Sub-Saharan African communities' experiences and engagement with COVID-19 and the related control strategies in Antwerp, Belgium.

BACKGROUND: Pre-existing racial/ethnic disparities in health, sustained by intersecting socio-economic and structural inequities, have widened due to the COVID-19 pandemic. Yet, little attention has been paid to the lived experiences of people in ethnic/racialised minority communities, and to the causes and effects underlying the COVID-19-related burden. This hinders tailored responses. This study explores Sub-Saharan African (SSA) communities' needs, perceptions, and experiences of the COVID-19 pandemic and its control measures in Antwerp (Belgium) in 2020. METHODS: This qualitative study using an interpretative ethnographical approach adopted an iterative and participatory methodology: a community advisory board advised on all stages of the research process. Interviews and a group discussion were conducted online, through telephone, and face-to-face. We analysed the data inductively using a thematic analytical approach. RESULTS: Our respondents, who mostly used social media for information, struggled with misinformation about the new virus and prevention measures. They reported to be vulnerable to misinformation about the origin of the pandemic, risk of infection with SARS-CoV-2, and the prevention measures. Not only did the epidemic affect SSA communities, but to a larger extent, the control strategies did-especially the lockdown. Respondents perceived the interaction of social factors (i.e. being migrants, being undocumented, having experienced racism and discrimination) and economic factors (i.e. working in temporary and precarious jobs, not being able to apply for unemployment benefit, crowded housing conditions) as increasing the burden of COVID-19 control measures. In turn, these experiences influenced people's perceptions and attitudes, and may have partially impaired them to follow some public health COVID-19 prevention guidelines. Despite these challenges, communities developed bottom-up initiatives to react quickly to the epidemic, including translation of prevention messages, food distribution, and online spiritual support. CONCLUSION: Pre-existing disparities influenced the perceptions of and attitudes towards COVID-19 and its control strategies among SSA communities. To better design support and control strategies targeted to specific groups, we need to not only involve communities and address their specific needs and concerns, but also build on their strengths and resilience. This will remain important in the context of widening disparities and future epidemics.

COVID-19 as a social disease: qualitative analysis of COVID-19 prevention needs, impact of control measures and community responses among racialized/ethnic minorities in Antwerp, Belgium.

BACKGROUND: In high income countries, racialized/ethnic minorities are disproportionally affected by COVID-19. Despite the established importance of community involvement in epidemic preparedness, we lack in-depth understanding of these communities' experiences with and responses to COVID-19. We explored information and prevention needs, coping mechanisms with COVID-19 control measures and their impact on lived experiences among selected racialized/ethnic minority communities. METHODS: This qualitative rapid assessment conducted in Antwerp/Belgium used an interpretative and participatory approach. We included migrant communities with geographic origins ranging from Sub-Saharan Africa, North-Africa to the Middle East, Orthodox Jewish communities and professional community workers. Data were collected between May 2020-May 2021 through key informant-, in-depth interviews and group discussions (N = 71). Transcripts were analyzed inductively, adopting a reflexive thematic approach. A community advisory board provided feedback throughout the research process. RESULTS: Participants indicated the need for tailored information in terms of language and timing. At the start of the epidemic, they perceived official public health messages as insufficient to reach all community members. Information sources included non-mainstream (social) media and media from home countries, hampering a nuanced understanding of virus transmission mechanisms and local and national protection measures. Participants felt the measures' most negative impact on their livelihoods (e.g. loss of income, disruption of social and immigration support). Economic insecurity triggered chronic stress and fears at individual and family level. High degrees of distrust in authorities and anticipated stigma were grounded in previously experienced racial and ethnic discrimination. Community-based initiatives mitigated this impact, ranging from disseminating translated and tailored information, providing individual support, and successfully reaching community members with complex needs (e.g. the elderly, digitally illiterate people, those with small social networks or irregular legal status). CONCLUSION: Study participants' narratives showed how coping with and responding to COVID-19 was strongly intertwined with socio-economic and ethnic/racial characteristics. This justifies conceptualizing COVID-19 a social disease. At the same time, communities demonstrated resilience in responding to these structural vulnerabilities. From a health equity perspective, we provide concrete policy recommendations grounded in insights into communities' structural vulnerabilities and resilience.

Stigma Mechanisms and Outcomes among Sub-Saharan African Descendants in Belgium-Contextualizing the HIV Stigma Framework.

