HIV infection, high-risk behaviors and substance use in homeless men sheltered in therapeutic communities in Central Brazil

Saúde dos indivíduos em situação de rua

Introdução: A população em situação de rua é vulnerabilizada por diversos fatores que determinam ou condicionam sua saúde e ocasionam aumento dos índices de comorbidades clínicas, entre elas as doenças mentais, crônicas e infectocontagiosas. A marginalização dos indivíduos que se encontram em situação de rua abre uma lacuna na assistência em saúde que, por vezes, é suprida por organizações sem fins lucrativos que exercem um papel social elementar. Objetivo: Mapear o perfil clínico da população em situação de rua de Curitiba (PR) atendida por iniciativa voluntária no período de um ano. Métodos: Trata-se de um estudo observacional descritivo de base documental realizado com fichas clínicas dos 509 pacientes maiores de 18 anos e que tiveram seu primeiro atendimento médico realizado pela Associação Médicos do Mundo, filial Curitiba (PR), no ano de 2019. Resultados: Indivíduos do sexo masculino, de etnia branca, faixa etária entre 36 e 45 anos, que cursaram o ensino fundamental e que se encontravam havia menos de um ano em situação de rua foram as condições sociodemográficas predominantes. As principais queixas motivadoras da procura pelo atendimento foram dor (45,19%), lesões cutâneas (15,71%) e queixas oftalmológicas (6,68%). Parte dos indivíduos mostrou acometimento crônico por hipertensão arterial sistêmica (9,03%), HIV/AIDS (3,53%) e diabetes mellitus (3,53%). Também foi identificada quantidade significativa de relatos de histórico de traumas físicos (59%). Encontrou-se correlação estatística entre hipertensão e medicamentos de uso contínuo (p=0,001). Menos que 10% dos indivíduos procuraram atendimento médico por queixas de saúde mental. Das mulheres que fizerem parte do estudo, 70% relataram fazer uso de substâncias e aproximadamente metade delas, uso regular de medicamentos. Já o uso de anticoncepcionais foi relatado por uma minoria delas (18,57%). Conclusões: As queixas de dor, as lesões cutâneas e as demandas oftalmológicas foram os principais motivadores da procura por ajuda médica pela população em situação de rua, além da prevalência de hipertensão arterial sistêmica como doença crônica. Os achados podem auxiliar e direcionar ações em saúde voltadas para essa população marginalizada.

Human immunodeficiency virus infection and syphilis among homeless people in a large city of Central-Western Brazil: prevalence, risk factors, human immunodeficiency virus-1 genetic diversity, and drug resistance mutations

Homeless people are at high risk for sexually transmitted infections (STIs), such as human immunodeficiency virus (HIV) infection and syphilis. We investigated the epidemiology of HIV-1 infection and syphilis among homeless individuals in a large city in Central-Western Brazil. In this cross-sectional study, we interviewed and tested 355 individuals from September 2014 to August 2015. Rapid test samples positive for syphilis were retested using the Venereal Disease Research Laboratory (VDRL) test. Blood samples from HIV-infected participants were collected for POL sequencing using HIV-1 RNA extracted from plasma, reverse transcription, and nested polymerase chain reaction. Anti-HIV-1-positive samples were subtyped by sequencing the nucleotides of HIV-1 protease and part of the HIV-1 reverse transcriptase genes. Transmitted and acquired drug resistance mutations and susceptibility to antiretroviral drugs were also analyzed. Anti-HIV was positive in 14 patients (3.9%; 95% confidence interval [CI]: 2.3–6.4). HIV-1 RNA was detected in 8 of the 14 samples. Two of the eight (25%) isolates showed HIV-1 drug resistance mutations. Furthermore, 78 (22%; 95% CI: 17.9–26.5) and 29 (8.2%; 95% CI: 5.6–11.4) homeless individuals tested positive for syphilis using the rapid test and VDRL test, respectively. Two individuals were anti-HIV-1 and VDRL test positive. Daily alcohol use (adjusted odds ratio [AOR]: 3.2, 95% CI: 1.0–10.4), sex with people living with HIV (PLWH) infection (AOR: 6.8, 95% CI: 1.9–25.0), and sex with people of the same sex (AOR: 5.4, 95% CI: 1.7–17.5) were predictors of HIV infection. Age ≤35 years (AOR: 3.8, 95% CI: 1.4–10.8), previous syphilis testing (AOR: 3.5, 95% CI: 1.4–8.4), history of genital lesions (AOR: 4.9, 95% CI: 1.3–19.1), and crack use in the last six months (AOR: 3.1, 95% CI: 1.3–7.6) were predictors of syphilis. Our findings highlight the importance of STI prevention and control strategies among the homeless.

How does hard-to-reach status affect antiretroviral therapy adherence in the HIV-infected population? Results from a meta-analysis of observational studies

Background

Socially disadvantaged groups, such as drug users, sex workers and homeless individuals, are labelled as “hard-to-reach” (HTR) in public health and medical research. HIV disproportionately impacts these populations, but data on how the HTR status could affect antiretroviral therapy (ART) adherence among HIV-positive people are limited and have not been previously synthesized in a systematic manner. We performed a meta-analysis to explore the association between HTR status and optimal antiretroviral therapy adherence in the HIV-infected population to provide evidence and recommendations regarding ART adherence improvement and HIV infection control and prevention among HTR people.

Methods

The PubMed, EMBASE, and Cochrance Library databases and the bibliographies of relevant studies were systematically searched up to December 2018. Full-text studies published in English were included, and no geographic or race restrictions were applied. Studies that quantitatively assessed the association between HTR status and optimal ART adherence among HIV-infected populations with a status of homelessness, sex work, or drug use were eligible for inclusion. We estimated the pooled odds ratios (ORs) of HTR characteristics related to ART adherence from each eligible study using a random effects model. The sensitivity, heterogeneity and publication bias were assessed.

Results

Our search identified 593 articles, of which 29 studies were eligible and included in this meta-analysis. The studies were carried out between 1993 and 2017 and reported between 1999 and 2018. The results showed that HTR status resulted in a 45% reduction in the odds of achieving optimal ART adherence compared to odds in the general population (OR = 0.55, 95% confidential intervals (CIs) 0.49–0.62), and this significant inverse association was consistently found regardless of study design, exposure measurement, adherence cut-off points, etc. Subgroup analyses revealed that the HTRs tend to be suboptimal adhering during a longer observational period.

Conclusions

HIV treatment adherence is extremely negatively affected by HTR status. It is crucial to develop appropriate interventions to improve ART adherence and health outcomes among HTR people who are HIV-infected.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7135-0) contains supplementary material, which is available to authorized users.