.5

 

45–59 years

700

26.7

143/332

43.0

 

140/367

38.1

 

60–69 years

308

11.7

89/142

63.0

 

99/166

59.8

 

Immigration status

        

French/French parents

1688

64.4

329/832

39.5

.0031

257/856

30.0

.001

French/foreign parent (s)

544

20.7

116/243

48.0

 

111/301

36.7

 

Foreigners

389

14.8

92/187

49.4

 

83/203

40.9

 

Children and pregnancy

        

No child under 20 years of age

1921

73.3

514/1201

42.8

.5360

333/720

46.3

<.0001

Child under 20 years of agea

701

26.7

23/60

38.8

 

118/640

18.4

 

Education level

        

None or primary school

145

5.6

52/75

68.8

<.0001

50/70

71.3

<.0001

Secondary school

941

35.9

234/468

50.1

 

173/473

36.6

 

Postsecondary

1535

58.4

251/718

35.0

 

228/817

27.9

 

Employment status

        

Actively employed

1940

74.0

386/1012

38.1

<.0001

233/928

25.1

<.0001

All others

682

26.0

151/249

60.7

 

218/432

50.4

 

Socio-occupational category

        

Never worked

249

9.5

63/83

76.4

<.0001

91/166

54.9

<.0001

Blue collar

190

7.2

88/162

54.0

 

13/27

48.8

 

Lower white-collar

948

36.2

147/362

40.7

 

202/586

34.5

 

Tradespeople, salespeople

479

18.1

93/238

39.2

 

74/237

22.2

 

Upper white-collar

758

28.9

146/416

35.1

 

70/342

20.5

 

Monthly income (€/CU)

        

First quartile (< 1100)

652

24.9

150/305

49.2

.0002

143/347

41.4

.0010

Second quartile (1100–1700)

663

25.3

142/304

46.8

 

113/359

31.5

 

Third quartile (1701–2500)

657

25.1

130/333

39.0

 

84/324

27.3

 

Fourth quartile (≥2501)

649

24.8

115/319

36.1

 

106/330

32.1

 

Health insurance status

final

       

HI + additional insurance

2104

80.4

416/976

42.6

0.0380

345/1128

30.6

<0.0001

HI for the poor

178

6.8

27/86

31.4

 

36/92

39.1

 

HI with no additional insurance

335

12.8

94/198

47.5

 

66/137

48.2

 

Self-perception of HIV risk

        

High

708

27.0

73/349

20.9

<.0001

49/359

13.7

<.0001

Low

1913

73.0

465/912

51.0

 

402/1001

40.1

 

Knowing PLWHA

        

Yes

1650

63.0

396/807

49.1

<.0001

341/844

40.4

<.0001

No

971

37.0

141/455

31.1

 

110/516

21.3

 

Stigma towards PLWHA

        

Score ≤ 2

1740

66.4

320/840

38.1

<.0001

267/900

29.7

.0002

Score > 2

882

33.6

217/421

51.6

 

184/460

39.9

 

Self-reported sexual orientation

        

Heterosexual

2515

95.9

522/1190

43.9

<.0001

435/1325

32.9

<.0001

Homo/bisexual

75

2.9

6/58

10.2

 

1/16

9.4

 

Not answered

31

1.2

10/13

76.9

 

14/19

74.9

 

Sexual partnerships during the previous 5 years

        

No partnerships

243

9.3

43/84

51.9

<.0001

99/159

61.9

<.0001

One partnership

1638

62.5

336/712

47.2

 

302/926

32.6

 

Multiple partnerships

740

28.2

158/465

33.9

 

50/274

18.1

 

Couple status at the time of the survey

        

Not in a relationship

569

21.7

143/279

51.5

<.0001

132/290

45.7

<.0001

Love affair

335

12.8

50/157

32.0

 

59/178

32.9

 

Non-cohabiting couple

156

5.9

21/82

25.5

 

15/73

20.3

 

Cohabiting couple

1562

59.6

323/743

43.4

 

245/818

29.9

 

Lifetime number of couple relationships

        

None

556

21.2

160/320

50.0

<.0001

116/237

49.0

<.0001

One

1317

50.3

285/565

50.5

 

268/753

35.6

 

≥ 2

747

28.5

92/377

24.5

 

67/370

18.0

 

History of STI

        