HIV-related stigma and discrimination are recognized barriers to HIV prevention, testing and treatment among people of Sub-Saharan African descent (SSA) origin living in Belgium, but insights into HIV related-stigma mechanisms and outcomes are lacking for this population with high HIV prevalence. Guided by Earnshaw and Chaudoir's stigma framework (2009), we conducted this qualitative study using 10 focus-groups with 76 SSA community members and 20 in-depth interviews with SSA descendants living with HIV to explore specific HIV-stigma mechanisms and outcomes and underlying drivers. Inductive and deductive thematic analysis showed high degrees of stigma among SSA communities driven by fear of HIV acquisition and misconceptions in a migration context, negatively affecting SSA descendants living with HIV. The results allowed for contextualization of the framework: At the community level, prejudices and stereotypes were major stigma mechanisms, while physical distancing, gossips, sexual rejection, violence and increased HIV prevalence emerged as stigma outcomes. Among SSA descendants living with HIV, enacted, anticipated and internalized stigmas were validated as stigma mechanisms, with witnessed stigma as an additional mechanism. Self-isolation, community avoidance and low utilization of non-HIV specialized healthcare were additional outcomes. These results are relevant for tailoring interventions to reduce HIV-related stigma.

Understanding how communities respond to COVID-19: experiences from the Orthodox Jewish communities of Antwerp city.

BACKGROUND: The importance of community involvement in the response against disease outbreaks has been well established. However, we lack insights into local communities' experiences in coping with the current COVID-19 pandemic. This study explored both the impact of, and response to, COVID-19 within the Orthodox Jewish communities of Antwerp (Belgium) during the first lockdown period (March 2020 - May 2020). METHODS: We conducted an explorative qualitative study using a participatory approach. First, we performed a community mapping to identify relevant stakeholders. Through the active involvement of a community advisory board and based on qualitative interviews with key-informants and community members, we elicited lived experiences, attitudes, and perceptions towards COVID-19. Interviews were conducted both face-to-face and using online web conferencing technology. Data were analyzed inductively according to the principles of thematic analysis. RESULTS: Government-issued outbreak control measures presented context-specific challenges to the Orthodox Jewish communities in Antwerp. They related mainly to the remote organization of religious life, and practicing physical distancing in socially and culturally strongly connected communities. Existing community resources were rapidly mobilized to adapt to the outbreak and to self-organize response initiatives within communities. The active involvement of community and religious leaders in risk communication proved to be of great importance to facilitate the coverage and uptake of pandemic control measures while protecting essential community values and traditions. Creating bottom-up and community-adapted communication strategies, including addressing language barriers and involving Rabbis in the dissemination of prevention messages, fostered a feeling of trust in government's response measures. However, unmet information and prevention needs were also identified, such as the need for inclusive communication by public authorities and the need to mitigate the negative effects of stigmatization. CONCLUSION: The experiences of Orthodox Jewish communities in Antwerp demonstrate a valuable example of a feasible community-centered approach to health emergencies. Increasing the engagement of communities in local decision-making and governance structures remains a key strategy to respond to unmet information and prevention needs.

First HIV prevalence estimates of a representative sample of adult sub-Saharan African migrants in a European city. Results of a community-based, cross-sectional study in Antwerp, Belgium.

INTRODUCTION: While sub-Saharan African migrants are the second largest group affected by HIV in Europe, sound HIV prevalence estimates based on representative samples of these heterogeneous communities are lacking. Such data are needed to inform prevention and public health policy. METHODS: This community-based, cross-sectional study combined oral fluid HIV testing with an electronic behavioral survey. Adopting a two-stage time location sampling HIV prevalence estimates for a representative sample of adult sub-Saharan African migrants in Antwerp, Belgium were obtained. Sample proportions and estimated adjusted population proportions were calculated for all variables. Univariable and multivariable logistic regression analysis explored factors independently associated with HIV infection. RESULTS: Between December 2013 and October 2014, 744 sub-Saharan African migrants were included (37% women). A substantial proportion was socially, legally and economically vulnerable: 21% were probably of undocumented status, 63% had financial problems in the last year and 9% lacked stable housing. Sexual networks were mostly African and crossed national borders, i.e. sexual encounters during travels within Europa and Africa. Concurrency is common, 34% of those in a stable relationship had a partner on the side in the last year. HIV prevalence was 5.9%(95%CI:3.4%-10.1%) among women and 4.2% (95%CI:1.6%-10.6%) among men. Although high lifetime HIV testing was reported at community level (73%), 65.2% (CI95%:32.4%-88.0%) of sub-Saharan African migrants were possibly undiagnosed. Being 45 years or older, unprotected sex when travelling within Europe in the last year, high intentions to use condoms, being unaware of their last sexual partners' HIV status, recent HIV testing and not having encountered partner violence in the last year were independently associated with HIV infection in multivariable logical regression. In univariable analysis, HIV infection was additionally associated to unemployment. CONCLUSIONS: This is the first HIV prevalence study among adult sub-Saharan African migrants resettling in a European city based on a representative sample. HIV prevalence was high and could potentially increase further due to the high number of people with an undiagnosed HIV infection, social vulnerability, high levels of concurrency and mainly African sexual networks. Given this population's mobility, an aligned European combination prevention approach addressing these determinants is urgently needed.

