1. 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 to
determine whether this recommendation is followed independently of a woman's ethnicity. It
is based on a 1992 survey regarding knowledge, attitudes, beliefs, and practices on HIV
infection and testing among pregnant women in southeastern France.
Survey results revealed that North-African women (n=207) were more likely to have a
low 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 pregnancy
was 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' compliance
with the official recommendation is needed. (J Nati Med Assoc. 1 998;90:87-92.)
Key words: * human immunodeficiency virus ate for general policies of human immunodeficiency
(HIV) * HIV transmission * minorities virus (HIV) screening and counseling to reach all
women.2 This is especially true in France, where the
In France, as in most other industrialized countries, public social insurance system guarantees universal
the proportion of women among the total number of health coverage for all pregnant women living in the
registered acquired immunodeficiency syndrome country. Since the early 1970s, a minimum of four
(AIDS) cases has increased steadily since the begin- free-of-charge prenatal care medical consultations
ning of the epidemic (from 13.9% in 1987 to 20.4% in (including testing for syphilis, rubella, and toxoplas-
1995.1 Prenatal care is viewed as especially appropri- mosis at the first visit) have been mandatory. It is wide-
ly accepted that this legislation greatly contributed to
From the South-Eastern French Center for Disease Control and the recent progress in prenatal care and prevention of pre-
Institut Paoli-Calmettes, Marseille, France. This study was supported term births and children's handicaps.3
by the French Agency for Aids Research. Requests for reprints In December 1991, the French Ministry of Health
should be addressed to Dr Antoine Messiah, INSERM U-379, Institut issued an official recommendation that general practi-
Paoli Calmettes, 232 bd Sainte Marguerite, BP 156, 13273 tioners, gynecologists, and obstetricians systematically
Marseille Cedex 09, France. offer, an HIV test to all pregnant women consulting
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 90, NO. 2 87

2. HIV TESTING AMONG MINORITIES
foreigners; among them, 35% come from North
Table 1. Sociodemographic Data and Conditions Africa.6 Evidence from other countries strongly sug-
of Pregnancy, by Ethnic Group gests that HIV prevention programs have specific dif-
% North- ficulties in reaching women from ethnic minorities
African % French and emphasizes the need for culturally adapted mes-
Women Women sages and interventions.79 It is therefore important to
(n=207) (n=2234) P Value know, if despite the official recommendation, there
Age (years) are differences in access to HIV testing and counsel-
<25 26 21 ing between members and nonmembers of these
25 to 34 60 67 NS minorities and to determine to which factors these dif-
,35 14 12 ferences are related.
Matrimonial status A survey on HIV screening among pregnant
Married 71 64 women conducted in southeastern France in 1992,
Unmarried but living
with a partner 13 28 <.001 the Prevagest survey,'0'11 included North-African and
Living alone 16 7 French women. The survey examined sociodemo-
Level of education graphic characteristics, pregnancy conditions, HIV
University graduate 15 52 testing experience, risk situation and risk perception,
Secondcary school and knowledge and beliefs about HIV transmission.
graduate 44 37 <.001
Lower level of METHODS
education 41 11 Population
Occupational status The Prevagest survey is described elsewhere.'0"'1 It
Employed 27 70 <.00 1 consists of three subsurveys directed at pregnant
Unemployed 73 30 women and the health-care institutions caring for
Level of income
,6000 francs 58 14 <.001 them. The first subsurvey is an unlinked anonymous
>6000 francs 42 86 HIV seroprevalence survey. The second subsurvey,
Religion which is analyzed in this article, is a survey on the
None or not knowledge, beliefs, attitudes, and practices of the
practicing 30 64 <.001 women. Through the data collected by the third sub-
Practicing 70 36 survey, directed at the institution, we could determine
Prenatal care whether the women were in a ward conducting sys-
delivered by tematic testing; the accuracy of this information was
Private ambulatory checked by direct observation at each site. In south-
physicians 44 76 <.001 eastern France, 77 wards attend pregnant women for
Public prenatal delivery. Seventy-one wards agreed to participate in
institutions 56 24
No. of prenatal the study during April 1992. A total of 3148 women
consultations were cared for during the study period; of these, 114
<4 2 1 (4%) neither spoke nor read French and 209 (7%)
4 6 1 <.001 refused to participate. The remaining 2825 women
I,< 4 92 98 included North Africans (n=207), French metropoli-
Abbreviations: NS=not significant. tans (born in continental France) (n=2234), French
Caribbeans (n=37), Europeans (n=207), sub-Saharan
Africans (n=35), other (n=63), and unknown (n=42).
