1
|
Shuper PA, Joharchi N, Varatharajan T, Bogoch II, Loutfy M, El-Helou P, Giolma K, Woodward K, Rehm J. Medical chart-reported alcohol consumption, substance use, and mental health issues in association with HIV pre-exposure prophylaxis (PrEP) nonadherence among gay, bisexual, and other men-who-have-sex-with-men. BMC Public Health 2024; 24:3487. [PMID: 39696067 DOI: 10.1186/s12889-024-20934-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/02/2024] [Indexed: 12/20/2024] Open
Abstract
BACKGROUND Although some evidence suggests that alcohol, substance use, and mental health issues diminish adherence to HIV Pre-Exposure Prophylaxis (PrEP) among gay, bisexual, and other men-who-have-sex-with-men (gbMSM), findings are somewhat inconsistent and have primarily derived from studies involving non-random samples. Medical chart extraction can provide unique insight by in part surmounting sampling-related limitations, as data for entire PrEP clinic populations can be examined. Our investigation entailed comprehensive chart extraction to assess the extent to which chart-reported alcohol, substance use, and mental health issues were associated with chart-reported PrEP nonadherence. METHODS Data from medical charts of gbMSM at two PrEP clinics in Toronto, Canada were extracted for a retrospective 12-month period (02/2018-01/2019). Charts were reviewed for all patients who were 1) ≥ 18 years old; 2) gbMSM; 3) prescribed PrEP ≥ 3 months, and 4) not in a PrEP-related drug trial. Information regarding PrEP, alcohol, substance use, mental health, and sexual behavior was extracted. PrEP adherence was classified in terms of (1) any reported nonadherence, and (2) 'suboptimal adherence,' reflecting nonadherence patterns indicative of insufficient pharmacological protection from HIV. Multivariate logistic regression was employed to identify factors associated with adherence outcomes. RESULTS Data were extracted from 4,292 clinic visits among 501 eligible patients (age: M = 39.1; duration on PrEP: M = 17.4 months; daily PrEP regimen = 93.8%). Hazardous/harmful drinking, club drug use, and mental health issues were reported among 8.8%, 22.2%, and 26.1% of patients, respectively. Any nonadherence and suboptimal adherence were reported among 37.5% and 12.4% of patients, respectively. Factors significantly associated with any nonadherence included age < 25 (AOR = 3.08, 95%CI = 1.54-6.15, p < .001), club drug use (AOR = 2.71, 95%CI = 1.65-4.47, p < .001), and condomless sex (AOR = 1.83, 95%CI = 1.19-2.83, p = .006). For suboptimal adherence, significant factors included age < 25 (AOR = 4.83, 95%CI = 2.28-10.22, p < .001), non-daily PrEP regimens (AOR = 2.94, 95%CI = 1.19-7.22, p = .019), missing PrEP appointments (AOR = 1.97, 95%CI = 1.09-3.55, p = .025), and club drug use (AOR = 1.97, 95%CI = 1.01-3.68, p = .033). Neither alcohol nor mental health issues were associated with nonadherence outcomes. CONCLUSIONS Chart-indicated suboptimal adherence was present among a small subgroup of PrEP-prescribed gbMSM. Adherence-related interventions should target gbMSM who use club drugs, are younger, experience challenges attending PrEP care, and are prescribed non-daily regimens. Offering long-acting injectable PrEP when available and feasible may also improve PrEP's HIV-preventive impact among this population.
Collapse
Affiliation(s)
- Paul A Shuper
- Institute for Mental Health Policy Research & Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), 33 Ursula Franklin St, Toronto, ON, M5S 2S1, Canada.
- Department of Psychiatry, University of Toronto, 250 College St, Toronto, ON, M5T 1R8, Canada.
- Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON, M5T 3M7, Canada.
| | - Narges Joharchi
- Institute for Mental Health Policy Research & Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), 33 Ursula Franklin St, Toronto, ON, M5S 2S1, Canada
| | - Thepikaa Varatharajan
- Institute for Mental Health Policy Research & Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), 33 Ursula Franklin St, Toronto, ON, M5S 2S1, Canada
| | - Isaac I Bogoch
- Internal Medicine and Infectious Diseases, University Health Network, 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada
- Department of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
| | - Mona Loutfy
- Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON, M5T 3M7, Canada
- Department of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
- Women's College Hospital, 76 Grenville S.t, Toronto, ON, M5S 1B2, Canada
- Maple Leaf Medical Clinic, 14 College St, Toronto, ON, M5G 1K2, Canada
| | - Philippe El-Helou
- Department of Medicine, Division of Infectious Diseases, McMaster University, 1200 Main St. W, Hamilton, ON, L8N 3Z5, Canada
| | - Kevin Giolma
- Maple Leaf Medical Clinic, 14 College St, Toronto, ON, M5G 1K2, Canada
| | - Kevin Woodward
- Department of Medicine, Division of Infectious Diseases, McMaster University, 1200 Main St. W, Hamilton, ON, L8N 3Z5, Canada
| | - Jürgen Rehm
- Institute for Mental Health Policy Research & Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), 33 Ursula Franklin St, Toronto, ON, M5S 2S1, Canada
- Department of Psychiatry, University of Toronto, 250 College St, Toronto, ON, M5T 1R8, Canada
- Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON, M5T 3M7, Canada
- Center for Interdisciplinary Addiction Research (ZIS), Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf (UKE), Martinistraße 52, Hamburg, 20246, Germany
- Klinische Psychologie & Psychotherapie, Technische Universität Dresden' Chemnitzer Str, 46D-01187, Dresden, Germany
- Department of International Health Projects, Institute for Leadership and Health Management, I.M. Sechenov First Moscow State Medical University, 8-2 Trubetskaya str, Moscow, 119991, Russian Federation
- Graduate Department of Community Health, Institute of Medical Science, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
| |
Collapse
|
2
|
Stoebenau K, Muchanga G, Ahmad SSO, Bwalya C, Mwale M, Toussaint S, Maambo C, Peters CJ, Baumhart C, Mwango LK, Lavoie MCC, Claassen CW. Barriers and facilitators to uptake and persistence on prep among key populations in Southern Province, Zambia: a thematic analysis. BMC Public Health 2024; 24:1617. [PMID: 38886691 PMCID: PMC11184712 DOI: 10.1186/s12889-024-19152-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 06/14/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Especially in high HIV prevalence contexts, such as Zambia, effective biomedical prevention tools are needed for priority populations (PPs), including key populations (KPs), who are at higher risk. HIV pre-exposure prophylaxis (PrEP) has been scaled up nationally in Zambia, but little is known about barriers to PrEP use among specific PPs to date. METHODS To understand barriers and facilitators to PrEP use in Zambia, we conducted a qualitative case study of PrEP services to PPs including sero-discordant couples (SDCs), female sex workers (FSWs), and men who have sex with men (MSM) in Livingstone. The study conducted in 2021 included in-depth interviews (n = 43) guided by the socio-ecological model, and focus group discussions (n = 4) with clinic and community-based providers and PrEP-eligible clients including users and non-users across PP groups. We used thematic analysis to analyze data using codes derived both deductively and inductively. RESULTS We found multilevel barriers and facilitators to PrEP use. Cross-cutting barriers shared across PP groups included amplifying effects of PrEP being mistaken for antiretroviral drugs used to treat HIV, including anticipated stigma, and concerns about side-effects based on both misinformation and experience. In addition, stigmatized identities, particularly that of MSM, served as a barrier to PrEP use. The fear of being mislabeled as having HIV was of greatest concern for FSWs. Facilitators to PrEP use primarily included the importance of confidential, KP-sensitive services, and the role of informed, supportive family, friends, and peers. Participants across all PP groups urged expanded education efforts to increase awareness of PrEP within the general population toward mitigating concerns of being mislabeled as living with HIV. CONCLUSION To our knowledge, this is the first qualitative study of the PrEP cascade among multiple PPs in Zambia. This study provides important explanation for the low rates of PrEP continuation found in earlier demonstration trials among KPs in Zambia. The study also offers recommendations for programming efforts going forward such as inclusive PrEP awareness campaigns, expanded KP sensitivity training, and related efforts to thwart PrEP stigma while expanding access.
