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Vol. 25. Issue 4.
(July - August 2021)
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Vol. 25. Issue 4.
(July - August 2021)
Original Article
Open Access
Serosurvey of anti-treponema pallidum (syphilis), anti-hepatitis C virus and anti-HIV antibodies in homeless persons of São Paulo city, southeastern Brazil
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Laís Giuliani Felipettoa, Pedro Irineu Teider-Juniora, Felipe Fortino Verdan da Silvab, Anahi Chechia do Coutoc, Louise Bach Kmetiukc, Camila Marinelli Martinsd, Leila Sabrina Ullmanne, Jorge Timenetskyf, Andrea Pires dos Santosg, Alexander Welker Biondoa,c,h,
Corresponding author
abiondo@ufpr.br

Corresponding author at: Federal University of Paraná, Department of Veterinary Medicine, College of Veterinary Science, Curitiba, PR, Brazil.
a Federal University of Paraná, Department of Veterinary Medicine, College of Veterinary Science, Curitiba, PR, Brazil
b Federal University of Paraná, Clinics Hospital, Clinical Analysis Laboratory Unit, Curitiba, PR, Brazil
c Federal University of Paraná, Department of Cellular and Molecular Biology, College of Cellular and Molecular Biology, Curitiba, PR, Brazil
d State University of Ponta Grossa, Department of Nursing and Public Health, Ponta Grossa, PR, Brazil
e São Paulo State University, Institute of Biotechnology, Botucatu, São Paulo, Brazil
f University of São Paulo, Department of Medical Microbiology, São Paulo, Brazil
g Purdue University, Department of Comparative Pathobiology, West Lafayette, IN, USA
h Federal University of Paraná, Department of Veterinary Medicine, Curitiba, PR, Brazil
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Tables (2)
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.
Table 2. Results of anti-Treponema pallidum, anti-HCV and anti-HIV antibodies in homeless people of São Paulo city, Brazil.
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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.

Keywords:
Homeless
Syphilis
HCV
HIV
Vulnerability
Full Text
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.1,2

Similarly, other infectious diseases frequently occur in this population.3,4 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.5,6

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.7,8 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).9 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.10 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.11 Reagent results may represent early syphilis in recent infection or untreated late syphilis, also in activity.11

Statistical analysis was performed using SPSS 20.0.12 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.

