Highlights The precarious immigrant population is often invisible because it is at the interstices of care devices and, in the current epidemic context, isolation facilities. Confinement affects individuals' abilities to act, and generates a "disaffiliation process" to placing this precarious immigrant population even more on the margins of society. Covid-19 crisis exacerbates pre-existing difficulties, generating not so new situations for these precarious immigrant population. Need to formulate specifics interventions : targeted outreach intervention, participatory approach and deliberative spaces ; promote health promotion intervention; right based intervention.

BackgroundSub-Saharan and Caribbean immigrants are particularly affected by HIV in Europe, and recent evidence shows that a large portion of them acquired HIV after arrival. There is a need for efficient interventions that can reduce immigrants’ exposure to HIV. We describe the pilot phase of a community-based empowerment outreach intervention among sub-Saharan and Caribbean immigrants in the greater Paris area aimed at 1) constructing the intervention, 2) assessing its feasibility, and 3) assessing the feasibility of its evaluation based on a stepped-wedge approach.Methods1) To develop the intervention, a literature review was conducted on existing interventions and participatory approaches developed, including the constitution of peer groups. 2) To assess the intervention’s feasibility, a pilot was conducted between April 2018 and December 2018. A daily register was used to collect data on sociodemographic characteristics of all persons who visited the mobile team to assess eligibility and acceptability. 3) To assess the feasibility of performing a stepped-wedge trial to evaluate the intervention, we compared eligibility, enrolment and retention at 3 months in two arms (immediate vs deferred). Chi-squared tests were used to compare reach and retention between the two arms.ResultsIntervention development. The Makasi intervention was designed as an outreach intervention that starts with the persons’ capacities and helps them appropriate existing resources and information and obtain knowledge about sexual health, based upon motivational interviewing techniques.Intervention Feasibility. Between April 2018 and December 2018, a total of 485 persons were identified as eligible. Participation in the intervention was proposed to 79% of eligible persons. When proposed, the persons enrolled in the intervention with a response rate of 69%. Some were lost to follow-up, and 188 persons were finally included.Evaluation Feasibility. The proportions of eligible (45 and 42%) individuals and of enrolled individuals (65 and 74%) were similar and not significantly different in the immediate and deferred arms, respectively.ConclusionsA community-based outreach intervention aimed at improving sub-Saharan and Caribbean immigrants’ empowerment in sexual health is feasible. The pilot phase was key to identifying challenges, designing a relevant intervention and validating the stepped-wedge protocol for evaluation.

BackgroundOne of the classic challenges for prevention programmes is reaching the populations they serve. In France, a substantial number of African migrants living with HIV acquired their infection after migrating. The aim of this paper is to better understand the characteristics of the population reached by a community-based outreach approach.MethodsWe compared sociodemographic characteristics across three different groups in the Paris greater area: (1) the general African migrant population (Population census), (2) the African migrant population using either the regular healthcare system or the system for vulnerable populations (PARCOURS Survey) and (3) the African migrant population reached through a community-based mobile unit (Afrique Avenir). Comparisons were conducted according to sex, age, region of origin, duration of residence and occupational and legal statuses using χ2 tests.ResultsThe migrants reached by the mobile unit were mostly men (69%), 52% of whom were younger than 35 years old. They more often lived in precarious situations than did the general sub-Saharan population (49% vs 35% were unemployed, respectively, p<0.001) and the ones accessing the regular healthcare system. Fewer of them lived in precarious situations than did migrants seeking healthcare consultations for vulnerable populations (42% in the mobile unit vs 54% in healthcare consultations were undocumented, p<0.028).ConclusionOur study shows that the outreach approach can constitute a missing link in the prevention chain among sub-Saharan African migrants, reaching a group that differs from the general migrant population and from the migrant population in healthcare services—not only the newly arrived migrants who live in more precarious situations but also those who have been in France for several years and are still affected by social hardship.

Background The Makasi community-based research project offered an innovative health-related empowerment intervention to immigrants from sub-Saharan Africa living in precarious situations in the greater Paris area, to reduce their social vulnerability and their exposure to HIV. Our objective is to evaluate the impact of the intervention on access to health coverage in this population. Methods Participants were recruited based on precariousness criteria in public places in Ile-de-France (squares, railway stations, markets, etc.) by mobile teams of social workers and health mediators. Following a stepped-wedge design, participants were randomised into two groups receiving the intervention sequentially (immediately in one group and 3 months later in the other). We evaluated the impact of the Makasi intervention on access to health coverage among 821 individuals observed at 0, 3, and 6 months, between 2018 and 2021. We implemented random-effects panel models - allowing for unobserved heterogeneity - using a Heckman selection approach to correct for attrition. Finally, we used seemingly unrelated regressions (SUR) to examine the extent to which the effect of the intervention was mediated by health-related empowerment. Results Participants - 77% of which were men - had been living in France for 4 years on average. 44% of them had no health coverage at the time of inclusion. Our results provided evidence for a significant impact of the Makasi intervention on participants’ access to health coverage, with an 18 percentage-point increase in the probability of accessing health coverage 6 months after having received the intervention (p &lt; 0.01). The mediation analysis revealed that this effect operated partly through an empowerment process in terms of knowledge of social and health resources. Conclusions We showed that a health empowerment intervention provided by social workers and health mediators largely favours access to health rights for immigrants in precarious situations. Key messages • A health empowerment intervention improved access to health coverage among immigrants from sub-Saharan Africa living in precarious situations in France. • Improvement in access to health coverage was found to be partly mediated by reinforcement of participants’ health literacy in terms of social and health resources.