No

2260

86.2

513/1113

46.1

<.0001

409/1147

35.7

<.0001

Yes

361

13.8

24/148

16.4

 

42/213

19.5

 

Feeling of being supported

        

Yes

2597

99.1

533/1248

42.7

0.561

443/1349

32.8

0.0082

No

24.5

0.9

5/14

35.7

 

8/11

72.7

 

Living alone

        

Yes

414

15.8

75/223

33.6

0.002

73/190

38.4

0.1077

No

2207

84.2

463/1038

44.6

 

378/1169

32.3

 

Sense of belonging to a community

        

No

1806

68.9

347/872

39.8

.0024

273/934

29.3

<.0001

Yes

815

31.1

191/390

48.9

 

177/426

41.7

 

Practice of a religion

        

Practices a religion regularly

492

18.8

86/183

47.1

.1313

136/309

44.0

<.0001

Practices a religion but not on a regular basis

483

18.4

85/199

42.8

 

97/284

34.3

 

Affiliation but does not practice

699

26.7

154/353

43.6

 

101/346

29.1

 

No practicing or affiliation

949

36.2

212/526

40.4

 

117/422

27.8

 

Neighborhood variables

        

Mean annual household income (€/CU)

        

First quartile (< 17,000)

392

14.9

107/182

58.4

<.0001

81/209

38.8

.0026

Second quartile (17,000–21,999)

673

25.7

146/330

44.2

 

133/343

38.9

 

Third quartile (22,000–29,519)

776

29.6

157/375

41.8

 

112/401

28.0

 

Fourth quartile (≥ 29,520)

780

29.8

128/373

34.3

 

124/406

30.4

 

Proportion of immigrants

        

First quartile

791

30.2

155/378

41.1

.0001

113/413

27.3

.0011

Second quartile

735

28.0

127/385

33.1

 

113/350

32.3

 

Third quartile

585

22.3

111/257

43.3

 

124/327

38.0

 

Fourth quartile

511

19.5

143/241

59.4

 

101/269

37.4

 

Proportion of unemployed persons

        

First quartile

707

27.0

130/334

39.0

.0003

112/373

29.9

.0008

Second quartile

835

31.9

156/399

39.2

 

134/436

30.7

 

Third quartile

622

23.7

143/315

45.5

 

98/306

32.0

 

Fourth quartile

457

17.4

107/213

50.3

 

107/244

44.0

 

Proportion of persons with a primary education or less

        

First quartile

868

33.1

153/417

36.7

.0001

115/451

25.4

.0001

Second quartile

831

31.7

162/406

39.9

 

141/425

33.2

 

Third quartile

515

19.7

112/243

46.3

 

110/272

40.3

 

Fourth quartile

406

15.5

110/195

56.2

 

85/211

40.3

 

a including 42 pregnant women

For each characteristic, the category with the lowest number of never-testers was used as the reference in the multivariate models. All the analyses used STATA software (STATA® v.12; STATA College Station, TX) with the xtmelogit procedure (specifying that collected data were clustered by census block). At each step, the level 2 variance was estimated to test for area-level variation, and the median odds ratio (MOR) was calculated. The MOR measures the median value of the adjusted OR between the most and least at-risk individual when comparing all pairs of neighborhoods [25].

Results

Characteristics of the study population

The sample consisted of 1261 men (48.1 %) and 1360 women (51.9 %). The participants’ mean age (± SD) at the time of the interview was 41.6 (±15.4) years for the men and 42.3 (± 13.1) years for the women. With regard to SES (Table 1), 58.4 % had a higher education level, 74.0 % were actively employed, 21.7 % were not in a couple relationship at the time of the survey, and 15.8 % were living alone. A sense of belonging to a community was shared by 31.1 % of the study population, and 37.2 % practiced a religion.

In 2010, 42.6 % (n = 537) of the men and 33.2 % (n = 451) of the women reported that they had never been tested for HIV during their lifetime. The men were more likely to have never been tested for HIV than the women (42.6 % vs. 33.2 %, p < 0.001). Of the 1639 (62.0 %) participants tested at least once in their lifetime, 56.8 % had been tested at least once at their request, 56.8 % during a systematic or routine examination (including pregnancy, marriage, blood donations and preop exams), and 20 % at their physician’s request. Of the participants who had been tested, 39.7 % had been so during the previous 24 months. The main reasons given for no testing were low risk perception (93 %), fear of HIV disease (3 %) and fear of HIV diagnosis disclosure (2 %).