VariablesSyphilisHCV
Positive/N  OR (CI 95%)  p-value  Positive/N  OR (CI 95%)  p-value 
SexMale  24/103  23.3  0.49 (0.4–1.62)  0.234  3/103  2.9  0.38 (0.04–3.39)  0.383 
Female  5/13  38.5  (ref)    1/13  7.7  (ref)   
PregnancyYes  1/2  50.0  3.07 (0.19–50.73)  0.410  0/2  0.0  *  0.932 
No  28/114  24.6  (ref)    4/114  3.5  (ref)   
Marital StatusUnmarried  25/105  23.8  0.55 (0.15–2.02)  0.360  4/105  3.8  *  0.668 
Accompanied  4/11  36.4  (ref)    0/11  0.0  (ref)   
Racial self-declarationWhite  6/27  22.2  0.82 (0.29–2.28)  0.704  0/27  0.0  *  0.572 
Non-white  23/89  25.8  (ref)    4/89  4.5  (ref)   
Educational backgroundNone to 8th grade  20/77  26.0  1.09 (0.44–2.71)  0.850  4/77  5.2  *  0.302 
High school and university  9/37  24.3  (ref)    0/37  0.0  (ref)   
IncomeNo income  26/97  26.8  2.93 (0.63–13.63)  0.154  2/97  2.1  0.19 (0.03-1.23)  0.115 
With income  2/18  11.1  (ref)    2/18  11.1  (ref)   
Assistance by Psychosocial Care Centers (CAPS)Yes  4/29  13.8  0.39 (0.12–1,26)  0.108  2/29  6.9  3.00 (0.44-20.35)  0.260 
No  25/87  28.7  (ref)    2/87  2.3  (ref)   
Use of licit and/or illicit drugsYes  22/87  25.3  1.06 (0.40–2.83)  0.901  3/87  3.4  1.00 (0.11-9.24)  0.740 
No  7/29  24.1  (ref)    1/29  3.4  (ref)   
Alcohol consumption  Yes  16/62  25.8  1.09 (0.47–2.55)  0.830  2/62  3.2  0.87 (0.13–5.97)  0.637 
Tobacco use  Yes  8/32  25.0  1.00 (0.39–2.56)  1.000  2/32  6.2  0.96 (0.10–8.84)  0.725 
Cocaine use  Yes  4/31  12.9  0.36 (0.11–1.12)  0.069  1/30  3.3  2.62 (0.39–17.85)  0.305 
Marijuana use  Yes  6/30  20.0  0.68 (0.25–1.89)  0.463  0/31  0.0  *  0.283 
Crack use  Yes  3/14  21.4  0.79 (0.08–6.91)  0.742  0/14  0.0  *  0.593 
Other drugs  Yes  1/5  20.0  0.74 (0.08–6.91)  0.792  0/5  0.0  *  0.836 
City of originOthers  25/80  31.3  3.52 (1.12–11.05)  0.043  4/80  5.0  *  0.394 
São Paulo  4/35  11.4  (ref)    0/35  0.0  (ref)   
Shelter typeHostel  14/64  21.9  0.69 (0.29–1.60)  0.389  4/64  6.2  *  0.089 
Street  9/28  32.1  1.61 (0.63–4.11)  0.316  0/30  0.0  *  0.326 
Causes for becoming homeless 
Family conflictsYes  6/47  12.8  (ref)  0.035  1/64  1.6  0.23 (0.02–2.31)  0.213 
No  19/64  29.7  2.88 (1.05–7.93)    3/47  6.4  (ref)   
UnemploymentYes  8/33  24.2  1.15 (0.44–3.00)  0.778  1/33  3.0  0.79 (0.08–7.30)  0.657 
No  17/78  21.8  (ref)    3/78  3.8  (ref)   
Alcohol and drugsYes  5/26  19.2  0.77 (0.26–2.32)  0.646  2/26  7.7  3.27 (0.48–22.08)  0.233 
No  20/85  23.5  (ref)    2/85  2.4  (ref)   
Another motiveYes  5/18  27.8  1.40 (0.45–4.41)  0.560  1/18  5.6  1.72 (0.19–15.64)  0.512 
No  20/93  21.5  (ref)    3/93  3.2  (ref)   
Housing lossYes  4/12  33.3  1.86 (0.51–6.77)  0.342  0/12  0.0  *  0.629 
No  21/99  21.2  (ref)    4/99  4.0  (ref)   