Summary The concept of empowerment in sexual health is widely used in health promotion. This scoping review aims to identify how it is defined and measured. PubMed, Sage Journals, PsycInfo and the Web of Science are data sources. The inclusion criteria for studies were as follows: (1) an analysis of empowerment in sexual health, (2) quantitative evaluation and (3) publication in a peer-reviewed journal in French or English since January 1996. Data were extracted using a summary table of the definitions and indicators of empowerment in sexual health. Of the 2181 articles found, 29 met the inclusion criteria. Only 4 studies on 29 clearly defined empowerment in sexual health. Five dimensions emerged from the indicators used in the 29 studies in relation to sexual empowerment (social participation, participation in decision making, power to act, sexual health knowledge and gender norms), with two types of indicators: indicators unspecific to sexual health, which can be viewed as empowerment basic skills, and indicators specific to sexual health. Most studies concerned women and focused on individual empowerment, with a lack of measure of collective and structural levels of empowerment. Despite great heterogeneity in the definitions and indicators used, a set of core indicators emerged: participation in decision making, sexual negotiation power and sexual communication skills, knowledge and use of contraceptive methods, and HIV and sexually transmitted infections risk perception. This set could be systematically used in each study based on sexual empowerment concept, completed by supplementary indicators considering the specific context.

Purpose The MAKASI intervention aimed to empower sub-Saharan African immigrants living in precarious situations in the Paris metropolitan area. Because there are factors specifically related to immigration that may increase the risk for common mental disorders, the present study aimed to examine participants' levels of depression and loneliness and analyze the effect of the intervention on depression and loneliness. Methods The MAKASI study was designed as a stepped-wedge randomized intervention trial. Study participants were recruited through an outreach program led by a nongovernmental organization and randomly assigned to two groups, with an intervention delay of three months between groups. Both groups were assessed for six months after inclusion and the effect of the intervention on depression and loneliness was assessed using generalized linear mixed models. The study was conducted from 2018 to 2021 and we took in consideration whether being interviewed during one of the Covid-19 confinement had an effect on the results. Results A total of 821 subjects participated in the Makasi study. High levels of depression and loneliness were found in the study population. We found no effect of the intervention on depression [95%CI 0.77 to 2.40]. Similarly, no effect of the intervention was found on loneliness [95%CI 0.87 to 2.54]. Conclusions The intervention we tested did not appear to improve the level of depression and loneliness among participants. However, the high prevalence of mental and emotional problems in the study population suggests a public health crisis among immigrants in the greater Paris area. Clinical Trial Registration Number: Trial registration Clinicaltrials.gov, NCT04468724 (July 13, 2020)

Background In France, post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) have been available for several years. However, there is still no evidence on the level of knowledge of these HIV prevention tools among immigrants from sub-Saharan Africa living in precarious situations, a population particularly affected by HIV. The aim of this study is to describe the knowledge of these tools in this population and analyse the factors associated with this knowledge. Methods The data mobilized are from the Makasi interventional research that was conducted between 2018 and 2020 among immigrants from sub-Saharan Africa in precarious situations in the greater Paris area. Using data collected from 601 participants, we described levels of knowledge of HIV treatment effectiveness, treatment as prevention (TasP), post-exposure prophylaxis (PEP), and pre-exposure prophylaxis (PrEP), by sex with a chi2 test. We investigated factors associated with their knowledge with logistic regressions adjusted for sociodemographic characteristics, living conditions and sexual behaviors (p ≤ 0.2). Results The population surveyed was predominantly men (76%), from West Africa (61%) and in a precarious situation: 69% were unemployed, 74% were undocumented, 46% had no health coverage and 13% were homeless. In this population, knowledge of antiretroviral treatments for HIV prevention was heterogeneous: the effectiveness of HIV treatment was well known (84%), but only half of the respondents (46%) were aware of TasP and very few knew about PEP and PrEP: 6% and 5% respectively. Multivariable-adjusted models showed that these tools was better known by educated people, those who had a social network in France, those who have had access to the health system and those who were exposed to sexual risks. Conclusions While sub-Saharan African immigrants know the effectiveness of HIV treatment and use certain prevention tools such as HIV testing, they are not aware of PEP and PrEP. Key messages

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