Literature DB >> 34389284

Serosurvey of anti-treponema pallidum (syphilis), anti-hepatitis C virus and anti-HIV antibodies in homeless persons of São Paulo city, southeastern Brazil.

Laís Giuliani Felipetto1, Pedro Irineu Teider-Junior1, Felipe Fortino Verdan da Silva2, Anahi Chechia do Couto3, Louise Bach Kmetiuk3, Camila Marinelli Martins4, Leila Sabrina Ullmann5, Jorge Timenetsky6, Andrea Pires Dos Santos7, Alexander Welker Biondo8.   

Abstract

Homeless persons have been considered as one of the most susceptible populations to sexually transmitted infections. In Brazil, these population experienced an increase of 140% from 2012 to 2020. Accordingly, the present study aimed to assess the seroprevalence of anti-Treponema pallidum, anti-HCV, anti-HIV antibodies, and the risk factors associated with homeless persons in a daytime attendance shelter of São Paulo city during the syphilis epidemic in Brazil. Blood samples of 116 volunteers and epidemiological data were conveniently collected in the shelter from June through August 2018. Detection of syphilis, HCV, and HIV antibodies was performed by chemiluminescent microparticle immunoassay (CMIA). CMIA-reagent samples for anti-T. pallidum antibodies were confirmed by Venereal Disease Research Laboratory (VDRL) non-treponemal test. VDRL non-reagent samples were confirmed by treponemal rapid immunochromatographic test. A rapid immunoblot assay confirmed seropositivity to HIV. Overall, anti-T. pallidum antibodies were observed in 29/116 (25.0%), anti-HCV antibodies in 4/116 (3.4%), and anti-HIV antibodies in 2/116 (1.7%) individuals, both co-infected with anti-T. pallidum antibodies. Associated risk factors for syphilis in homeless persons were being born or previously living in another city (p = 0.043) and becoming homeless due to family conflicts (p = 0.035). Besides homeless vulnerability, worldwide shortage of benzathine penicillin supply and increasing of syphilis testing access through rapid testing in primary health care services may have also impacted disease spreading at the time. The prevalence of syphilis found herein is the highest worldwide to date in this population.
Copyright © 2021 Sociedade Brasileira de Infectologia. Published by Elsevier España, S.L.U. All rights reserved.

Entities:  

Keywords:  HCV; HIV; Homeless; Syphilis; Vulnerability

Mesh：

Substances：

Year:  2021        PMID： 34389284      PMCID： PMC9392160          DOI： 10.1016/j.bjid.2021.101602

Source DB:  PubMed          Journal:  Braz J Infect Dis        ISSN： 1413-8670            Impact factor:   3.257


Introduction

Homeless persons have been considered one of the most susceptible populations to sexually transmitted infections (STI) such as those caused by Treponema pallidum, hepatitis C virus (HCV), and human immunodeficiency virus (HIV), mostly due to social vulnerability and limited access to preventive care and health services., Similarly, other infectious diseases frequently occur in this population., A recent report estimates 221,869 homeless persons living in Brazil, of which 24,344 in São Paulo city. There was a 140% increase in the country's homeless population from 2012 to 2020, mostly associated with the economic crisis leading to unemployment and poverty., Homeless persons are at increased risk of acquiring infectious diseases due to the limited access to treatment and prevention programs, poor hygiene, increased use of alcohol and injectable drugs, and unprotected sex., The present study aimed to investigate the presence of antibodies against syphilis, HCV, and HIV in homeless persons in São Paulo, Brazil, the largest city in Latin America.