The proportion of ever-testers varied greatly according to their neighborhood of residence, from 7.7 % (95 % CI: 0.0–19.6) to 85.7 % (95 % CI: 70.7–100.0) for the men, and from 19.3 % (95 % CI: 2.3–36.3) to 90.7 % (95 % CI: 80.1–100.0) for the women.

Factors associated with no lifetime HIV testing in men

In the men (Table 1), the factors associated with never-testing for HIV in univariate analysis were a young (<29 years) or an old age (>60 years), being a foreigner or a French person born to at least one foreign parent, a lower education level, not being actively employed, being a blue-collar worker or never having worked, a lower income, having no additional health insurance, a low self-perception of HIV risk, not knowing any PLWHA, a high stigma score towards PLWHA, perceiving oneself as heterosexual or not answered, having had no or only one sexual partner during the previous 5 years, not being in a couple relationship or living in a couple relationship at the time of the survey, having had no or only one couple relationship in one’s lifetime, not having a history of STIs, living alone, and the sense of belonging to a community. All the contextual variables tested were associated with the outcome. On the other hand, having a regular general practitioner, having social support and practicing a religion were not associated with no lifetime HIV testing in the men.

In multivariate multilevel analysis (Table 2), an area-level effect was found in the null model (level 2 variance of 0.2898 [0.1087], p = 0.008). Model 1 (with demographic and socioeconomic variables) showed that the factors associated with no lifetime HIV testing were all the age groups, except 30–44 years, a low or an intermediate education level, never having worked, and health insurance status (having health insurance specifically for low-income individuals was associated with a lower likelihood of never having been tested than being insured through the usual system, with or without additional insurance). Introducing these characteristics reduced the level 2 variance by 14 %. In Model 2, the factors associated with our outcome included a low self-perception of HIV risk, a high stigma score towards PLWHA, not knowing any PLWHA, having had no or only one lifetime couple relationship, and not having a history of STIs. Introducing these characteristics led to a 53 % reduction in the initial level 2 variance. When further introducing neighborhood characteristics, only the proportion of immigrants in the neighborhood of residence was significant. In Model 3, the area-level variance (0.0978 [0.0803]) was no more significantly different from zero when both the individual and area-level variables were taken into account, and the MOR gradually decreased from 1.67 in the empty model to 1.35 in the full model.
Table 2

Factors associated with never-testing for HIV among men (n = 1261) as determined by multilevel multivariate logistic regression

  

Model 1

Model 2

Model 3

  

aOR [95 % CI]

aOR [95 % CI]

aOR [95 % CI]

Individual variables

    

Age

18–29 years

2.07 [1.32–3.24]

1.88 [1.11–3.24]

1.86 [1.08–3.18]

 

30–44 years

Ref.

Ref.

Ref.

 

45–59 years

1.38 [0.97–1.96]

1.76 [1.20–2.58]

1.77 [1.21–2.59]

 

60–69 years

2.89 [1.88–4.42]

3.16 [1.98–5.04]

3.23 [2.02–5.14]

Education level

    
 

None or primary school

3.29 [1.83–5.94]

2.82 [1.49–5.33]

2.51 [1.32–4.78]

 

Secondary school

1.77 [1.24–2.51]

1.72 [1.18–2.52]

1.63 [1.11–2.39]

 

Postsecondary

Ref.

Ref.

Ref.

Socio-occupational category

    
 

Never worked

3. 33 [1.42–7.76]

3.62 [1.44–9.09]

3.34 [1.34–8.33]

 

Blue collar

1.24 [0.73–2.09]

1.06 [0.60–1.89]

0.99 [0.56–1.77]

 

Lower white-collar

0.81 [0.52–1.24]

0.74 [0.46–1.18]

069 [0.43–1.10]

 

Tradespeople, etc.

0.91 [0.59–1.40]

0.95 [0.60–1.52]

0.90 [0.56–1.44]

 

Upper white-collar

Ref.

Ref.

Ref.

Health insurance status

    
 

HI + additional insurance

2.30 [1.29–4.09]

2.23 [1.19–4.18]

2.34 [1.24–4.39]

 

HI for the poor

Ref.

Ref.

Ref.

 

HI with no additional insurance

2.43 [1.28–4.63]

2.43 [1.21–4.87]

2.46 [1.22–4.94]

Self-perception of HIV risk

    
 

High

 

Ref.

