ABSTRACT

OBJECTIVE

Analyze, systematize, and compile social, individual, and programmatic vulnerability factors associated with tuberculosis and HIV in homeless persons.

METHODS

This is a systematic literature review assessing quantitative studies, published between 2014 and 2020, on the prevalence of tuberculosis in homeless persons. Our review grouped studies according to vulnerabilities, followed the PRISMA recommendation guide, and used the Joanna Briggs Institute Critical Appraisal tool for bias analysis.

RESULTS

Of the 372 publications found, 16 were selected according to our eligibility criteria. In total, 10 studies assessed tuberculosis and HIV. The most commonly described factors for individual, social, and programmatic vulnerability were drug use, HIV coinfection, and tuberculosis treatment failure, respectively. The literature also claims that average homelessness length related to a higher frequency of tuberculosis and latent tuberculosis infection.

CONCLUSION

All reviewed studies described how homeless persons suffer with stigma and dehumanization, which are important barriers to their access to health services. Homelessness enhances the risks of chronic and infectious diseases and prioritizes issues which are more pragmatic for the maintenance of life, such as safety and food, to the detriment of health. The results can be used to support hypotheses for future research and to reinforce and direct existing public health and social policies to cope with tuberculosis and HIV in homeless persons.

Homeless Persons; Tuberculosis; HIV Infections; Coinfection, epidemiology; Health Vulnerability; Social Vulnerability

INTRODUCTION

Tuberculosis is a respiratory disease caused by the agent Mycobacterium tuberculosis . It is currently among the 10 most lethal diseases in the world and the first, among infectious diseases¹1 World Health Organization. Global tuberculosis report 2020: executive summary. Geneva (CH): WHO; 2020. . Its transmission occurs by inhalation of aerosols leading to a granulomatous infection in the lower respiratory tract²2 Quinn PJ, Markey BK, Carter ME, Donnelly WJ, Leonard F. Microbiologia veterinária e doenças infecciosas. Vol. 5. Porto Alegre, RS: Artmed; 2005. . Its occurrence is associated with socioeconomic factors since, according to the UN, 95% of cases occur in low- and middle-income countries³3 Nações Unidas. ONU quer acabar com epidemia de tuberculose até 2030. ONU News. 24 mar 2016 [cited 2018 Nov 10]. Available from: https://news.un.org/pt/story/2016/03/1545481-onu-quer-acabar-com-epidemia-de-tuberculose-ate-2030
https://news.un.org/pt/story/2016/03/154... . Africa and the Americas¹1 World Health Organization. Global tuberculosis report 2020: executive summary. Geneva (CH): WHO; 2020. are at the top of the ranking of estimated cases and deaths for the disease.

The global estimate of tuberculosis infection was 10 million cases in 2020, with an estimated incidence of 132/100,000 inhabitants, and 1.2 million deaths, of which 208,000 among people who are HIV+¹1 World Health Organization. Global tuberculosis report 2020: executive summary. Geneva (CH): WHO; 2020. . The END TB strategy, proposed by the World Health Organization, aims to reduce the incidence of tuberculosis to less than 10/100,000 inhabitants and decrease the number of deaths by at least 95% so tuberculosis could no longer be considered a global public health problem⁴4 Ministério da Saúde (BR), Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Departamento de Ciência e Tecnologia. Adesão ao tratamento de tuberculose pela população em situação de rua. Brasília, DF; 2016. .

In Brazil, tuberculosis is an important health problem, with a death rate of 2.2/100,000 and an incidence of 31.6/100,000 inhabitants⁵5 Ministério da Saúde (BR), Secretaria de Vigilância em Saúde. Tuberculose. 2021. Bol Epidemiológico. Número Especial. Brasília, DF; 2021 [cited 2021 Jun 3]. Available from: https://www.gov.br/saude/pt-br/media/pdf/2021/marco/24/boletim-tuberculose-2021_24.03
https://www.gov.br/saude/pt-br/media/pdf... . The Sistema Único de Saúde ( SUS - Brazilian Unified Health System ) promotes specific programs to combat it, such as the Programa Nacional de Controle da Tuberculose (National Tuberculosis Control Program) and the establishment of treatment directly managed by the basic health network⁶6 Presidência da República (BR), Casa Civil, Subchefia para Assuntos Jurídicos. Emenda Constitucional Nº 95, de 15 de dezembro de 2016. Altera o Ato das Disposições Constitucionais Transitórias, para instituir o Novo Regime Fiscal, e dá outras providências. Brasília, DF; 2016. . However, patient adherence is low⁷7 Rabahi MF, Silva Júnior JLR, Ferreira ACG, Tannus-Silva DGS, Conde MB. al. Tratamento da tuberculose. J Bras Pneumol. 2017;43(6):472-86. https://doi.org/10.1590/S1806-37562016000000388
https://doi.org/10.1590/S1806-3756201600... , and treatment abandonment and wrong or intermittent medication administration cause the number of deaths to remain high and the emergence of drug-resistant strands⁷7 Rabahi MF, Silva Júnior JLR, Ferreira ACG, Tannus-Silva DGS, Conde MB. al. Tratamento da tuberculose. J Bras Pneumol. 2017;43(6):472-86. https://doi.org/10.1590/S1806-37562016000000388
https://doi.org/10.1590/S1806-3756201600... .