Material and methods

This study was a descriptive cross-sectional seroepidemiological approach of a homeless population in a major daytime attendance shelter of western São Paulo city. The research was conducted along with the city's multi-professional team of the Secretary of Health, called "Street Outreach Office", part of the Brazilian Unified Health System (SUS). This study was approved by the Ethics Committee in Human Research of the Federal University of Paraná (CAAE: 80099017.3.0000.0102, protocol number: 2.512.196), by the Ethics Committee in Human Health of the São Paulo City Secretary of Health (CAAE: 80099017.3.3004.0086, protocol number: 3.366.684) and by the Ethics Committee in Human Research of the Clinics Hospital at the Federal University of Paraná (CAAE: 80099017.3.3005.0096, protocol number: 3.623.845). The patients/participants provided their written informed consent to participate in this study. Homeless persons were recruited by city health officials and invited to voluntarily participate in the research. Blood samples of 116 volunteers were conveniently collected from June to August 2018, which was the permitted timeframe. Epidemiological data collection was carried out using a questionnaire designed for homeless persons; refusal to fully or partially answer any question or incomplete answers was accepted and registered. Detection of syphilis, HCV and HIV was performed by chemiluminescent microparticle immunoassay (CMIA) (Anility i Syphilis TP, Anti-HCV, HIVAg/Ab, Abbott Laboratories, Chicago, IL, USA). Cases of reactive serology for HIV were confirmed by a rapid immunoblot test (DPP HIV1/2®, Fiocruz, Rio de Janeiro, Brazil), as recommendations of the Brazilian Ministry of Health. Although screening for viral hepatitis B by rapid test has been also incorporated by SUS, the São Paulo Secretary of Health had a shortage of these tests throughout 2018. CMIA-reagent samples for anti-T. pallidum antibodies were confirmed by Venereal Disease Research Laboratory (VDRL) non-treponemal test. VDRL non-reagent samples were confirmed by treponemal rapid immunochromatographic test (MedTeste Sífilis MedLevensohn®, São Paulo, Brazil), as recommended by SUS. Reagent results may represent early syphilis in recent infection or untreated late syphilis, also in activity. Statistical analysis was performed using SPSS 20.0. Frequencies of syphilis and HCV seropositivity (absolute and relative) were determined by the stratification of the observations according to variables. Chi-Square test was used to determine univariate association between studied variables, and odds ratios (OR) were used to assess the association between syphilis and HCV prevalence and potential risk factors. Association between factors was considered when p < 0.05.

Results

In short, profile of surveyed homeless volunteers included 103/116 (88.8%) males, 105/116 (90.5%) unmarried and 89/116 (76.7%) non-white individuals. A total of 77/116 (66.4%) persons had none to 8th grade as educational background and 97/116 (83.6%) declared receiving no income at the time. While 29/116 (25.0%) individuals were assisted by psychosocial service, 87/116 (75.0%) persons referred use of legal or illegal substances, mostly alcohol in 62/87 (71.3%), followed by tobacco in 32/87 (36.8%) and cocaine in 31/87 (35.6%) individuals. São Paulo was not the city of birth for 80/116 (69.0%) individuals, 64/116 (55.2%) slept in shelters at night, and family conflicts was the main reported reason to have become homeless in 47/116 (40.5%) answers (Table 1).
Table 1

Statistical results of univariate and multiple logistic regression models of associated risk factors for seropositivity of anti- Treponema pallidum and anti- HCV antibodies in homeless persons.

VariablesSyphilis
HCV
Positive/N%OR (CI 95%)p-valuePositive/N%OR (CI 95%)p-value
SexMale24/10323.30.49 (0.4–1.62)0.2343/1032.90.38 (0.04–3.39)0.383
Female5/1338.5(ref)1/137.7(ref)
PregnancyYes1/250.03.07 (0.19–50.73)0.4100/20.0*0.932
No28/11424.6(ref)4/1143.5(ref)
Marital StatusUnmarried25/10523.80.55 (0.15–2.02)0.3604/1053.8*0.668
Accompanied4/1136.4(ref)0/110.0(ref)
Racial self-declarationWhite6/2722.20.82 (0.29–2.28)0.7040/270.0*0.572
Non-white23/8925.8(ref)4/894.5(ref)
Educational backgroundNone to 8th grade20/7726.01.09 (0.44–2.71)0.8504/775.2*0.302
High school and university9/3724.3(ref)0/370.0(ref)
IncomeNo income26/9726.82.93 (0.63–13.63)0.1542/972.10.19 (0.03-1.23)0.115
With income2/1811.1(ref)2/1811.1(ref)
Assistance by Psychosocial Care Centers (CAPS)Yes4/2913.80.39 (0.12–1,26)0.1082/296.93.00 (0.44-20.35)0.260
No25/8728.7(ref)2/872.3(ref)
Use of licit and/or illicit drugsYes22/8725.31.06 (0.40–2.83)0.9013/873.41.00 (0.11-9.24)0.740
No7/2924.1(ref)1/293.4(ref)
Alcohol consumptionYes16/6225.81.09 (0.47–2.55)0.8302/623.20.87 (0.13–5.97)0.637
Tobacco useYes8/3225.01.00 (0.39–2.56)1.0002/326.20.96 (0.10–8.84)0.725
Cocaine useYes4/3112.90.36 (0.11–1.12)0.0691/303.32.62 (0.39–17.85)0.305
Marijuana useYes6/3020.00.68 (0.25–1.89)0.4630/310.0*0.283
Crack useYes3/1421.40.79 (0.08–6.91)0.7420/140.0*0.593
Other drugsYes1/520.00.74 (0.08–6.91)0.7920/50.0*0.836
City of originOthers25/8031.33.52 (1.12–11.05)0.0434/805.0*0.394
São Paulo4/3511.4(ref)0/350.0(ref)
Shelter typeHostel14/6421.90.69 (0.29–1.60)0.3894/646.2*0.089
Street9/2832.11.61 (0.63–4.11)0.3160/300.0*0.326
Causes for becoming homeless
Family conflictsYes6/4712.8(ref)0.0351/641.60.23 (0.02–2.31)0.213
No19/6429.72.88 (1.05–7.93)3/476.4(ref)
UnemploymentYes8/3324.21.15 (0.44–3.00)0.7781/333.00.79 (0.08–7.30)0.657
No17/7821.8(ref)3/783.8(ref)
Alcohol and drugsYes5/2619.20.77 (0.26–2.32)0.6462/267.73.27 (0.48–22.08)0.233
No20/8523.5(ref)2/852.4(ref)
Another motiveYes5/1827.81.40 (0.45–4.41)0.5601/185.61.72 (0.19–15.64)0.512
No20/9321.5(ref)3/933.2(ref)
Housing lossYes4/1233.31.86 (0.51–6.77)0.3420/120.0*0.629
No21/9921.2(ref)4/994.0(ref)

