Willingness to use and distribute HIV self-test kits to clients and partners: a qualitative analysis of female sex workers' collective opinion and attitude in Cote d'Ivoire, Mali, and Senegal

Background: In West Africa, female sex workers are at increased risk of HIV acquisition and transmission. HIV self-testing could be an effective tool to improve access to and frequency of HIV testing to female sex workers, their clients and partners. This article explores their perceptions regarding HIV self-testing use and the redistribution of HIV self-testing kits to their partners and clients. Methods: Embedded within ATLAS, a qualitative study was conducted in Côte-d’Ivoire, Mali, and Senegal in 2020. Nine focus group discussions were conducted. A thematic analysis was performed. Results: A total of 87 participants expressed both positive attitudes toward HIV self-testing and their willingness to use or reuse HIV self-testing. HIV self-testing was perceived to be discreet, confidential, and convenient. HIV self-testing provides autonomy from testing by providers and reduces stigma. Some perceived HIV self-testing as a valuable tool for testing their clients who are willing to offer a premium for condomless sex. While highlighting some potential issues, overall, female sex workers were optimistic about linkage to confirmatory testing following a reactive HIV self-testing. Female sex workers expressed positive attitudes toward secondary distribution to their partners and clients, although it depended on relationship types. They seemed more enthusiastic about secondary distribution to their regular/emotional partners and regular clients with whom they had difficulty using condoms, and whom they knew enough to discuss HIV self-testing. However, they expressed that it could be more difficult with casual clients; the duration of the interaction being too short to discuss HIV self-testing, and they fear violence and/or losing them. Conclusion: Overall, female sex workers have positive attitudes toward HIV self-testing use and are willing to redistribute to their regular partners and clients. However, they are reluctant to promote such use with their casual clients. HIV self-testing can improve access to HIV testing for female sex workers and the members of their sexual and social network

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Knowledge, attitude and practices towards HIV testing following the introductionof self-testing: The case of the ATLAS project in Côte d’Ivoire

International audienceBackgroundHIV testing is a central element of the strategy to end AIDS epidemic, as status awareness is the entry point to HIV care. In West Africa, only 68% of people living with HIV (PLHIV) were aware of their HIV status in 2019. To address the testing gap, the ATLAS project distributed a total of 400000 self-tests (HIVST) in three West African countries between 2019 and 2022, including 200 000 kits in Côte d’Ivoire. The aim of this study is to assess levels and correlates of knowledge, attitude and practice towards HIV conventional testing (tests other than HIVST) and self-testing after the introduction of HIVST in Cote d’Ivoire.MethodWe conducted the population-based cross-sectional in the Bas-Sassandra District of Côte d’Ivoire, 24 months after HIVST was introduced in the region by ATLAS. ATLAS Household Survey (AHS) used a three-stage stratified sampling approach – 3 of the strata are the 3 departments with ATLAS activities and 1 includes departments with almost none, each further stratified on urban and rural settings. Face-to-face interviews were conducted in a representative a sample of the population aged 15-49. One main objective of the survey was to assess the effect of the ATLAS initiative on HIV testing.Weighed proportions and chi-square tests were used to assess knowledge of, attitude towards and practice of HIV conventional and self testing, comparing male and female on the one hand and departments with and without ATLAS HIVST distribution activities on the other hand. Logistic regressions were used to identified factors associated with knowledge of, attitude towards and practice of HIV conventional and self testing (ongoing analysis).Preliminary resultsA total of 6274 people with median age of 29 were interviewed and completed the questionnaire (3205 males and 3069 females). Most participants were in couple (44% males and 59% females) and have attended school (63% males and 45% females).Despite most participants knowing about HIV-AIDS (97 % Males and 96% females), very few reported having heard about HIVST (11% males and 10% females). However, most participants showed a positive attitude toward HIVST and reported that they would be interested/very interested to use it if freely available for themselves (75% males and 71% females), as well as for their sexual partners. About 18% of females and 10% of males reported having performed at least 1 conventional test in the last 12 months, while 3% of participants had already used a HIVST in the past.ConclusionAlthough knowledge and use of HIVST remain relatively low in the region, participants show a positive attitude toward HIVST, and express willingness to use it if freely available. Next results will tell how the observed results differ between participants living in department with ATLAS HIVST distribution and others, and how significant are the differences. It will also provide an overview of associated factors. This will provide policy makers with tools for potential actions in order to improve HIV testing and advance progress towards UNAIDS targets to achieve 95 % of PLHIV who know their status by 2025