Acceptability of a Community-Based Outreach HIV-Testing Intervention Using Oral Fluid Collection Devices and Web-Based HIV Test Result Collection Among Sub-Saharan African Migrants: A Mixed-Method Study.

BACKGROUND: Late human immunodeficiency virus (HIV) diagnosis is common among sub-Saharan African migrants. To address their barriers to HIV testing uptake and improve timely HIV diagnoses and linkage to care, the outreach HIV testing intervention, "swab2know," was developed. It combined a community-based approach with innovative testing methods: oral fluid self-sampling and the choice between Web-based HIV test result collections using a secured website or post-test counseling at a sexual health clinic. The sessions included an informational speech delivered by a physician of sub-Saharan African origin and testimonies by community members living with HIV. OBJECTIVES: The objectives of this study were to evaluate the intervention's acceptability among sub-Saharan African migrants and its potential to reach subgroups at higher risk for HIV infection and to identify facilitators and barriers for HIV testing uptake. METHODS: This mixed-method study combined qualitative (participant observations and informal interviews with testers and nontesters) and quantitative data (paper-pencil survey, laboratory data, and result collection files). Data were analyzed using a content analytical approach for qualitative and univariate analysis for quantitative data. RESULTS: A total of 10 testing sessions were organized in sub-Saharan African migrant community venues in the city of Antwerp, Belgium, between December 2012 and June 2013. Overall, 18.2% of all people present (N=780) underwent HIV testing; 29.8% of them tested for HIV for the first time, 22.3% did not have a general practitioner, and 21.5% reported 2 or more sexual partners (last 3 months). Overall, 56.3% of participants chose to collect their HIV test results via the protected website. In total, 78.9% collected their results. The qualitative analysis of 137 participant observation field notes showed that personal needs and Internet literacy determined the choice of result collection method. Generally, the oral fluid collection devices were well accepted mainly because sub-Saharan African migrants dislike blood taking. For some participants, the method raised concerns about HIV transmission via saliva. The combination of information sessions, testimonies, and oral fluid collection devices was perceived as effectively reducing thresholds to participation. Acceptability of the intervention differed between individual participants and settings. Acceptance was higher among women, in churches and settings where community leaders were engaged in HIV awareness raising. Higher preventive outcomes were observed in settings with lower acceptance. The presence of the intervention team visualized the magnitude of the HIV epidemic to the public and promoted HIV testing uptake at large, for example, those who declined indicated they would take up testing later. CONCLUSIONS: When accompanied by tailored provision of information, outreach HIV testing interventions adopting a community-based approach and innovative methods such as Web-based result collection and oral fluid collection devices are acceptable and reduce thresholds for HIV testing uptake. The swab2know intervention was able to reach sub-Saharan African migrants at risk of HIV infection, and with limited access to regular HIV testing. Among nontesters, the intervention contributed to awareness raising and therefore has a place in a multipronged HIV test promotion strategy.

TOGETHER Project to Increase Understanding of the HIV Epidemic Among Sub-Saharan African Migrants: Protocol of Community-Based Participatory Mixed-Method Studies.