For the purpose of this article, the first two groups
for prenatal care, provided the women gave informed were compared.
consent and could decline the offer. In this context,
screening appears as a universal policy, expected to be Data Collection and Analysis
equal for everyone, but it assumes that preventive A self-administered anonymous questionnaire was
counseling targeted at the general population is able to proposed by a nurse to all the hospitalized women
reach all subgroups, including cultural minorities.4'5 within 3 days after childbirth. Topics included
Of the entire population living in France, 6.3% are detailed sociodemographic information, the woman's
88 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 90, NO. 2

3. HIV TESTING AMONG MINORITIES
experience with prenatal care and HIV testing during
her pregnancy, HIV-related individual risk behaviors Table 2. Risk Behavior and Individual Risk
and perception, and knowledge concerning horizon- Perception, by Ethnic Group
tal and vertical HIV transmission. For the institutions % North-
whose policy was systematic testing, a woman's African % French
answers to the question, "Were you offered an HIV Risk Women Women
test here?" allowed us to determine whether she had Behavior (n=207) (n=2234) P Value
been tested with or without her knowledge. Multiple sexual partners in the past 2 years
Univariate comparisons between ethnic groups Yes 5 7 NS
were performed with the chi-squared test (qualitative No 95 93
data) and Student's t-test (quantitative data).'2 All sig- Intravenous drug use (at least once)
nificant variables (P<.05) were introduced into a Yes 1 1 NS
logistic regression model,'3 with a woman's declara- No 99 99
HIV-positive sexual partner (at least once)
tion of having been tested (versus not) during her Yes 0 0 NS
pregnancy as the dependent variable. The final No 100 100
model consisted of variables with P<.10. Calculations Intravenous drug user sexual partner (at least once)
were done using SPSS software. Yes 0 2 NS
No 100 98
RESULTS Declared
Sociodemographic Data and Conditions of At least one of
Pregnancy the above 6 8 NS
Regarding age, North-African women were similar None of
to French metropolitan women (Table 1). North- the above 94 92
African women were more likely to live alone, to be Declared higher or average risk of being infected,
in comparison with overall women's population
unemployed and less educated, to have a low Yes 7 20 <.001
income, to practice a religion, and to have their pre- No 93 80
natal care delivered by public institutions. French
metropolitan women were more likely to have more Abbreviations: NS=not significant and HIV=human
than four prenatal consultations.
immunodeficiency virus.
HIV Testing Experience, Risk Situation and Risk
Perception, Knowledge, and Beliefs About HIV tan women (P<.001) had had a routine HIV test with-
Transmission out their being aware of it because of a lack or inade-
Declaration of prenatal HIV testing was signifi- quacy of informed consent procedures. Thus, the
cantly lower among North-African women (42%) actual frequency of prenatal HIV testing was similar
than among French metropolitan women (65%; between North-African women (75%) and French
P<.001). Eighty-three percent of French metropolitan metropolitan women (73%).
women declared that they had been tested at least North-African women declared HIV-related risk
once for HIV, including the ones who had a test behaviors as frequently as French metropolitan
before the pregnancy, versus 49% among North- women did (Table 2). However, they were less likely
African women (P<.001). Among the 907 women to perceive themselves at higher or average risk.