Modélisation numérique du tsunami dans les districts de Banda Aceh et Lhok Nga

The 2004 tsunami in the Indian Ocean has given the opportunity to gather an unprecedented database of observations, which allows discussing the numerical methods of tsunami modeling. Most of these methods solve the hydrodynamical equations under the “shallow water assumption”, considering that the tsunami wavelengths are much longer than the water depth. Numerical schemes using finite differences are applied, with an initiation equal to the coseismic seafloor deformation, which can be computed thanks to seismological studies. Bathymetric and topographic data acquired in the framework of Tsunarisque have allowed to build a digital bathymetry and topography model describing the devastated area in Banda Aceh and Lhok Nga, and necessary for the modeling.In this study, the seismological source is taken from the inversion of tsunami waveforms recorded by altimetry satellites two hours after the mainshock. Using the corresponding initial seafloor deformation, tsunami waves are modelled in the area of Banda Aceh. On average the modelling results indicate a horizontal penetration reaching 5 to 6 km, and runup heights not exceeding 8 m, except in Lhok Nga where the computed amplitudes reach 14 m. The modelled wave heights fit rather well the observations. However in the area of Lhok Nga, the modelled amplitudes are well below the observed extreme amplitudes. The results underline that this preliminary study also allows to further consider other seismological parameters to describe the source of the 2004 mega-tsunami

Mesure de l’impact populationnel de l’auto-dépistage du VIH par la triangulation de données programmatiques de routine : Exemple du projet ATLAS en Côte d’Ivoire

International audienceObjectifsL’auto-dépistage du VIH (ADVIH) est recommandé comme stratégie de dépistage par l’OMS. Il a pour avantage de permettre aux personnes de réaliser elles-mêmes leur test et de garantir la discrétion et confidentialité, permettant de toucher des populations non testées et difficiles à atteindre. Cependant, son caractère confidentiel et l'approche de distribution via les réseaux (ciblant les population clés et leurs proches et partenaires) rendent difficile l'estimation de l’impact de l’ADVIH au niveau populationnel. Cette étude propose un moyen de surmonter ce défi et utilise des données programmatiques de routine pour estimer indirectement les impacts du projet ATLAS sur l'accès au dépistage du VIH, le dépistage du VIH conventionnel (c'est-à-dire autre que l’ADVIH), les nouveaux diagnostics du VIH et l’initiation de traitement antirétroviral (TAR) en Côte d'Ivoire.Matériels et MéthodesLes données sur le nombre de kits d’ADVIH distribués par ATLAS proviennent des rapports des partenaires de mise en oeuvre entre le troisième trimestre (T3) de 2019 et le T1 2021. Nous utilisons également les indicateurs de routine du PEPFAR agrégées par districts sanitaires et par trimestre. Les analyses se font par une régression de séries chronologiques écologiques à l'aide de modèles mixtes linéaires.RésultatsEntre T3 2019 et T1 2021, 99353 kits d’ADVIH ont été distribués par ATLAS dans les 78 districts sanitaires inclus dans l'analyse. Les résultats (tableau 1) montrent un effet négatif mais non significatif sur le volume de tests conventionnels (-195) ce qui traduirait une légère substitution entre ADVIH et test conventionnel. Malgré cela l’effet net est positif sur l’accès au dépistage : pour 1000 ADVIH distribués via ATLAS, 589 personnes supplémentaires ont eu accès au dépistage du VIH avec l’hypothèse d’un taux d'utilisation d’ADVIH (TU) de 80 % et 393 avec une hypothèse de 60%. L'effet de l’ADVIH sur le diagnostic du VIH était significatif et positif (8). Pas d’effet significatif observé sur l’initiation TAR (-2).ConclusionNos résultats mettent en évidence qu'une stratégie de distribution de l’ADVIH basée sur les réseaux ciblant les population clés et leurs proches et partenaires augmentent l’accès au dépistage du VIH et améliore le diagnostic. La méthodologie utilisée dans cet article pourrait être reproduite dans différents contextes pour l'évaluation des programmes d’ADVIH, sans nécessité de systèmes de collecte additionnels