Homeless persons (HP) are constantly exposed to different types of vulnerable and degrading living conditions, increasing the challenge for health care and requiring specific interventions for these people⁴4 Ministério da Saúde (BR), Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Departamento de Ciência e Tecnologia. Adesão ao tratamento de tuberculose pela população em situação de rua. Brasília, DF; 2016. , ⁸8 Carmo ME, Guizardi FL. O conceito de vulnerabilidade e seus sentidos para as políticas públicas de saúde e assistência social. Cad Saude Publica. 2018;34(3):e00101417. https://doi.org/10.1590/0102-311X00101417
https://doi.org/10.1590/0102-311X0010141... . As a result of this exposure and the precarization of their lives, tuberculosis in HP is very frequent. This population is 56 times more likely to be affected by this disease in Brazil.

This vulnerabilization has three dimensions⁹9 Ayres JRCM, Paiva V, França Jr I, Gravato N, Lacerda R, Della Negra M, et al. Vulnerability human rights, and comprehensive health care needs of young people living with HIV/AIDS. Am J Public Health. 2006;96(6):1001-6. https://doi.org/10.2105/AJPH.2004.060905
https://doi.org/10.2105/AJPH.2004.060905... : 1) Individual – determined by individuals’ access to information; their ability to put it into practice; and material, cultural, cognitive, and moral aspects – among many others participating in the construction of the human “being”; 2) Social – guided by social and cultural contexts and 3) programmatic – scenarios concerning social institutions (especially health, education, culture, and social assistance) which enable unfavorable contexts to increase these social conditions.

Treating tuberculosis in HP is more expensive and complex than in the rest of the population due to their lower treatment adherence, according to the Evidence Informed Policy Network of the Brazilian Ministry of Health⁴4 Ministério da Saúde (BR), Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Departamento de Ciência e Tecnologia. Adesão ao tratamento de tuberculose pela população em situação de rua. Brasília, DF; 2016. . Moreover, issues such as safety, food, and rest, compete in importance with health care. In addition to tuberculosis, HIV/Aids, dermatological diseases (including leprosy), and hypertension are the main diseases in this population. Psychosocial treatment due to drug and alcohol abuse is also prominent¹⁰10 Governo Federal (BR). Política Nacional para Inclusão Social da População em Situação de Rua. Brasília, DF; 2008 [cited 2018 Nov 10]. Available from: https://www.justica.pr.gov.br/sites/default/arquivos_restritos/files/documento/2019-08/pol.nacional-morad.rua_.pdf
https://www.justica.pr.gov.br/sites/defa... . Homeless persons live marginalized and distant from public policies and lack the effective exercise of their basic rights, including access to medical primary care in SUS¹¹11 Cunha JVQ, Rodrigues M, organizadores. Rua: aprendendo a contar. Pesquisa Nacional sobre População em Situação de Rua. Brasília, DF: Ministério do Desenvolvimento Social e Combate à Fome; 2009. .