The percentages can go higher than 100% because individuals could answer more than one option. N= number total; OR= odds ratio.

Statistical results of univariate and multiple logistic regression models of associated risk factors for seropositivity of anti- Treponema pallidum and anti- HCV antibodies in homeless persons. The percentages can go higher than 100% because individuals could answer more than one option. N= number total; OR= odds ratio. CMIA-reagent samples for anti-T. pallidum antibodies were confirmed by VDRL non-treponemal test. VDRL non-reagent samples were confirmed by treponemal rapid immunochromatographic test. A rapid immunoblot assay confirmed seropositivity to HIV. Overall, anti-T. pallidum antibodies were observed in 29/116 (25.0%), anti-HCV antibodies in 4/116 (3.4%), and anti-HIV antibodies in 2/116 (1.7%) individuals, both co-infected with T. pallidum (Table 2).
Table 2

Results of anti-Treponema pallidum, anti-HCV and anti-HIV antibodies in homeless people of São Paulo city, Brazil.

Sample IDSyphilisCMIASyphilisVDRLSyphilisTreponemalRapid TestHCVCMIAHIVCMIAHIV imunoblot
SP01seronegativeseronegativeseronegativeseronegative
SP02seronegativeseronegativeseronegativeseronegative
SP0317.861:2seronegativeseronegativeseronegative
SP04seronegativeseronegativeseronegativeseronegative
SP05seronegativeseronegativeseronegativeseronegative
SP0613.721:1seronegativeseronegativeseronegative
SP08seronegativeseronegativeseronegativeseronegative
SP11seronegativeseronegativeseronegativeseronegative
SP1315.231:4seronegativeseronegativeseronegative
SP14seronegativeseronegativeseronegativeseronegative
SP16seronegativeseronegativeseronegativeseronegative
SP17seronegativeseronegativeseronegativeseronegative
SP18seronegativeseronegativeseronegativeseronegative
SP19seronegativeseronegativeseronegativeseronegative
SP20seronegativeseronegativeseronegativeseronegative
SP21seronegativeseronegativeseronegativeseronegative
SP2310.231:2seronegativeseronegativeseronegative
SP24seronegativeseronegativeseronegativeseronegative
SP25seronegativeseronegativeseronegativeseronegative
SP265.191:1seronegativeseronegativeseronegative
SP2713.911:1seronegative692.63HIV-1
SP28seronegativeseronegativeseronegativeseronegative
SP2915.881:1seronegativeseronegativeseronegative
SP30seronegativeseronegativeseronegativeseronegative
SP31seronegativeseronegativeseronegativeseronegative
SP32seronegativeseronegativeseronegativeseronegative
SP33seronegativeseronegativeseronegativeseronegative
SP3416.871:2seronegativeseronegativeseronegative
SP35seronegativeseronegativeseronegativeseronegative
SP36seronegativeseronegativeseronegativeseronegative
SP371.57NRseropositiveseronegativeseronegativeseronegative
SP3820.011:128seronegativeseronegativeseronegative
SP39seronegativeseronegativeseronegativeseronegative
SP40seronegativeseronegativeseronegativeseronegative
SP4120.091:128seronegativeseronegativeseronegative
SP42seronegativeseronegativeseronegativeseronegative
SP43seronegativeseronegativeseronegativeseronegative
SP44seronegativeseronegativeseronegativeseronegative
SP45seronegativeseronegativeseronegativeseronegative
SP46seronegativeseronegativeseronegativeseronegative
SP47seronegativeseronegativeseronegativeseronegative
SP48seronegativeseronegativeseronegativeseronegative
SP49seronegativeseronegativeseronegativeseronegative
SP50seronegativeseronegativeseronegativeseronegative
SP514.1NRseropositiveseronegativeseronegativeseronegative
SP52seronegativeseronegativeseronegativeseronegative
SP53seronegativeseronegativeseronegativeseronegative
SP54seronegativeseronegative0.91seronegative
SP55seronegativeseronegativeseronegativeseronegative
SP5617.94seronegativeseronegativeseronegative
SP57seronegativeseronegativeseronegativeseronegative
SP58seronegativeseronegativeseronegativeseronegative
SP59seronegativeseronegativeseronegativeseronegative
SP60seronegativeseronegativeseronegativeseronegative
SP61seronegativeseronegativeseronegativeseronegative
SP62seronegativeseronegativeseronegativeseronegative