who said they had not been tested for HIV during Knowledge about the main routes of HIV trans-
pregnancy, only a few (3.3% of North-African women mission was less accurate among North-African
and 1.3% of French metropolitan women) had women; the difference was larger for horizontal than
refused the test offered to them; this contrasts with for vertical transmission (Table 3). North-African
68% of North-African women and 56% of French women more frequently believed in HIV transmis-
metropolitan women to whom the test had not been sion through casual contact and mosquito bite.
proposed (P<.001). When the women's statements
and those of the medical ward attending them were Multivariate Analysis
pooled, it appeared that an additional 33% of North- To determine how differences in HIV testing dur-
African women versus only 8% of French metropoli- ing pregnancy were correlated with the variables dif-
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4. HIV TESTING AMONG MINORITIES
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 Transmission
Correct answers to 'People can get AIDS from'*
Sexual intercourse (yes) 73 95 <.001
Intravenous drug use (yes) 73 91 <.001
Receiving blood (yes) 68 88 <.001
Donating blood (no) 31 55 <.001
Being admitted in the same hospital ward as
a person with AIDS (no) 44 72 <.001
Using public lavatories (no) 32 60 <.001
Drinking in a glass used by a person with AIDS (no) 41 65 <.001
A mosquito bite (no) 33 57 <.001
Knowledge scoret m=4.3 m=5.9 <.001
SD=2.2 SD=1.7
Vertical Transmission
Correct answers to "HIV can be transmitted
from an infected mother to her baby"*
During pregnancy (yes) 69 90 <.001
During delivery (yes) 19 37 <.001
Through breast-feeding (yes) 32 39 NS
By taking care of the child after birth (no) 37 68 <.001
Knowledge scoret m=1.7 m=2.4 <.001
SD=1.1 SD=1.0
Abbreviations: 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- nant women delivering in southeastern France were
ropolitan women, logistic regression was performed surveyed during the study period, but not all could be
(Table 4). It showed a positive correlation between reached because the study protocol was restricted to
knowledge scores, risk perception, and the likeli- French-speaking women for practical reasons. It is
hood of being tested (with the woman's knowledge). likely, however, that if non-French speaking women
It also showed that those women who were married, had been included, differences between migrants and
had a low educational level, and low income level nonmigrants would have been even larger. Southern
were significantly less likely to be tested. Finally, it France has historical links with North Africa and is
showed that even when these covariates were con- the focus for migration and travel to Europe; effec-
trolled for, being a North-African women was still tively, non-French women in our sample were pri-
significantly associated with a lower likelihood of marily from North Africa. Only small populations
being tested with informed consent. come from other non-European countries, which pre-
vented their inclusion in this analysis. The situation of
DISCUSSION these other minorities may be quite different, but in-
This survey was the first in France to compare depth analysis would require surveys in French
access to HIV screening and counseling between regions where they are better represented.