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 ID  SyphilisCMIA  SyphilisVDRL  SyphilisTreponemalRapid Test  HCVCMIA  HIVCMIA  HIV imunoblot 
SP01  seronegative      seronegative  seronegative  seronegative 
SP02  seronegative      seronegative  seronegative  seronegative 
SP03  17.86  1:2    seronegative  seronegative  seronegative 
SP04  seronegative      seronegative  seronegative  seronegative 
SP05  seronegative      seronegative  seronegative  seronegative 
SP06  13.72  1:1    seronegative  seronegative  seronegative 
SP08  seronegative      seronegative  seronegative  seronegative 
SP11  seronegative      seronegative  seronegative  seronegative 
SP13  15.23  1:4    seronegative  seronegative  seronegative 
SP14  seronegative      seronegative  seronegative  seronegative 
SP16  seronegative      seronegative  seronegative  seronegative 
SP17  seronegative      seronegative  seronegative  seronegative 
SP18  seronegative      seronegative  seronegative  seronegative 
SP19  seronegative      seronegative  seronegative  seronegative 
SP20  seronegative      seronegative  seronegative  seronegative 
SP21  seronegative      seronegative  seronegative  seronegative 
SP23  10.23  1:2    seronegative  seronegative  seronegative 
SP24  seronegative      seronegative  seronegative  seronegative 
SP25  seronegative      seronegative  seronegative  seronegative 
SP26  5.19  1:1    seronegative  seronegative  seronegative 
SP27  13.91  1:1    seronegative  692.63  HIV-1 
SP28  seronegative      seronegative  seronegative  seronegative 
SP29  15.88  1:1    seronegative  seronegative  seronegative 
SP30  seronegative      seronegative  seronegative  seronegative 
SP31  seronegative      seronegative  seronegative  seronegative 
SP32  seronegative      seronegative  seronegative  seronegative 
SP33  seronegative      seronegative  seronegative  seronegative 
SP34  16.87  1:2    seronegative  seronegative  seronegative 
SP35  seronegative      seronegative  seronegative  seronegative 
SP36  seronegative      seronegative  seronegative  seronegative 
SP37  1.57  NR  seropositive  seronegative  seronegative  seronegative 
SP38  20.01  1:128    seronegative  seronegative  seronegative 
SP39  seronegative      seronegative  seronegative  seronegative 
SP40  seronegative      seronegative  seronegative  seronegative 
SP41  20.09  1:128    seronegative  seronegative  seronegative 
SP42  seronegative      seronegative  seronegative  seronegative 
SP43  seronegative      seronegative  seronegative  seronegative 
SP44  seronegative      seronegative  seronegative  seronegative 
SP45  seronegative      seronegative  seronegative  seronegative 
SP46  seronegative      seronegative  seronegative  seronegative 
SP47  seronegative      seronegative  seronegative  seronegative 
SP48  seronegative      seronegative  seronegative  seronegative 
SP49  seronegative      seronegative  seronegative  seronegative 
SP50  seronegative      seronegative  seronegative  seronegative 
SP51  4.1  NR  seropositive  seronegative  seronegative  seronegative 
SP52  seronegative      seronegative  seronegative  seronegative 
SP53  seronegative      seronegative  seronegative  seronegative 
SP54  seronegative      seronegative  0.91  seronegative 
SP55  seronegative      seronegative  seronegative  seronegative 
SP56  17.94      seronegative  seronegative  seronegative 
SP57  seronegative      seronegative  seronegative  seronegative 
SP58  seronegative      seronegative  seronegative  seronegative 
SP59  seronegative      seronegative  seronegative  seronegative 
SP60  seronegative      seronegative  seronegative  seronegative 
SP61  seronegative      seronegative  seronegative  seronegative 
SP62  seronegative      seronegative  seronegative  seronegative 
SP63  seronegative      seronegative  seronegative  seronegative 
SP64  seronegative      seronegative  seronegative  seronegative 
SP65  seronegative      seronegative  seronegative  seronegative 
SP66  seronegative      seronegative  seronegative  seronegative 
SP67  13.76  1:1    seronegative  seronegative  seronegative 
SP68  seronegative      seronegative  seronegative  seronegative 
SP69  seronegative      seronegative  seronegative  seronegative 
SP70  seronegative      seronegative  seronegative  seronegative 
SP71  12.68  1:.1    seronegative  seronegative  seronegative 
SP72  seronegative      seronegative  seronegative  seronegative 
SP73  seronegative      seronegative  seronegative  seronegative 
SP74  15.78  1:4    seronegative  seronegative  seronegative 
SP75  seronegative      seronegative  seronegative  seronegative 
SP76  seronegative      seronegative  seronegative  seronegative 
SP77  seronegative      seronegative  seronegative  seronegative 
SP78  seronegative      seronegative  seronegative  seronegative 
SP79  2.33  NR  seropositive  1.25  seronegative  seronegative 
SP80  seronegative      seronegative  seronegative  seronegative 
SP81  seronegative      seronegative  seronegative  seronegative 
SP82  seronegative      seronegative  seronegative  seronegative 
SP83  seronegative      seronegative  seronegative  seronegative 
SP84  seronegative      seronegative  seronegative  seronegative 
SP85  2.52  NR  seronegative  seronegative  seronegative  seronegative 
SP86  15.89  1:32    seronegative  seronegative  seronegative 
SP87  seronegative      seronegative  seronegative  seronegative 
SP88  seronegative      seronegative  seronegative  seronegative 
SP89  19.89  1:256    seronegative  seronegative  seronegative 
SP90  9.21  NR  seropositive  seronegative  seronegative  seronegative 
SP91  20.01  1:8    seronegative  1.35  seronegative 
SP92  seronegative      seronegative  seronegative  seronegative 
SP93  seronegative      seronegative  seronegative  seronegative 
SP94  seronegative      seronegative  seronegative  seronegative 
SP95  seronegative      seronegative  seronegative  seronegative 
SP96  seronegative      seronegative  seronegative  seronegative 
SP97  seronegative      seronegative  seronegative  seronegative 
SP98  14.15  1:4    seronegative  seronegative  seronegative 
SP99  seronegative      seronegative  seronegative  seronegative 
SP100  2.95  NR  seropositive  1.11  seronegative  seronegative 
SP101  seronegative      15.97  seronegative  seronegative 
SP102  seronegative      seronegative  seronegative  seronegative 
SP103  seronegative      7.66  seronegative  seronegative 
SP104  15.79  1:2    seronegative  261.79  HIV-1 
SP105  seronegative      seronegative  seronegative  seronegative 
SP106  seronegative      seronegative  seronegative  seronegative 
SP107  18.77  1:8    seronegative  seronegative  seronegative 
SP108  seronegative      seronegative  seronegative  seronegative 
SP109  seronegative      seronegative  seronegative  seronegative 
SP110  seronegative      seronegative  seronegative  seronegative 
SP111  10.65  1:2    seronegative  seronegative  seronegative 
SP112  seronegative      seronegative  seronegative  seronegative 
SP113  seronegative      seronegative  seronegative  seronegative 
SP114  seronegative      seronegative  seronegative  seronegative 
SP115  seronegative      seronegative  seronegative  seronegative 
SP 116  19.03  1:8    seronegative  seronegative  seronegative 
SP118  seronegative      seronegative  seronegative  seronegative 
SP119  seronegative      seronegative  seronegative  seronegative 
SP120  15.96  1:16    seronegative  seronegative  seronegative 
SP121  seronegative      seronegative  seronegative  seronegative 
SP122  seronegative      seronegative  seronegative  seronegative 
SP123  17.02  1:8    seronegative  seronegative  seronegative 