Ref.

 

Low

 

3.41 [2.29–5.08]

3.33 [2.24–4.96]

Knowing PLWHA

    
 

Yes

 

ref

ref

 

No

 

1.54 [1.09–2.18]

1.57 [1.12–2.22]

Stigma towards PLWHA

    
 

Score ≤ 2

 

Ref.

Ref.

 

Score > 2

 

1.70 [1.23–2.34]

1.67 [1.21–2.30]

Lifetime number of couple relationships

   
 

None

 

2.96 [1.75–5.00]

2.97 [1.75–5.01]

 

One

 

2.19 [1.53–3.14]

2.16 [1.51–3.10]

 

≥ 2

 

Ref.

Ref.

History of STI

    
 

Yes

 

Ref.

Ref.

 

No

 

2.88 [1.64–5.07]

2.89 [1.65–5.06]

Neighborhood variables

    

Proportion of immigrants

   
 

First quartile

  

1.04 [0.64–1.70]

 

Second quartile

  

ref

 

Third quartile

  

1.12 [0.68–1.85]

 

Fourth quartile

  

1.98 [1.18–3.33]

Level 2 variance

 

0.2495 (0.1064)

0.1545 (0.0942)

0.0978 (0.0803)

p-value

 

0.019

0.101

0.223

MOR

 

1.61

1.45

1.35

Empty model: level 2 variance = 0.2898 (0.1087); p = 0.008; MOR = 1.67

Factors associated with no lifetime HIV testing in women

In the women (Table 1), the factors positively associated with never-testing for HIV in univariate analysis were a younger (< 29 years) or an older age (> 60 years), being a foreigner or a French person born to at least one foreign parent, not having a child < 20 years of age, a low education level, not being actively employed, being a blue–collar worker or never having worked, a lower income, not having additional health insurance or having insurance for low-income individuals, a low self-perception of HIV risk, not knowing any PLWHA, a high stigma score towards PLWHA, being self-reported as heterosexual or not answered, having had no or only one sexual partner during the previous 5 years, not being in a couple relationship at the time of the survey, never having been in a couple relationship, not having a history of STIs, weak social support, a sense of belonging to a community, and practicing a religion on a regular basis. On the other hand, neither having a regular practitioner nor living alone was associated with never having been tested for HIV. All the contextual variables were significantly associated with the outcome.

In multivariate multilevel analysis (Table 3), an area-level effect was found in the null model (area-level variance of 0.1864 [0.0698], p = 0.008). The following characteristics were selected in Model 1: the age groups other than 30–44 years, being a foreigner, not having a child < 20 years of age, a low or intermediate education level, not being actively employed, never having worked or being in an intermediate socio-occupational category, and not having additional health insurance. Introducing these characteristics reduced the level 2 variance by 38 %, and the area-level variance (0.1179 [0.0637]) was no more significantly different from zero. In Model 2, the attitudes and behavioral factors associated with never having been tested for HIV included a low self-perception of HIV risk, not knowing any PLWHA, a high stigma score towards PLWHA, having had no or only one sexual partner during the previous 5 years, not being in a couple relationship or being in a cohabiting couple relationship at the time of the survey, never having been in a couple relationship, not having a history of STIs, and a sense of belonging to a community. In the full model, the only neighborhood variable selected in the absence of any individual covariables (the neighborhood proportion of inhabitants with a low education level) was not significantly associated with the outcome. Overall, the successive adjustments had smaller impacts on level 2 variance and MOR in the woman than in the men.
Table 3

Factors associated with never-testing for HIV among women (n = 1360) as determined by multilevel multivariate logistic regression

  

Model 1

Model 2

  

aOR [95 % CI]

aOR [95 % CI]

Individual variables

   

Age

18–29 years

1.70 [1.12–2.56]

1.66 [1.04–2.66]

 

30–44 years

Ref.

Ref.

 

45–59 years

2.15 [1.54–2.99]

2.18 [1.50–3.17]

 

60–69 years

2.55 [1.60–4.05]

2.69 [1.57–4.62]

Immigration status

   
 

French/French parents

Ref.

Ref.

 

French/foreign parent (s)

1.25 [0.91–1.73]

1.07 [0.75–1.55]

 

Foreigner

1.55 [1.06–2.27]

1.37 [0.89–2.10]

Child under 20 years of age

   
 

Yes

Ref.