SP63seronegativeseronegativeseronegativeseronegative
SP64seronegativeseronegativeseronegativeseronegative
SP65seronegativeseronegativeseronegativeseronegative
SP66seronegativeseronegativeseronegativeseronegative
SP6713.761:1seronegativeseronegativeseronegative
SP68seronegativeseronegativeseronegativeseronegative
SP69seronegativeseronegativeseronegativeseronegative
SP70seronegativeseronegativeseronegativeseronegative
SP7112.681:.1seronegativeseronegativeseronegative
SP72seronegativeseronegativeseronegativeseronegative
SP73seronegativeseronegativeseronegativeseronegative
SP7415.781:4seronegativeseronegativeseronegative
SP75seronegativeseronegativeseronegativeseronegative
SP76seronegativeseronegativeseronegativeseronegative
SP77seronegativeseronegativeseronegativeseronegative
SP78seronegativeseronegativeseronegativeseronegative
SP792.33NRseropositive1.25seronegativeseronegative
SP80seronegativeseronegativeseronegativeseronegative
SP81seronegativeseronegativeseronegativeseronegative
SP82seronegativeseronegativeseronegativeseronegative
SP83seronegativeseronegativeseronegativeseronegative
SP84seronegativeseronegativeseronegativeseronegative
SP852.52NRseronegativeseronegativeseronegativeseronegative
SP8615.891:32seronegativeseronegativeseronegative
SP87seronegativeseronegativeseronegativeseronegative
SP88seronegativeseronegativeseronegativeseronegative
SP8919.891:256seronegativeseronegativeseronegative
SP909.21NRseropositiveseronegativeseronegativeseronegative
SP9120.011:8seronegative1.35seronegative
SP92seronegativeseronegativeseronegativeseronegative
SP93seronegativeseronegativeseronegativeseronegative
SP94seronegativeseronegativeseronegativeseronegative
SP95seronegativeseronegativeseronegativeseronegative
SP96seronegativeseronegativeseronegativeseronegative
SP97seronegativeseronegativeseronegativeseronegative
SP9814.151:4seronegativeseronegativeseronegative
SP99seronegativeseronegativeseronegativeseronegative
SP1002.95NRseropositive1.11seronegativeseronegative
SP101seronegative15.97seronegativeseronegative
SP102seronegativeseronegativeseronegativeseronegative
SP103seronegative7.66seronegativeseronegative
SP10415.791:2seronegative261.79HIV-1
SP105seronegativeseronegativeseronegativeseronegative
SP106seronegativeseronegativeseronegativeseronegative
SP10718.771:8seronegativeseronegativeseronegative
SP108seronegativeseronegativeseronegativeseronegative
SP109seronegativeseronegativeseronegativeseronegative
SP110seronegativeseronegativeseronegativeseronegative
SP11110.651:2seronegativeseronegativeseronegative
SP112seronegativeseronegativeseronegativeseronegative
SP113seronegativeseronegativeseronegativeseronegative
SP114seronegativeseronegativeseronegativeseronegative
SP115seronegativeseronegativeseronegativeseronegative
SP 11619.031:8seronegativeseronegativeseronegative
SP118seronegativeseronegativeseronegativeseronegative
SP119seronegativeseronegativeseronegativeseronegative
SP12015.961:16seronegativeseronegativeseronegative
SP121seronegativeseronegativeseronegativeseronegative
SP122seronegativeseronegativeseronegativeseronegative
SP12317.021:8seronegativeseronegativeseronegative
Results of anti-Treponema pallidum, anti-HCV and anti-HIV antibodies in homeless people of São Paulo city, Brazil. Associated risk factors for syphilis exposure in homeless were to be born or had previously lived in another city (p = 0.043) and to have become homeless due to family conflicts (p = 0.035). Other variables such as sex (p = 0.234), pregnancy (p = 0.410), marital status (p = 0.360), racial self-declaration (p = 0.704), educational background (p = 0.850), income (p = 0.154), assistance by psychosocial care centers (CAPS) (p = 0.108), use of licit and/or illicit drugs (p > 0.05), use of shelter (hostels, street, occupancy) (p > 0.05) were not statistically significant (Table 1). There were no risk factors significantly associated with the presence of anti-HCV antibodies (p > 0.05) (Table 1). Risk factors associated with HIV could not be analyzed due to the low HIV seropositive rate.