Is manufacturer’s Instructions-For-Use sufficient in a multilingual and low literacy context? The example of HIV self-testing in West Africa

Background: The ATLAS project aims to promote the use of HIV self-testing (HIVST) in Côte d'Ivoire, Mali and Senegal. In order to ensure accurate HIVST use, it was necessary to evaluate if the manufacturer’s Instructions-For-Use (IFUs), standardized at the international level, provides complete, accessible and adapted information in the 3 countries’ contexts.Materials & Methods: In December 2018, cognitive interviews were conducted with 64 participants, mostly Men who have Sex with Men (40,6%) and Female Sex Workers (43,8%) in Côte d'Ivoire, Mali and Senegal. Among them, 17,2 % never performed HIV test before and 38% of participants cannot read. They were invited to perform an oral HIVST (OraQuick®) and were requested, at each step of the procedure to share their understanding of the IFU for HIVST use, of the result interpretation and of related actions to be taken. All participants had in hands the manufacturer's IFUs in French, including the free national hotline number. Half of them additionally received manufacturer's demonstration video translated into local languages. Directive interviews guide included 50 questions to collect participants’ perception of what was missing or unclear in the supporting tools. The methodology was validated with all national AIDS programmes and ministries of health.Results: Out of 64 HIVST performed, 5 results were positive (7,8%) and confirmed with additional tests. Overall, the IFU was well understood: 58 participants (92%) were able to interpret their HIVST result correctly without assistance. However, some misuses were observed at various stages, particularly for people who cannot read, with some instructions misunderstood or perceived as not adapted. Only participants who can read have access to information as “do not eat” or “do not use the test if you are on ART” as it is not illustrated in the IFUs. Most of the participants did not spontaneously identify the promotion of the free hotline number and/or the link to the demonstration video. Some procedure’s steps were misinterpreted: 7 participants (11%) did not swab correctly the flat pad along the gum, 3 participants (5%) have read the result at inaccurate time (at 20 seconds, at 5 minutes or after 40 minutes), 13 participants (20%) did not put the stand (for the tube including the liquid) in the right way and 8 other participants struggled to slide tube into the stand. Among 42 participants who can not read and/or who had not seen the video beforehand, 14 of them (33%) had at least one difficulty to interpret the result or to understand what to do after the test/result. On the other hand, the results of the cognitive interviews showed that demonstration video provides a real added value to the user’s understanding and accurate HIVST use (31 participants out of 32 found it very easy to understand with 9 of them who felt they do not need the IFUs if they previously watched the demonstration video). The video translation into local languages, produced by the ATLAS project, was very much appreciated by the participants.Conclusion: The manufacturer's IFUs alone appear not to be sufficient in a multilingual, low-literacy context to ensure accurate HIVST use. Access to additional supporting tools (complementary leaflet, demonstration video or free hotline) is essential in the 3 countries’ contexts

Costs and scale-up costs of integrating HIV self-testing into civil society organisation-led programmes for key populations in Côte d'Ivoire, Senegal, and Mali

