Knowledge, Attitude, Behavior, and Practices Regarding HIV, Viral Hepatitis, and Sexually Transmitted Infections Among Migrants From Sub-Saharan Africa Living in Germany: A Multicenter Survey Protocol

Background: Migration has an impact on the epidemiology of viral hepatitis B and C (HEP) and HIV in Germany; migrants from sub-Saharan Africa (MisSA) in Germany are disproportionally affected by HIV. In the last 10 years, a total of 10%-15% of all newly diagnosed HIV cases were among MisSA; 20%-30% of them acquired HIV in Germany. Prevalence of HEP among MisSA in Germany is unknown, but Western Africa, from where most MisSA in Germany originate, reports the highest prevalence of hepatitis B worldwide. There is limited information on knowledge, attitudes, behaviors, and practices (KABP) regarding HIV, HEP, and sexually transmitted infections (STIs), as MisSA are not reached with surveys targeting the general population. Objective: Our objective was to determine the HIV, HEP, and STI information and prevention needs of MisSA in Germany. Methods: We conducted a multicenter, cross-sectional, KABP survey regarding HIV, HEP, and STIs among MisSA living in Germany using convenience sampling. The study design was developed as a community-based participatory health research (CBPHR) project; HIV/STI-prevention specialists, key persons from MisSA communities, and HIV/STI researchers were involved in all steps of the research process. Trained peer researchers recruited participants in six study cities. Potential modes of survey administration were interview or self-completion, and the questionnaire was available in English, French, and German. Questions on knowledge about HIV, HEP, and STIs were presented as true statements; participants were asked if they had known the information before. Focus groups with MisSA were conducted to interpret results. Data collection took place from October 2014 to November 2016. Results: Recruitment by peer researchers concluded with 3040 eligible participants. Data collection was completed in November 2016. We are currently analyzing the quantitative data and qualitative data from focus groups. We are conducting working group meetings to discuss the results in the respective study cities and to evaluate the application of participatory health research in epidemiological studies. First results are expected by the end of 2017. Conclusions: Working with peer researchers to collect data allowed accessibility to a diverse sample of MisSA and, particularly, allowed us to reach vulnerable subgroups, such as MisSA without legal status. The ability to access hard-to-reach groups is one of the big advantages of CBPHR. The active inclusion of the persons under study in the design of the study resulted in higher acceptance and ownership of the research project in the target community; this ultimately lead to better quality of collected data. Furthermore, the participation of MisSA in the development of study design and data collection assures a better understanding of the interests, needs, and living conditions of this group

Integrating the social sciences in epidemic preparedness and response : A strategic framework to strengthen capacities and improve Global Health security

Background: The importance of integrating the social sciences in epidemic preparedness and response has become a common feature of infectious disease policy and practice debates. However to date, this integration remains inadequate, fragmented and under-funded, with limited reach and small initial investments. Based on data collected prior to the COVID-19 pandemic, in this paper we analysed the variety of knowledge, infrastructure and funding gaps that hinder the full integration of the social sciences in epidemics and present a strategic framework for addressing them. Methods: Senior social scientists with expertise in public health emergencies facilitated expert deliberations, and conducted 75 key informant interviews, a consultation with 20 expert social scientists from Africa, Asia and Europe, 2 focus groups and a literature review of 128 identified high-priority peer reviewed articles. We also analysed 56 interviews from the Ebola 100 project, collected just after the West African Ebola epidemic. Analysis was conducted on gaps and recommendations. These were inductively classified according to various themes during two group prioritization exercises. The project was conducted between February and May 2019. Findings from the report were used to inform strategic prioritization of global investments in social science capacities for health emergencies. Findings: Our analysis consolidated 12 knowledge and infrastructure gaps and 38 recommendations from an initial list of 600 gaps and 220 recommendations. In developing our framework, we clustered these into three areas: 1) Recommendations to improve core social science response capacities, including investments in: human resources within response agencies; the creation of social science data analysis capacities at field and global level; mechanisms for operationalizing knowledge; and a set of rapid deployment infrastructures; 2) Recommendations to strengthen applied and basic social sciences, including the need to: better define the social science agenda and core competencies; support innovative interdisciplinary science; make concerted investments in developing field ready tools and building the evidence-base; and develop codes of conduct; and 3) Recommendations for a supportive social science ecosystem, including: the essential foundational investments in institutional development; training and capacity building; awareness-raising activities with allied disciplines; and lastly, support for a community of practice. Interpretation: Comprehensively integrating social science into the epidemic preparedness and response architecture demands multifaceted investments on par with allied disciplines, such as epidemiology and virology. Building core capacities and competencies should occur at multiple levels, grounded in country-led capacity building. Social science should not be a parallel system, nor should it be “siloed” into risk communication and community engagement. Rather, it should be integrated across existing systems and networks, and deploy interdisciplinary knowledge “transversally” across all preparedness and response sectors and pillars. Future work should update this framework to account for the impact of the COVID-19 pandemic on the institutional landscape