migrant and metropolitan women. Most of the preg- The French public social insurance system guaran-
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5. HIV TESTING AMONG MINORITIES
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 status
Married 0.59 0.39-0.88 .010
Unmarried but living with a partner 0.83 0.55-1.27 .398
Living alone* 1 .00
Level of education
University graduate* 1.00
Secondary school graduate 0.59 0.49-0.73 <.001
Lower 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 infected
when compared with average risk among women
Higher or average risk 1.25 0.99-1.58 .066
Lower or no risk, or no evaluation* 1.00
Knowledge scores (numeric variables)
Of horizontal HIV transmissiont .027
Of vertical HIV transmissiont .019
Ethnic group
North-African women 0.61 0.44-0.90 .007
French 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 living HIV transmission through casual contact and mos-
in the country, and the legislation recommends that quito bite, as found in other ethnic minorities.8'9 Such
all pregnant women be offered HIV screening, pro- cultural beliefs create specific challenges for HIV pre-
vided they give informed consent. Screening policy vention.'4"5 In addition, married women were less
therefore is expected to be equal for everyone. Our likely to have been tested for HIV, contrasting with
survey shows that if all HIV tests taken with or with- unmarried women living with their partner. This sug-
out the woman's knowledge are considered, the fre- gests that marriage restrains women of ethnic minori-
quency of prenatal HIV testing is similar between ties from being tested. Until now, North Africa was
groups independently of ethnic origin. However, the relatively unaffected by the epidemic; most HIV-
survey also shows that equality is not achieved in positive women were infected by their husbands.'6
practice. It reveals a dramatic difference in applica- In France, only 3% of cumulated AIDS patients in
tion of the testing policy: North-African women were 1993 were born in North Africa." It often is argued
more frequently tested without their knowledge and that the traditional cultural norms of North-African
less likely to have been proposed a test by the physi- women have a protective effect against HIV infec-
cian, suggesting a lack of adequate preventive coun- tion.18 Some of the HIV-related beliefs of these
seling associated with testing for these women. This is women are closely linked to the Islamic religion, eg,
especially unfortunate because, as the survey shows, risk of vertical contamination through breast-feed-
North-African women lack knowledge about AIDS ing and, more generally, risk of transmission
transmission and are less likely to feel at risk although through contact with body fluids.
they declared at risk behaviors as frequently as Numerous aspects differentiating North-African
French women did. women from French women, including lower
North-African women more frequently believed in socioeconomic and educational levels, could
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 90, NO. 2 91

6. HIV TESTING AMONG MINORITIES
explain the lesser tendency of North-African women Naitre en France, dix ans d'ivolution. Paris, France: Doin-INSERM;
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who neither spoke nor understood French did not ofAIDS New York, NY: Plenum Press; 1995
8. Peruga A, Rivo M. Racial differences in AIDS knowledge
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Our survey strongly suggests that universal routine 9. Nyamathi A, Bennett C, Leake B, Lewis C, FlaskerudJ.
prenatal HIV screening does not guarantee adequate AIDS-related knowledge, perceptions and behaviors among
counseling, especially for women of ethnic minorities. impoverished minority women. AmJPublic Health. 1993;83:65-71.
Additional studies on ethnic minorities other than 10. Obadia Y, Rey D, Moatti JP, Pradier C, Couturier E,
Brossard Y, et al. HIV prenatal screening in South-Eastern
North-African women are necessary to confirm this France: differences in seroprevalences and screening policies by
in the French context. pregnancy outcomes. AIDS Care. 1994;1:29-38.
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which significantly reduces the risk of vertical trans- GilletJ, et al. Differences in HIV testing, knowledge and attitudes
mission,19'20 creates more incentives for the develop- in pregnant women who deliver and those who terminate:
Prevagest 1992-France. AIDS Care. 1995;7:S39-S46.
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underscores the need for culturally sensitive pro- Research. 2nd ed. Oxford, England: Blackwell Scientific
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Acknowledgments VIH au Maroc. In: The Proceeding of the VIII International
The authors thank Claire Julian-Reynier and Michel Morin Conference on AIDS in Africa, Marrakech 1993. Abstract.
for help and advice during manuscript preparation, Colette 17. Lariven S, Bouvet E, Verdon R, Casalino E, Laporte A,
Boirot and Fabienne Micollier for documentation, Anderson Vachon F. HIVInfection in Maghrebin Population in France. In: The
Loundou for computations, Carole Giovannini for typing the Proceeding of the VIII International Conference on AIDS in
manuscript, and Gary Burkhart for editing the text. Antoine Africa, Marrakech 1993. Abstract.
Messiah is supported by a fellowship from the Fondation pour la 18. Moumen-Marcoux R. Migrants et Perception du Sida: Le
Recherche Medicale. Maitre des Infideles. Paris, France: L'harmattan; 1993
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