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,13 5/175 (2.9%) in Kenya,14 22/554 (4.0%) in India,15 to 18/132 (13.6%) in the USA.16 Additionally, syphilis was detected in 19/330 (5.7%) homeless persons in 2002-2003,17 and in 97/1,391 (7.0%) in 2006-2007,2 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,18 82/222 (36.9%) sex workers in Brazil,19 273/598 (45.6%) in Argentina 20 and 51.1% (1,010/1,978) in Rwanda,21 and 269/529 (50.8%) refugees in Italy.22

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 refugees17 and with broken or fragile family bonds,9 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.23 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.24 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.25 Not surprisingly, the Brazilian epidemic of syphilis contrasts with other Latin American countries, which have moved towards syphilis eradication.26,27 Other aspects may have also contributed to increase syphilis rates, including greater access to syphilis testing through rapid testing in primary health care services.25 The detection rate of acquired syphilis in Brazil increased from 2.1/100,000 in 2010 to 34.1/100,000 in 201528 and to 75.8 100,000 inhabitants in 2018.29

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.11 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.30

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.10 Also, anti-HCV antibodies were detected in 4/116 individuals by CMIA, as recommended by Brazilian Ministry of Health.11 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.

Acknowledgments

This research has been partially supported by the Veterinary Science Graduate Program at the Federal University of Paraná, Clinical Analysis Laboratory Unit, Clinics Hospital (UFPR), Institute of Biotechnology (UNESP), Department of Veterinary Hygiene and Public Health (UNESP), and Purdue University. The authors are thankful to Dr. Mara Lúcia Gravinatti, Dr. Gabriela Hartmann, Dr. Daniela Patricia Tozetto and the Social Center "Our Lady of Good Delivery" for helping with collection, sampling, and follow-up information.