Knowledge, information needs and behavior regarding HIV and sexually transmitted infections among migrants from sub-Saharan Africa living in Germany: Results of a participatory health research survey

Background: A total of 3,419 new HIV diagnoses were reported in Germany in 2016, with migrants from sub-Saharan Africa (misSA) accounting for 14.1%. To understand the driving factors behind the epidemiological situation, we conducted a quantitative cross-sectional survey on knowledge, attitudes, behavior, and practices regarding HIV and sexually transmitted infections (STIs) among misSA living in six German cities utilizing participatory health research. Methods: Participants were recruited by peer researchers. Levels of knowledge, information needs, and preferred methods of information dissemination were analyzed to inform future prevention planning. Additionally, we analyzed sexual behavior and other risk factors for contracting HIV and STIs. The results may facilitate the formulation of targeted prevention messages in the future. Results: We included 2,432 participants in the analysis. General knowledge about HIV was adequate, as 86.9% were aware of the presented information. Statements about HIV co-infections were prior knowledge for 53.4% of the participants and about German HIV policies and HIV testing for 54.7%. Knowledge about other STIs differed, ranging from 69.6% who have ever heard of gonorrhea to 23.8% who have ever heard of genital warts. Groups with particular knowledge gaps were i) younger misSA, ii) recent migrants, iii) misSA without regular access to the German health care system, iv) misSA of lower socioeconomic status, and v) misSA with Muslim religious affiliation. The majority of participants reported information needs (72.8%), and 71.3% wanted to obtain this information from health professionals. Male misSA were more likely to report five or more sexual partners compared to females. Less than half of participants reported always using condoms with non-steady sexual partners (46.8%). Reasons for not using condoms differed between males and females. A considerable proportion of females (16.3%) and males (6.8%) experienced sexualized violence. More than one fourth of women (26.9%) were affected by female genital mutilation/cutting. Discussion: Future prevention planning should focus on sub-groups with particular knowledge gaps, recognizing their preferred methods of information dissemination. Prevention messages for male misSA should focus on their own risk perception and for female misSA on empowerment, e.g. to negotiate condom use.Peer Reviewe

Impact of HIV knowledge and stigma on the uptake of HIV testing – Results from a community-based participatory research survey among migrants from sub-Saharan Africa in Germany

Background: In 2015, 3,674 new HIV diagnoses were notified in Germany; 16% of those newly diagnosed cases originated from sub-Saharan Africa (sSA). One quarter of the newly diagnosed cases among migrants from sSA (MisSA) are notified as having acquired the HIV infection in Germany. In order to reach MisSA with HIV testing opportunities, we aimed to identify which determinants influence the uptake of HIV testing among MisSA in Germany. Methods: To identify those determinants, we conducted a quantitative cross-sectional survey among MisSA in Germany. The survey was designed in a participatory process that included MisSA and other stakeholders in HIV-prevention. Peer researchers recruited participants to complete standardized questionnaires on HIV knowledge and testing. We conducted multivariable analyses (MVA) to identify determinants associated with ever having attended voluntary HIV testing; and another MVA to identify determinant associated with having had the last voluntary HIV test in Germany. Results: Peer researchers recruited 2,782 participants eligible for inclusion in the MVA. Of these participants, 59.9% (1,667/2,782) previously had an HIV test. For each general statement about HIV that participants knew prior to participation in the study, the odds of having been tested increased by 19% (OR 1.19; 95%-CI: 1.11–1.27). Participants reporting that HIV is a topic that is discussed in their community had 92% higher odds of having been tested for HIV (OR 1.92; 95%-CI: 1.60–2.31). Migrants living in Germany for less than a year had the lowest odds of having had their last HIV test in Germany (OR 0.17; 95%-CI: 0.11–0.27). Additionally, MisSA 18 to 25 years (OR 0.55; 95%-CI: 0.42–0.73) and participants with varied sexual partners and inconsistent condom use (OR 0.75; 95%-CI: 0.44–0.97) had significantly lower odds of having had their last HIV test in Germany. Discussion: Through participatory research, we were able to show that knowledge about HIV and discussing HIV in communities increased the odds of having attended HIV testing among MisSA. However, recent migrants and young sexually active people are among the least reached by testing offers in Germany. Community-based interventions may present opportunities to reach such migrants and improve knowledge and increase discussion about HIV

Determinants of HIV, viral hepatitis and STI prevention needs among African migrants in Germany; a cross-sectional survey on knowledge, attitudes, behaviors and practices