Ref.

 

No

2.94 [2.17–3.99]

3.49 [2.41–5.07]

Education level

   
 

None or primary school

3.04 [1.77–5.23]

2.61 [1.45–4.71]

 

Secondary school

1.57 [1.15–2.12]

1.52 [1.08–2.13]

 

Post-secondary

Ref.

Ref.

Employment status

   
 

Actively employed

Ref.

Ref.

 

All others

1.54 [1.12–2.12]

1.11 [0.78–158]

Socio-occupational category

   
 

Never worked

2.39 [1.39–4.10]

1.81 [0.99–3.27]

 

Blue collar

1.28 [0.59–2.80]

1.02 [0.44–2.36]

 

Lower white-collar

1.30 [0.88–1.91]

1.12 [0.74–1.72]

 

Tradespeople, etc.

1.71 [1.15–2.54]

1.82 [1.18–2.80]

 

Upper white-collar

Ref.

Ref.

Health insurance status

   

HI + additional insurance

Ref.

Ref.

 
 

HI for the poor

0.95 [0.58–1.54]

1.29 [0.75–2.22]

HI with no additional insurance

1.72 [1.15–2.57]

2.09 [1.32–3.32]

 

Self-perception of HIV risk

   
 

High

 

Ref.

 

Low

 

5.04 [3.43–7.41]

Knowing PLWHA

   
 

Yes

 

Ref.

 

No

 

2.01 [1.49–2.71]

Sexual partnerships during previous 5 years

   
 

No partnerships

 

2.15 [1.26–3.67]

 

One partnership

 

1.73 [1.12–2.68]

 

Multiple partnerships

 

Ref.

Couple status at the time of the survey

   
 

No relationship

 

2.35 [1.15–4.78]

 

Love affair

 

2.03 [0.97–4.27]

 

Non-cohabiting couple

 

Ref.

 

Cohabiting couple

 

3.25 [1.57–6.72]

Lifetime number of couple relationships

   
 

None

 

2.63 [1.55–4.46]

 

One

 

1.39 [0.99–1.93]

 

≥ 2

 

Ref.

History of STI

   
 

No

 

1.62 [1.05–2.50]

 

Yes

 

Ref.

Sense of belonging to a community

   
 

Yes

 

1.33 [0.99–1.79]

 

No

 

Ref.

Level 2 variance

 

0.1179 (0.0637)

0.1655 (0.0804)

P-value

 

0.064

0.039

MOR

 

1.39

1.47

Empty model: level 2 variance = 0.1864 (0.0698); p = 0.008; MOR = 1.51

Discussion

In addition to the socioeconomic factors usually observed to be associated with prevention attitudes and practices, we found that the absence of any lifetime HIV testing was associated with a low risk perception, health insurance status, not knowing any PLWHA, a high stigma score towards PLWHA, a low lifetime number of couple relationships, the absence of any history of STIs and, for men only, the neighborhood proportion of immigrants.

Our sample was limited to the Paris metropolitan area, which limits its external validity, particularly in nonurban contexts. However, since this region bears the largest part of the HIV burden in mainland France, our conclusions could be useful in helping manage the epidemic [26]. Unfortunately, because of the sampling design, we were unable to reach the most vulnerable populations, such as homeless people (among whom immigrants are overrepresented) [27]. Also, we interviewed only French-speaking individuals, thereby excluding still more foreigners but non-French-speaking individuals accounted for 5 % of the initial sample. If they had been included in the SIRS cohort, the difference between French persons and foreigners may have been accentuated by the inclusion of more individuals not reached by prevention messages.

The participants were interviewed retrospectively about any previous HIV testing. The last test had been performed on average about 5 years before the survey date. Thus, there was a possible recall bias concerning the circumstances of the last test. In addition, some respondents may have confused certain routine laboratory tests with the HIV screening test, which would have led to an overestimation of HIV testing, especially among recent immigrants and less educated and/or less health-literate individuals.

Many studies on the utilization of health-care services have shown that people with a low SES are less likely to avail themselves of preventive care, even in countries where national health services and/or universal health insurance should preclude any financial obstacles to such care [28]. For instance, we reported similar socioeconomic gradients in women’s cancer screening in the same survey population [29, 30].