Discussion

To the authors’ knowledge, the seroprevalence of anti-T. pallidum antibodies assessed herein (25.0%) is the highest in homeless persons worldwide, which ranges from 3/569 (0.5%) in Iran, 5/175 (2.9%) in Kenya, 22/554 (4.0%) in India, to 18/132 (13.6%) in the USA. Additionally, syphilis was detected in 19/330 (5.7%) homeless persons in 2002-2003, and in 97/1,391 (7.0%) in 2006-2007, both in São Paulo city, which is about 4-fold lower than the rate in present study. Five surveys have found a higher prevalence of syphilis, in other vulnerable populations, including 141/450 (31.3%) prisoners in Ethiopia, 82/222 (36.9%) sex workers in Brazil, 273/598 (45.6%) in Argentina and 51.1% (1,010/1,978) in Rwanda, and 269/529 (50.8%) refugees in Italy. In the present study, seropositivity of anti-T. pallidum antibodies among homeless persons was associated with city of birth or previously living in a city other than Sao Paulo (p = 0.043) and had become homeless due to family conflicts (p = 0.035). In São Paulo city, most homeless persons are migrants or refugees and with broken or fragile family bonds, corroborating the findings of a previous study with migrant workers in Eastern China, which reported higher seroprevalence of anti-T. pallidum antibodies among migrants with multiple sex partners and being divorced or widowed. A retrospective case-control study in China with 17,585 inpatients screened for syphilis infection by serological tests, T. pallidum exposure was also associated to migration between cities. No risk factors for HCV exposure among homeless persons were significantly associated in the present study. Future investigations should be conducted to fully ascertain risk factors for HCV and HIV coinfection in homeless persons. Besides homeless vulnerability, worldwide shortage of benzathine penicillin supply, the drug of choice for active syphilis treatment, may have also impacted disease spreading at the time. Not surprisingly, the Brazilian epidemic of syphilis contrasts with other Latin American countries, which have moved towards syphilis eradication., Other aspects may have also contributed to increase syphilis rates, including greater access to syphilis testing through rapid testing in primary health care services. The detection rate of acquired syphilis in Brazil increased from 2.1/100,000 in 2010 to 34.1/100,000 in 2015 and to 75.8 100,000 inhabitants in 2018. According to the recent national guidelines for management of sexually transmitted infections, the diagnosis of syphilis should incorporate clinical history, history of previous treatment, symptoms, in addition to results of treponemal and non-treponemal tests. As limitation, VDRL reagent results may represent early syphilis in recent infection or untreated late syphilis, also in activity. Therefore, the prevalence of syphilis in activity herein may be underestimated. Further studies should also consider molecular diagnosis, particularly due to higher sensitivity in primary syphilis, associated with clinical signs such as exanthema and ulcers. In the present study, 2/116 (1.7%) individuals have shown anti-HIV antibodies. Herein, a 4th generation test (CMIA) was used as screening test and confirmed by a 2nd generation test (immunoblot assay), according to a recognized algorithm of the Brazilian Ministry of Health. Also, anti-HCV antibodies were detected in 4/116 individuals by CMIA, as recommended by Brazilian Ministry of Health. Although the Ministry of Health has also recommended molecular testing for HIV and HCV clinical cases, the present study focused on the epidemiological approach of viral exposure rather than viral load, prognosis and treatment. In summary, the highest worldwide syphilis prevalence to date found in the present study indicates multiple preventable causes, which may profoundly impact homeless persons' health and wellbeing. More critical, strongly associating syphilis to homeless vulnerability and lack of preventive measures and treatment. Further studies should be conducted to fully establish risk factors for sexually transmitted infections exposure in homeless people.

Conflicts of interest

The authors declare that they have no conflict of interest.
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