Background: Migrants from sub-Saharan Africa (MisSA) are a relevant sub-group for HIV-transmission in Germany. A total of 10-15 % of all newly diagnosed cases are MisSA, and approximately one third acquired HIV in Germany. There is limited information on knowledge, attitudes, behaviors and practices (KABP) regarding sexual health in African communities residing in Germany. Methods: From October-December 2013 we conducted a cross-sectional survey on KABP regarding HIV, viral hepatitis (HEP), and sexually transmitted infections (STI) among MisSA in Hamburg as a community-based participatory research project to identify knowledge gaps, sexual risk behavior regarding HIV/HEP/STI, HIV/STI-testing history and attitudes toward people living with HIV (PLWH). Trained peer researchers recruited participants through outreach. Questionnaires in German, English or French were either administered face-to-face or self-completed. Questions on knowledge about HIV/HEP/STI presented true statements; participants were asked if they knew the information before. To detect differences in sub-groups, unadjusted odds ratios (OR) were calculated, and a multivariate analysis for knowledge on HIV/HEP/STI was performed. Results: The final sample included 569 participants of whom 57 % were men. Most participants originated from Western and Central sub-Saharan Africa. Median time living in Germany was 6 years. Overall, 28 % had a university degree and 54 % reported a good level of German language. Over 80 % knew the risks for HIV transmission. A total of 44 % of respondents wrongly assumed that an HIV-diagnosis might lead to deportation and 64 % were not aware of the free and anonymous local HIV/STI-testing service. The proportion of participants with knowledge of presented facts on HEP varied from 40-58 %. The respective proportion on STI was 28-68 % and better among women compared to men (44 % vs. 54 %; OR = 1.45; 95 % CI 1.22-1.74). Men reported more often casual sex partners than women (43 % vs. 23 %; OR = 2.6; 95 % CI 1.7-4.0), and more frequently a previous STI (58 % vs. 39 %; OR = 2.1; 95 % CI 1.1-4.1). Overall, 16 % of women reported a history of sexual violence. The majority of respondents (75 %) reported that they would treat PLWH like any other person. Conclusion: Study participants demonstrated good knowledge on HIV-transmission but knowledge gaps regarding HIV/STI-testing services, HEP and STI. This calls for targeted interventions providing more information about these topics in African communities in Hamburg and possibly also elsewhere

From peer to peer: Reaching migrants from sub-Saharan Africa with research on sexual health utilizing community-based participatory health research

Migrants from sub-Saharan Africa (misSA) in Germany are disproportionally affected by HIV. To develop targeted interventions, it is necessary to collect data on knowledge, attitudes, behaviour and practices (KABP) regarding HIV and sexual health. However, misSA are difficult to reach and to sample: a) it is unknown how many people with an African migration background are living in Germany, and b) HIV and sexual health topics are highly stigmatized in these communities. We utilized a community-based participatory health research approach to develop a study protocol and conducted a KABP survey on HIV and sexual health among misSA in six German cities between 2015 and 2016. A convenience sample of 2,879 participants was recruited by 99 trained peer researchers through outreach in their local communities. Due to steering of recruitment, the study population reflected the official registered misSA population well and was diverse in terms of sociodemographic characteristics. Peer researchers mainly recruited participants that were similar to themselves with regard to gender, age and regions of origin. Male and younger peer researchers more often recruited participants from vulnerable sub-groups like migrants with a probably undocumented legal status who could not have been reached by probability sampling based on population registers.Peer Reviewe

Univariable and multivariable analysis for the association between having had the last HIV test in Germany and sociodemographic factors, HIV knowledge, stigma and risk factors among participants of the MisSA study in Germany 2014–2016 (excluding testing without consent for visa, asylum and work purposes) (n = 2,782).

<p>Univariable and multivariable analysis for the association between having had the last HIV test in Germany and sociodemographic factors, HIV knowledge, stigma and risk factors among participants of the MisSA study in Germany 2014–2016 (excluding testing without consent for visa, asylum and work purposes) (n = 2,782).</p

Additional file 2: of Determinants of HIV, viral hepatitis and STI prevention needs among African migrants in Germany; a cross-sectional survey on knowledge, attitudes, behaviors and practices

Results of stratified analysis of sexual behavior by school education, age group and religion, HIV/STI-testing history by school education, age and religion and attitudes toward PLWH by age and religion. (DOCX 31 kb

Univariable and multivariable analysis for the association between uptake of HIV testing (ever having undertaken an HIV test) and sociodemographic factors, HIV knowledge, stigma and risk factors among participants of the MisSA study in Germany 2014–2016 (excluding testing without consent for visa, asylum and work purposes) (n = 2,782).

<p>Univariable and multivariable analysis for the association between uptake of HIV testing (ever having undertaken an HIV test) and sociodemographic factors, HIV knowledge, stigma and risk factors among participants of the MisSA study in Germany 2014–2016 (excluding testing without consent for visa, asylum and work purposes) (n = 2,782).</p

Reasons for not having undertaken an HIV test among the participants of the MisSA study in Germany 2014–2016 (n = 1,054, multiple answers possible).

<p>Reasons for not having undertaken an HIV test among the participants of the MisSA study in Germany 2014–2016 (n = 1,054, multiple answers possible).</p