BACKGROUND: Sub-Saharan African Migrants (SAM) are the second largest group affected by HIV/AIDS in Belgium and the rest of Western Europe. Increasing evidence shows that, more than previously thought, SAM are acquiring HIV in their host countries. This calls for a renewed focus on primary prevention. Yet, knowledge on the magnitude of the HIV epidemic among SAM (HIV prevalence estimates and proportions of undiagnosed HIV infections) and underlying drivers are scarce and limit the development of such interventions. OBJECTIVE: By applying a community-based participatory and mixed-methods approach, the TOGETHER project aims to deepen our understanding of HIV transmission dynamics, as well as inform future primary prevention interventions for this target group. METHODS: The TOGETHER project consists of a cross-sectional study to assess HIV prevalence and risk factors among SAM visiting community settings in Antwerp city, Belgium, and links an anonymous electronic self-reported questionnaire to oral fluid samples. Three formative studies informed this method: (1) a social mapping of community settings using an adaptation of the PLACE method; (2) a multiple case study aiming to identify factors that increase risk and vulnerability for HIV infection by triangulating data from life history interviews, lifelines, and patient files; and (3) an acceptability and feasibility study of oral fluid sampling in community settings using participant observations. RESULTS: Results have been obtained from 4 interlinked studies and will be described in future research. CONCLUSIONS: Combining empirically tested and innovative epidemiological and social science methods, this project provides the first HIV prevalence estimates for a representative sample of SAM residing in a West European city. By triangulating qualitative and quantitative insights, the project will generate an in-depth understanding of the factors that increase risk and vulnerability for HIV infection among SAM. Based on this knowledge, the project will identify priority subgroups within SAM communities and places for HIV prevention. Adopting a community-based participatory approach throughout the full research process should increase community ownership, investment, and mobilization for HIV prevention.

HIV testing in primary care: feasibility and acceptability of provider initiated HIV testing and counseling for sub-Saharan African migrants.

Provider-initiated HIV testing and counseling (PITC) is recommended to reduce late HIV diagnoses, common among Sub-Saharan African migrants (SAM) residing in Europe. Primary care represents an ideal entry point for PITC. To support Flemish general practitioners (GPs), we developed a culturally sensitive PITC tool. Over a 12-week period, 65 GPs implemented PITC to assess acceptability and feasibility of PITC. The qualitative evaluation showed high acceptability among physicians. Routine PITC was challenged by physicians' personal discomfort, assumptions of patients' sexual risk, perceived incoherence with reasons for consultation, and time pressure. The best opportunity for PITC was an indicated blood analysis for other medical reasons. Counseling skills improved during the implementation, but participants still advocated for reduced counseling requirements. PITC proved to be feasible in primary care settings, but the up-scaling requires a reformulation of counseling guidelines, a policy stipulating the role of GPs in the prevention-care continuum, and an investment in (continuous) training.

"It is not easy": challenges for provider-initiated HIV testing and counseling in Flanders, Belgium.

This study identified physicians' HIV testing practices and their barriers toward implementing provider-initiated HIV testing and counseling (PITC) for Sub-Saharan African migrants (SAM) in Flanders, Belgium. In-depth interviews were conducted on a purposive sample of 20 physicians (ten GPs and ten internists). GPs performed mainly patient-initiated tests, while internists carried out tests based on disease indicators and risk behavior. For the most part, World Health Organization (WHO) guidelines were not followed. Study participants were not in favor of implementing PITC. Reasons included lack of information on the HIV epidemic among SAM, fear of stigmatizing patients, perceiving testing as unethical for undocumented patients, questionable relevance of pre-test counseling, lack of expertise in discussing sexuality, language barriers, lack of time, and the absence of a national or regional HIV testing policy. Implementing PITC will require appropriate training of service providers. Also, supporting policies should be developed with the participation of stakeholders encouraging "normalization" of HIV testing.

"It's better not to know": perceived barriers to HIV voluntary counseling and testing among sub-Saharan African migrants in Belgium.

This study explored perceptions, needs, and barriers of sub-Saharan African migrants in relation to HIV voluntary counseling and testing (VCT). Using an inductive qualitative methodological approach, data were obtained from focus group discussions. Results showed that participants were in principle in favor of VCT. However, they indicated that barriers outweighed advantages. Such barriers included fear of positive test results and its related personal and social consequences, lack of information, lack of preventive health behavior, denial of HIV risk, and missed opportunities. Limited financial resources were only a concern for some subgroups like young people, asylum seekers, and recent migrants. This study identified multiple and intertwined barriers to VCT from a community perspective. In order to promote VCT, interventions such as raising awareness through culturally sensitive education should be adopted at community level. At level of service provision, provider initiated HIV testing including target group tailored counseling should be promoted.