Collapse
Affiliation(s)
- Kirsten Stoebenau
- University of Maryland College Park, 4200 Valley Drive, College Park, MD, 20742-2611, USA.
| | | | - Sacha St-Onge Ahmad
- University of Maryland College Park, 4200 Valley Drive, College Park, MD, 20742-2611, USA
| | - Chiti Bwalya
- University of Maryland College Park, 4200 Valley Drive, College Park, MD, 20742-2611, USA
| | - Mwangala Mwale
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Samara Toussaint
- University of Maryland College Park, 4200 Valley Drive, College Park, MD, 20742-2611, USA
| | - Choolwe Maambo
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Carson J Peters
- University of Maryland College Park, 4200 Valley Drive, College Park, MD, 20742-2611, USA
| | - Caitlin Baumhart
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Marie-Claude C Lavoie
- Division of Global Health Sciences, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Cassidy W Claassen
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Infectious Diseases, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
3
|
Nagai H, Adiibokah E, Tagoe H, Tun W, Pilgrim NA, Ankomah A, Rahman YAA, Addo SA, Atuahene SK, Essandoh E, Maher S, Kowalski M. Policymakers' and healthcare providers' perspectives on the introduction of oral pre-exposure prophylaxis for key populations in Ghana. BMC Public Health 2023; 23:1065. [PMID: 37277772 DOI: 10.1186/s12889-023-15871-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/11/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Key populations (KPs) such as female sex workers (FSWs), men who have sex with men (MSM), people who inject drugs (PWID), and their partners contribute more than a quarter (27.5%) of new HIV infection in Ghana. Oral pre-exposure prophylaxis (PrEP) can substantially reduce HIV acquisition among this group. While the available research indicates KPs willingness to take PrEP in Ghana, little is known about the position of policymakers and healthcare providers on the introduction of PrEP for KPs. METHODS Qualitative data were collected from September to October 2017 in the Greater Accra (GA) and Brong-Ahafo (BA) regions of Ghana. Key informant interviews were conducted with 20 regional and national policymakers and supplemented with In-depth Interviews with 23 healthcare providers to explore their level of support for PrEP and their perspectives on challenges and issues to consider for oral PrEP implementation in Ghana. Thematic content analysis was used to unearth the issues emerging from the interviews. RESULTS Policymakers and healthcare providers in both regions expressed strong support for introducing PrEP for KPs. Key concerns regarding oral PrEP introduction included potential for behavioral disinhibition, non-adherence and side effects of medication, cost and long-term financial implications, and stigma related to HIV and key populations. Participants stressed the need to integrate PrEP into existing services and the provision of PrEP should start with high risk groups like sero-discordant couples, FSWs and MSM. CONCLUSIONS Policymakers and providers recognize the value of PrEP in cubing new HIV infections but have concerns about disinhibition, non-adherence, and cost. Therefore, the Ghana health service should roll-out a range of strategies to address their concerns including: sensitization with providers to mitigate underlying stigma towards KPs, particularly MSM, integration of PrEP into existing services, and innovative strategies to improve continued use of PrEP.
Collapse
Affiliation(s)
- Henry Nagai
- JSI Research & Training Institute, Inc, Accra, Ghana
| | | | - Henry Tagoe
- JSI Research & Training Institute, Inc, Accra, Ghana.