Taking into account certain indicators of sexual behaviors and attitudes toward PLWHA enabled us to explore the contribution of these factors to some but not all of the observed socioeconomic and demographic differences. In particular, due to a lack of statistical power, we were unable to find a significant association with (self-reported) sexual orientation, since the number of participants who indicated that they were bi- or homosexual was too small in both genders (58 men and 16 women). Moreover, these numbers were probably underestimated, particularly in certain immigrant populations where sexuality and especially homosexuality are still taboo and/or punished by law in their country of origin [31].

The fact that younger people of both sexes were less likely to have been tested for HIV is particularly worrisome. Of course, HIV prevalence in young heterosexual people remains low, with the result that they are not the most at risk for HIV exposure (until now). However, a recent KABP study in the French capital region found that people in this age group had a poorer knowledge and a weaker perception of HIV risk compared not only to the other age groups in 2010, but also to the same age group interviewed previously, between 1992 and 2004 [26]. Indeed, in our study, 70.5 % of the men and 34.2 % of the women in this age group reported that they had had more than one sexual partner during the previous 5 years (compared to 24.9 % and 14.5 %, respectively, of the rest of the population), while in a regional KABP study, only 39 % of the men and 27 % of the women in this age group indicated that they had used a condom at last intercourse (compared to 45 % and 36 % in 2004, respectively) [26]. We also observed, in a previous analysis, that of the 655 HIV-negative individuals aged 18 to 29 years who had answered the question about their intention regarding protection in 2010, 376 (57.4 %) reported that they consistently used condoms to protect themselves from HIV (men more often than women: 71.0 % vs. 43.3 %, respectively, p < 0.001) [32].

We also observed that older age was independently associated with never-testing for HIV in both genders. The recent ANRS-Vespa2 study found that older people were also at higher risk for late presentation of HIV in all the subpopulations that were specifically examined, e.g., heterosexual male and female immigrants born in sub-Saharan Africa or North Africa and North Africans who practice a religion. Moreover, MSM over 50 who did not define themselves as gay were at higher risk for late HIV diagnosis [33]. Such a lower level of HIV testing in older individuals could certainly have major consequences on the epidemiology of HIV infection.

In a previous analysis of the same cohort in 2005 (with far fewer individual characteristics obtained by interview and analyzed), we found that gender, socioeconomic status, immigration status and neighborhood of residence were barriers to HIV testing in the adult population in the Paris metropolitan area [17]. We also found that measures aimed at increasing HIV testing in sub-Saharan immigrants may have been effective, given that people from sub-Saharan Africa were more likely to have been tested in their lifetime (78.5 %) than those of French (56.2 %) or Maghreb (39.7 %) origin (p < 0.0001) [34]. In 2010, we found that women with a sense of belonging to a community and, to a lesser extent, foreign women were less likely to have been HIV-tested than other women. Actually, these two characteristics are obviously correlated, given that a sense of belonging to a community is shared by 49 % of foreign women and 45 % of French women born to at least one foreign parent (compared to 22 % of French women born to French parents, p < 0.0001). In men, these figures were, respectively, 49 %, 45 % and 22 % (p < 0.0001).

In our study, we found that individuals with a low lifetime number of couple relationships were less likely to have been tested. Another French study among late-tested HIV-positive individuals found that both male and female heterosexuals in a steady relationship and with children felt that they were less at risk for HIV infection and that this put them at greater risk for never having been tested in the absence of symptoms [35]. Generally speaking, since they are not priority targets for testing promotion, individuals at low risk for HIV infection are at high risk for not being tested for HIV and for late diagnosis [36]. In our study, a low self-perceived risk for HIV infection was associated with no HIV testing in both sexes. Some studies have reported similar observations in immigrants in Portugal [6] and Spain [7], and in pregnant women in other European countries [2, 37, 38]. Deblonde et al., in a systematic review in Europe, found that the main barrier to HIV testing are a low risk perception, fear of HIV disease and of HIV diagnosis disclosure, and lack of access to health services. In our study. the two responses (fear of disease and fear of disclosure) were given, respectively, by only 3 % and 2 % of the never-testers. A minor gradient was observed for fear of disclosure according to immigration status in both sexes (respectively, 0 %, 0.5 % and 8.4 % in the women and 1 %, 1.8 % and 2.7 % in the men).