Despite significant progress on the proportion of individuals who know their HIV status in 2020, Côte d'Ivoire (76%), Senegal (78%), and Mali (48%) remain far below, and key populations (KP) including female sex workers (FSW), men who have sex with men (MSM), and people who use drugs (PWUD) are the most vulnerable groups with a HIV prevalence at 5-30%. HIV self-testing (HIVST), a process where a person collects his/her own specimen, performs a test, and interprets the result, was introduced in 2019 as a new testing modality through the ATLAS project coordinated by the international partner organisation Solthis (IPO). We estimate the costs of implementing HIVST through 23 civil society organisations (CSO)-led models for KP in Côte d'Ivoire (N = 7), Senegal (N = 11), and Mali (N = 5). We modelled costs for programme transition (2021) and early scale-up (2022-2023). Between July 2019 and September 2020, a total of 51,028, 14,472, and 34,353 HIVST kits were distributed in Côte d'Ivoire, Senegal, and Mali, respectively. Across countries, 64-80% of HIVST kits were distributed to FSW, 20-31% to MSM, and 5-8% to PWUD. Average costs per HIVST kit distributed were $15 for FSW (Côte d'Ivoire:$13, Senegal: $17, Mali:$16), $23 for MSM (Côte d'Ivoire:$15, Senegal: $27, Mali:$28), and $80 for PWUD (Côte d'Ivoire:$16, Senegal: $144), driven by personnel costs (47-78$11 for FSW (Côte d'Ivoire: $9, Senegal:$13, Mali: $10),$16 for MSM (Côte d'Ivoire: $9, Senegal:$23, Mali: $17), and$32 for PWUD (Côte d'Ivoire: $14, Senegal:$50). Cost reductions were mainly explained by the spreading of IPO costs over higher HIVST distribution volumes and progressive IPO withdrawal at scale-up. In all countries, CSO-led HIVST kit provision to KP showed relatively high costs during the study period related to the progressive integration of the programme to CSO activities and contextual challenges (COVID-19 pandemic, country safety concerns). In transition to scale-up and integration of the HIVST programme into CSO activities, this model shows large potential for substantial economies of scale. Further research will assess the overall cost-effectiveness of this model

Modelling the population-level impact of a national HIV self-testing strategy among key populations in Côte d'Ivoire

Background: A third of people living with HIV (PLHIV) in Western Africa are not diagnosed, hindering progress towards HIV elimination. Scaling-up HIV self-testing (HIVST) among key populations (KP) such as female sex workers (FSW), their clients, and men who have sex with men (MSM), may further curb HIV transmission in this region. Using data from the ATLAS program in Côte d’Ivoire, we projected the potential impact of a national HIVST strategy among KP in the country.Methods: A deterministic model of HIV transmission and different testing modalities among key and lower-risk populations was parameterized following a review of demographic, behavioural, HIV and intervention data of the epidemic in Côte d’Ivoire over time. The model was then calibrated to empirical outcomes, including HIV prevalence, the fractions of PLHIV ever HIV tested, diagnosed, and treated, by risk group. Based on interim ATLAS HIVST programme data among KP in southern Côte d’Ivoire, we assumed that 440,000 HIVST are distributed annually (i.e. 10% of all tests in the country), including 29%, 22%, 32%, and 18% to FSW, their clients, MSM, and lower-risk populations, respectively. We predicted the potential impact of this HIVST strategy on new HIV infections and deaths, and new diagnoses over 10 years.Results: After 10 years, the HIVST strategy is expected to increase the fraction of all PLHIV diagnosed by 18%-points in both FSW (86% vs 69% without HIVST) and MSM (95% vs 77%), resulting in small increases overall (85% vs 83%). Overall, this strategy may avert 10,800 (5,100-24,200) new HIV infections over 10 years; equivalent to one infection averted per 400 HIVST distributed. This corresponds to a relative decrease in new infections of 10% (5-17%), 9% (4-21%), and 32% (23-48%) among FSW, their clients, and MSM, respectively, and 5% (3-10%) overall. However, given the larger population size, two-thirds (63%; 44-78%) of all infections prevented over 10 years were among all lower-risk populations, reflecting the indirect effects of prioritizing KP. HIV mortality among FSW and MSM may be reduced by around 15% over 10 years, vs 4% among FSW clients and 2% overall (i.e. 2700 (1400-5600) total deaths averted).Conclusions and recommendations: A national HIVST strategy may prevent 3-10% of new HIV infections in Côte d’Ivoire, especially among FSW clients and MSM. This would help reduce disparities in HIV burden by reaching key populations and addressing their unmet treatment needs