| | | | | | | | | | | | | | | | - Sean Maher
- JSI Research & Training Institute, Inc, Boston, USA
| | | |
Collapse
|
4
|
Eubanks A, Coulibaly B, Keita BD, Anoma C, Dah TTE, Mensah E, Maradan G, Bourrelly M, Mora M, Riegel L, Rojas Castro D, Yaya I, Spire B, Laurent C, Sagaon-Teyssier L, the CohMSM-PrEP Study Group. Loss to Follow-Up from HIV Pre-Exposure Prophylaxis Care in Men Who Have Sex with Men in West Africa. Viruses 2022; 14:v14112380. [PMID: 36366478 PMCID: PMC9695325 DOI: 10.3390/v14112380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/17/2022] [Accepted: 10/26/2022] [Indexed: 01/31/2023] Open
Abstract
Loss to follow-up (LTFU) from HIV pre-exposure prophylaxis (PrEP) care compromises the goal of HIV elimination. We investigated the proportion of LTFU and associated risk factors among men who have sex with men (MSM) enrolled in a PrEP demonstration project in Burkina Faso, Côte d'Ivoire, Mali, and Togo. CohMSM-PrEP, a prospective cohort study, was conducted between November 2017 and June 2021 in community-based clinics. MSM aged 18 years or older at substantial risk of HIV infection received a comprehensive prevention package, including PrEP and peer education. LTFU was defined as not returning to the clinic for six months. Associated risk factors were investigated using a time-varying Cox's model. Of 647 participants followed up for a median time of 15 months, 372 were LTFU (57.5%). LTFU was associated with younger age (adjusted hazard ratio [95% Confidence Interval]; 1.50 [1.17-1.94]), unemployment (1.33 [1.03-1.71]), depression (1.63 [1.12-2.38]), and perceiving no HIV risk with stable male partners (1.61 [1.23-2.10]). Contacting peer educators outside of scheduled visits was protective (0.74 [0.56-0.97]). Our findings show that LTFU from PrEP care in West African MSM is a major challenge to achieving HIV elimination, but that the involvement of peer educators in PrEP delivery helps to limit LTFU by providing users with adequate support.
Collapse
Affiliation(s)
- August Eubanks
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, 13005 Marseille, France
- Correspondence: (A.E.); (L.S.-T.)
| | | | | | | | - Ter Tiero Elias Dah
- Association African Solidarité, Ouagadougou 01 BP 2831, Burkina Faso
- UFR Sciences de la Santé, Université de Ouahigouya, Ouahigouya 01 BP 346, Burkina Faso
| | | | - Gwenaëlle Maradan
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, 13005 Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d’Azur, 13005 Marseille, France
| | - Michel Bourrelly
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, 13005 Marseille, France
- Coalition Plus, Community-Based Research Laboratory, 93500 Pantin, France
| | - Marion Mora
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, 13005 Marseille, France
| | - Lucas Riegel
- Coalition Plus, Community-Based Research Laboratory, 93500 Pantin, France
| | - Daniela Rojas Castro
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, 13005 Marseille, France
- Coalition Plus, Community-Based Research Laboratory, 93500 Pantin, France
| | - Issifou Yaya
- TransVIHMI, Univ Montpellier, INSERM, IRD, 34394 Montpellier, France
| | - Bruno Spire
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, 13005 Marseille, France
| | - Christian Laurent
- TransVIHMI, Univ Montpellier, INSERM, IRD, 34394 Montpellier, France
| | - Luis Sagaon-Teyssier
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, 13005 Marseille, France
- ARCAD Santé PLUS, Bamako BP E2561, Mali
- Correspondence: (A.E.); (L.S.-T.)