The men with a high stigma score towards PLWHA and those who did not know any PLWHA among family, friends or coworkers were more likely to be never-testers. As suggested by Burkholder et al. [39], since they do not empathize or identify with PLWHA, people who stigmatize them cannot perceive themselves as possibly being concerned by this matter or at risk for HIV infection. In other words, people with stigmatizing attitudes may perceive a greater distance between themselves and those with the disease [31]. Stigma serves to emphasize and enhance the differences between the stigmatizers and those being stigmatized [40].

The association observed between no HIV testing and no history of STIs could be due to the fact that French health authorities recommend proposing an HIV test whenever an STI is suspected [41]. Practically, this recommendation seems to be followed by some health professionals but not a majority of them. Indeed, in a French study in newly diagnosed HIV-infected people carried out in 2010, only half of the individuals with STIs during the 3 years prior to HIV diagnosis had actually received an HIV testing proposal from a health-care provider [42] .

Lastly, our study found a contextual effect on no lifetime HIV testing in men. Indeed, the decrease in the level 2 variance and its p-values showed that introducing the proportion of immigrants living in the neighborhood of residence explained part of the observed differences between neighborhoods. In contrast, in women, the significant differences in the observed crude prevalence rates of HIV testing between neighborhoods were mainly explained by a composition effect (i.e., by individual characteristics).

The men living in neighborhoods with a high proportion of immigrants (more than 28 %) were two times less likely to have been HIV-tested those living in neighborhoods with a proportion of immigrants between 17 and 23 %. This could be explained by a number of norms shared by immigrant men in these neighborhoods, such as the fear of stigmatization or discrimination related to being tested for HIV (regardless of the result). Indeed, we observed that foreigners and French persons born to at least one foreign parent were more likely to have a positive stigma score than French persons born to French parents (61.0 %, 48.2 % and 34.3 %, respectively, in men, p < 0.0001; 60.2 %, 48.4 % and 31.3 %, respectively, in women, p < 0.0001). Similarly, foreigners and French persons born to at least one foreign parent were less likely to report that they knew a PLWHA than French persons born to French parents, (19.2 %, 28.8 % and 39.0 %, respectively, in men, p < 0.0001; 28.7 %, 27.6 % and 42.2 %, respectively, in women, p < 0.0001). Lastly, not knowing any PLWHA was significantly associated with a positive stigma score: 47.6 % of the men who did not know any PLWHA had a positive stigma score versus 28.1 % of those who did (p <0.001). In the women, these figures were, respectively, 47.9 % and 23.6 % (p <0.001).

No lifetime HIV testing could also be a consequence of differentiated practices by health professionals according to their patients’ social or demographic characteristics. For instance, in 2003, a French study found that the factors associated with the lack of proposing HIV/AIDS and hepatitis B and C screening in general practice to underprivileged immigrants were gender (women were screened less for HBV and HCV infection) and being from a non-sub-Saharan African country (especially from North Africa) for all three viruses [43].

Conclusions

At a time when, in France, many people remain unaware of their HIV status, when the proportion of people screened late is not decreasing and when many practitioners are not adhering to the recommendations for universal screening in primary care [44], it seems more important than ever that HIV screening services target not only the high-risk populations, but also those with a lower self-perceived risk of infection and/or at high risk for stigma, such as younger and older people, those in a steady relationship, and men living in immigrant neighborhoods. In 2016, a new French policy will merge (previously split) HIV, viral hepatitis and/or STI screening centers into comprehensive sexual health centers, which will provide all these screening tests, as well as information, contraception, STI care and linkage to specialist care. This will possibly increase access to HIV screening for those who stay away from HIV testing services. Also, community-based and/or outreach, combined, rapid screening test services should not be limited in France to MSM communities but rather extended to other communities, in particular, immigrant communities other than just that from sub-Saharan Africa.

Declarations

Funding

The SIRS survey was supported by the Institute for Public Health Research (IReSP) (grant number 2008-87; URL:http://www.iresp.net), the French National Agency for Research on AIDS and Viral Hepatitis (ANRS) (grant number 2009-072), and Sidaction.

The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Authors’ Affiliations

(1)
Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis Institute d’Epidémiologie et de Santé Publique (IPLESP UMRS 1136), Department of Social Epidemiology
(2)
Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis Institute d’Epidémiologie et de Santé Publique (IPLESP UMRS 1136), Department of HIV Clinical Research

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© Massari et al. 2015

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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