References
[1]
A Caccamo, R Kachur, SP. Williams.
Narrative review: sexually transmitted diseases and homeless youth-what do we know about sexually transmitted disease prevalence and risk?.
Sex Transm Dis, 44 (2017), pp. 466-476
[2]
VM Pinto, MV Tancredi, HDR Alencar, et al.
Prevalence of syphilis and associated factors in homeless people of Sao Paulo, Brazil, using a Rapid Test.
Rev Bras Epidemiol, 17 (2014), pp. 341-354
[3]
S Fazel, JR Geddes, M. Kushel.
The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations.
Lancet, 384 (2014), pp. 1529-1540
[4]
LG Felipetto, PI Teider-Junior, FFV da Silva, et al.
Serosurvey of anti-toxoplasma gondii antibodies in homeless persons of São Paulo City, Southeastern Brazil.
Front Public Health, 8 (2020),
[5]
Estimativa da população em situação de rua no Brasil (setembro de 2012 a março de 2020).
[6]
Pesquisa censitária da população em situação de rua, caracterização socioeconômica da população adulta em situação de rua e relatório temático de identificação das necessidades desta população na cidade de São Paulo –2019.
[7]
RH Westbrook, G. Dusheiko.
Natural history of hepatitis C.
J Hepatol, 61 (2014), pp. S58-S68
[8]
J Lopez-Zetina, W Ford, M Weber, et al.
Predictors of syphilis seroreactivity and prevalence of HIV among street recruited injection drug users in Los Angeles County, 1994–6.
Sex Transm Infect, 76 (2020), pp. 462-469
[9]
HC Paula, RDV Dahe, FF Koopmans, et al.
Implementation of the Street Outreach Office in the perspective of health care.
Rev Bras Enferm, 71 (2018), pp. 2843-2847
[10]
Manual técnico para o diagnóstico da infecção pelo HIV em adultos e crianças.
[11]
Protocolo Clínico e Diretrizes Terapêuticas, IST, Assistência e Tratamento, Saúde da Pessoa Vivendo, Medicamentos, Profissionais de Saúde IST. Available from: http://www.aids.gov.br/pt-br/pub/2015/protocolo-clinico-e-diretrizes-terapeuticas-para-atencao-integral-pessoas-com-infeccoes
[12]
IBM Corp. Released in 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp
[13]
F Jahanbakhsh, Amiri F Bagheri, A Sedaghat, et al.
Prevalence of HAV Ab, HEV (IgG), HSV2 IgG, and syphilis among sheltered homeless adults in Tehran, 2012.
Int J Health Policy Manag, 7 (2018), pp. 225-230
[14]
SE Winston, AK Chirchir, LN Muthoni, et al.
Prevalence of sexually transmitted infections including HIV in street-connected adolescents in western Kenya.
Sex Transm Infect, 91 (2015), pp. 353-359
[15]
B Bal, R Mitra, AH Mallick, et al.
Nontobacco substance use, sexual abuse, HIV, and sexually transmitted infection among street children in Kolkata, India.
Subst Use Misuse, 45 (2010), pp. 1668-1682
[16]
A Rosenblum, L Nuttbrock, HL McQuistion, et al.
Hepatitis C and substance use in a sample of homeless people in New York City.
J Addict Dis, 20 (2001), pp. 15-25
[17]
VOC Brito, D Parra, R Facchini, et al.
Infecção pelo HIV, hepatites B e C e sífilis em moradores de rua, São Paulo.
Rev Saúde Pública, 41 (2007), pp. 47-56
[18]
Y Kebede, J Pickering, JC McDonald, et al.
HIV infection in an Ethiopian prison.
Am J Public Health, 81 (1991), pp. 625-627
[19]
NDS Cavalcante, HRR Lima, DF Tabosa, et al.
Syphilis in female sex workers: an epidemiological study of the highway system of the state of Pará, northern Brazil.
Rev Soc Bras Med Trop, 52 (2019),
[20]
MA Pando, C Berini, M Fernández, et al.
Prevalence of HIV and other sexually transmitted infections among female commercial sex workers in Argentina.
Am J Trop Med Hyg, 74 (2006), pp. 233-238
[21]
M Mutagoma, L Nyirazinyoye, D Sebuhoro, et al.
Syphilis and HIV prevalence and associated factors to their co-infection, hepatitis B and hepatitis C viruses prevalence among female sex workers in Rwanda.
BMC Infect Dis, 17 (2017), pp. 525
[22]
S Tafuri, R Prato, D Martinelli, M de Palma, M Quarto, C. Germinario.
Prevalence of Hepatitis B, C, HIV and syphilis markers among refugees in Bari, Italy.
BMC Infect Dis, 20 (2010), pp. 213
[23]
X Pan, Y Zhu, Q Wang, et al.
Prevalence of HIV, Syphilis, HCV and their high risk behaviors among migrant workers in Eastern China.
[24]
Y Xiao, SL Li, HL Lin, et al.
Factors associated with syphilis infection: a comprehensive analysis based on a case-control study.
Epidemiol Infect, 144 (2015), pp. 1165-1174
[25]
S Nurse-Findlay, MM Taylor, M Savage, et al.
Shortages of benzathine penicillin for prevention of mother-to-child transmission of syphilis: an evaluation from multi-country surveys and stakeholder interviews.
[26]
DSM Marques, AKB Lopes, AG Roncalli, et al.
Trends of syphilis in Brazil: a growth portrait of the treponemic epidemic.
[27]
MF Silveira, Pde LR Gomez, F Becerra, et al.
Evolution towards the elimination of congenital syphilis in Latin America and the Caribbean: a multicountry analysis.
Rev Panam Salud Pública, 43 (2019), pp. e31
[28]
Ministry of Health.
Secretariat of health surveillance.
[29]
Ministry of Health.
Secretariat of health surveillance.
[30]
C Zhou, X Zhang, W Zhang, J Duan, F. Zhao.
PCR detection for syphilis diagnosis: status and prospects.
J Clin Lab Anal, 33 (2019), pp. e22890
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The Brazilian Journal of Infectious Diseases

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