| | | |
Collapse
|
5
|
Eubanks A, Coulibaly B, Dembélé Keita B, Anoma C, Dah TTE, Mensah E, Kaba S, Lokrou KJ, Ouedraogo FR, Badjassim AMF, Maradan G, Bourrelly M, Mora M, Riegel L, Rojas Castro D, Yaya I, Spire B, Laurent C, Sagaon-Teyssier L. Socio-behavioral correlates of pre-exposure prophylaxis use and correct adherence in men who have sex with men in West Africa. BMC Public Health 2022; 22:1832. [PMID: 36175860 PMCID: PMC9520809 DOI: 10.1186/s12889-022-14211-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multiple barriers compromise pre-exposure prophylaxis (PrEP) engagement (i.e., use and adherence) in men who have sex with men (MSM). In low/middle-income countries, little is known about PrEP engagement in this population. In West Africa, the CohMSM-PrEP study was one of the rare interventions providing PrEP to MSM. We estimated PrEP use and correct adherence rates in CohMSM-PrEP, together with associated factors over time. METHODS: CohMSM-PrEP recruited MSM in four community-based clinics in Mali, Côte d'Ivoire, Burkina Faso, and Togo. Quarterly follow-up included collecting socio-behavioral data, and providing a comprehensive HIV prevention package, PrEP (daily or event-driven), and peer educator (PE)-led counselling. Using repeated measures, multivariate generalized estimating equations models were used to identify factors associated with self-reported i) PrEP use and ii) correct PrEP adherence during participants' most recent anal intercourse (defined as four pills/week for daily users and 2 + 1 + 1 for event-driven users). RESULTS Five hundred twenty participants were included with a median follow-up time of 12 months (IQR 6-21). Of the 2839 intercourses declared over the follow-up period, PrEP use was self-reported for 1996 (70%), and correct PrEP adherence for 1461 (73%) of the latter. PrEP use was higher in participants who also attended participating clinics outside of scheduled visits (adjusted odds ratio (aOR) [95% Confidence Interval, CI], p-value; 1.32[1.01-1.71], 0.040), and in those who practiced condomless anal sex (1.86[1.54-2.24], < 0.001). Correct adherence was higher in those who often contacted PE outside of scheduled visits (2.16[1.01-4.64], 0.047) and in participants who adopted receptive/versatile sexual positions with stable partners (1.36[1.03-1.81], 0.030). Instead, after an interaction effect between financial situation and regimen was tested, it was lower in event-driven users with a difficult/very difficult financial situation (comfortable/just making ends meet & daily, 4.19[2.56-6.86], < 0.001; difficult/very difficult & daily, 6.47[4.05-10.30], < 0.001; comfortable/just making ends meet & event-driven, 1.63[1.22-2.17], 0.001), and in participants who felt alone (0.76[0.58-0.99], 0.042). CONCLUSIONS Community-based clinic attendance and PE contact outside of scheduled visits were both associated with higher PrEP engagement, but some socially and economically marginalized participants struggled with adherence. As scale-up continues in West Africa, we recommend implementing community-based interventions and providing extra support for vulnerable users to ensure adequate PrEP engagement.
Collapse
Affiliation(s)
- August Eubanks
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques and Sociales de La Santé and Traitement de L'Information Médicale, ISSPAM, Marseille, France.
| | | | | | | | - Ter Tiero Elias Dah
- Association African Solidarité, Ouagadougou, Burkina Faso.,Centre Muraz, Centre Muraz, Institut National de Santé Publique, Bobo-Dioulasso, Burkina Faso
| | | | | | | | | | | | - Gwenaëlle Maradan
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques and Sociales de La Santé and Traitement de L'Information Médicale, ISSPAM, Marseille, France.,ORS PACA, Observatoire Régional de La Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Michel Bourrelly
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques and Sociales de La Santé and Traitement de L'Information Médicale, ISSPAM, Marseille, France.,Coalition Plus, Community-Based Research Laboratory, Pantin, France
| | - Marion Mora
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques and Sociales de La Santé and Traitement de L'Information Médicale, ISSPAM, Marseille, France
| | - Lucas Riegel
- Coalition Plus, Community-Based Research Laboratory, Pantin, France
| | - Daniela Rojas Castro
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques and Sociales de La Santé and Traitement de L'Information Médicale, ISSPAM, Marseille, France.,Coalition Plus, Community-Based Research Laboratory, Pantin, France
| | - Issifou Yaya
- TransVIHMI, Univ Montpellier, INSERM, Montpellier, IRD, France
| | - Bruno Spire
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques and Sociales de La Santé and Traitement de L'Information Médicale, ISSPAM, Marseille, France
| | | | - Luis Sagaon-Teyssier
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques and Sociales de La Santé and Traitement de L'Information Médicale, ISSPAM, Marseille, France.,ARCAD Santé PLUS, Bamako, Mali
| | | |
Collapse
|