L'introduction de l'autodépistage du VIH dans les consultations des Infections Sexuellement Transmissibles (IST) peut-elle améliorer l'accès au dépistage des patients IST et leurs partenaires ? Une étude qualitative exploratoire du projet ATLAS à Abidjan/Côte d'Ivoire. N° de référence du poster : PV340

International audienceObjectifsDans le cadre de son projet d’introduction de l’auto dépistage du VIH (ADVIH), le programme ATLAS a initié une étude pour documenter les modalités de dispensation des kits d’ADVIH aux patient.e.s présentant une Infection Sexuellement Transmissible (IST) et leurs partenaires à Abidjan/Côte d’Ivoire.Matériels et MéthodesUne enquête qualitative a été réalisée entre mars et août 2021 dans trois services dispensant des ADVIH auprès des patient.e.s IST: (1) consultation prénatale (CPN) ; (2) consultation générale incluant IST et (3) dispensaire IST dédié. Les données ont été collectées par (i) des observations de consultations médicales de patient·e·s IST (N=98) et (ii) des entretiens auprès de soignants impliqués dans la dispensation des kits d’ADVIH (N=18), de patient.e.s ayant reçu des kits ADVIH à proposer à leurs partenaires (N=21) et de partenaires de patientes IST ayant réalisé l’ADVIH (N=2).RésultatsLes trois services présentent des différences d’organisation du circuit du patient et des modalités de dispensation des kits d’ADVIH. En CPN, le dépistage du VIH est proposé systématiquement à toute femme enceinte lors de la première consultation. Lorsqu’une IST est diagnostiquée, un ADVIH est proposé presque systématiquement pour le partenaire (N=27/29). En consultation générale, il y a eu peu de propositions de dépistage et d’ADVIH aux patient.e.s IST et pour leurs partenaires (N=3/16). Malgré l’existence d’une délégation des tâches du dépistage et l’offre d’ADVIH, il n’y a pas de routinisation du dépistage dans ce service. Au dispensaire IST, le circuit du patient est mieux défini : diffusion de la vidéo ADVIH en salle d’attente, consultation des patient.e.s et référencement aux infirmières pour le dépistage avec proposition fréquente de kits d’ADVIH aux patient.e.s IST pour leurs partenaires (N=28/53).De manière générale, l’ADVIH est accepté lorsqu’il est proposé. Mais, la proposition de l’ADVIH aux partenaires n’est pas toujours facile, surtout pour les femmes : difficultés à aborder la question du VIH avec le conjoint, relation de couple « fragile ».Les soignants en général ont une perception positive des ADVIH, mais, ils soulignent le caractère chronophage de la dispensation des ADVIH et souhaitent une meilleure organisation : délégation des tâches (CPN).ConclusionL’organisation des consultations est déterminante : les contraintes structurelles (organisation du service, délégation des tâches) influent sur la proposition d’un dépistage VIH et l’ADVIH ne suffit pas à les lever. La proposition par les soignants d’un ADVIH pour les partenaires nécessite du temps et un accompagnement des patients.e.s. La proposition est plus systématique quand le dépistage est « routinisé » et concerne tous les patient.e.s. Quand l’ADVIH est proposé, il est en général accepté. Si l’ADVIH constitue une opportunité d’améliorer l’accès au dépistage des patient.e.s et de leurs partenaires, une intégration réussie implique d’améliorer l’organisation des services et de promouvoir la délégation des tâches