Worldwide, tuberculosis is the leading cause of death in HIV-positive individuals, accounting for one third of their deaths¹²12 UNAIDS. Estatísticas Globais sobre HIV 2020. Brasília, DF: UNAIDS Brasil; 2020 2008 [cited 2021 Jun 8]. Available from: https://unaids.org.br/estatisticas/
https://unaids.org.br/estatisticas/... . People with HIV are 28 times more likely to become infected with tuberculosis¹³13 Ministério da Saúde (BR). Brasil Livre da Tuberculose: evolução dos cenários epidemiológicos e operacionais da doença. Bol Epidemiol. 2019 [cited 2020 Aug 10];50(9):18. Available from: http://portalarquivos2.saude.gov.br/images/pdf/2019/marco/22/2019-009.pdf
http://portalarquivos2.saude.gov.br/imag... , a coinfection responsible for almost 29% of deaths from tuberculosis in Brazil¹⁴14 Santos ML, Coeli CM, Batista JDL, Braga MC, Albuquerque MFPM. Factors associated with underreporting of tuberculosis based on data from Sinan Aids and Sinan TB. Rev Bras Epidemiol. 2018;21:e180019. https://doi.org/10.1590/1980-549720180019
https://doi.org/10.1590/1980-54972018001... . In 2018, he incidence of tuberculosis in HIV-positive patients was 5.2/100,000 inhabitants in Brazil. In the same year, of the new cases of tuberculosis, 75.5% were tested for HIV and, among the affected, only 47.4% underwent antiretroviral treatment concomitantly with tuberculosis treatment¹⁵15 Ministério da Saúde (BR). Panorama epidemiológico da coinfecção TB-HIV no Brasil 2019. Bol Epidemiol TB-HIV. 2019 [cited 2021 Jun 3];50(26):23. Available from: http://www.aids.gov.br/pt-br/pub/2019/boletim-epidemiologico-tb-hiv-2019
http://www.aids.gov.br/pt-br/pub/2019/bo... .

Due to the technological advances in tuberculosis and HIV/Aids treatment and the commitments made by World Health Organization member countries, this scenario is problematic and challenging since these diseases are historically important¹⁶16 Monteiro D. Tuberculose: pesquisas e melhorias no tratamento intensificam o combate à doença. Rio de Janeiro: Agência Fiocruz de Notícias; 2013 [cited 2021 Jun 8]. Available from: https://agencia.fiocruz.br/tuberculose-pesquisas-e-melhorias-no-tratamento-intensificam-o-combate-a-doenca
https://agencia.fiocruz.br/tuberculose-p... . Fostering knowledge and debate on the tuberculosis epidemic, which is related to social, individual, and programmatic vulnerability in homeless persons, is fundamental to cope with these diseases in Brazil, especially due to the current covid-19 epidemic, in which healthcare struggles to meet different demands. This study aimed to analyze, systematize, and compile the individual, social, and programmatic vulnerability factors associated with tuberculosis and tuberculosis+HIV collected from studies on these illnesses in homeless persons which were conducted between 2014 and 2020.

METHODS

A systematic literature review was conducted with studies, published from 2014 to 2020, assessing tuberculosis and tuberculosis+HIV in homeless persons. A systematic review is a research method which, in health, consists of seeking and selecting, evaluating, compiling, and showing the published evidence on an important topic and its impact on populations’ health. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Prisma) criteria were applied.

Survey Strategy

References were surveyed by the descriptors Tuberculosis, Homeless Persons, HIV, Social Vulnerability, and Health Vulnerability (and their combinations) in the PubMed and Latin American and Caribbean Health Sciences Literature (Lilacs) platforms, as shown in Table 1 . Articles were analyzed by two researchers at two different moments and the results, compiled.

Eligibility Criteria

Analyses included studies with a quantitative design, written in English, Spanish, and Portuguese and published from 2014 to 2020, which assessed tuberculosis, tuberculosis+HIV, and the vulnerability factors associated with these illnesses.

Bias Analysis

Bias in the evaluated studies was assessed in pairs, using the Joanna Briggs Institute Critical Appraisal (JBI – Systematic Reviews tools). JBI is composed of questions assessing the methodological quality of a study according to its design. Cross-sectional studies were evaluated with the JBI Critical Appraisal Checklist for Analytical Cross Sectional Studies with the following questions: (i) clearly defined inclusion and exclusion criteria; (ii) theme and method described in detail; (iii) appropriately measured exposures; (iv) objective and standardized definition criteria to determine the condition studied; (v) confounding factor identification; (vi) strategies to deal with confounding factors; (vii) adequately measured outcomes; and (viii) appropriate statistical analyses¹⁸18 Moola S, Munn Z, Tufanaru C, Aromataris &, Sears K, Sfetcu R, Currie M, Qureshi R, Mattis P, Lisy K, Mu P-F. Systematic reviews of etiology and risk . In: Aromataris E, Munn Z, editors. Joanna Briggs Institute Reviewer’s Manual. Adelaide (AU): The Joanna Briggs Institute; 2017 [cited 2018 Nov 12]. Chapter 7. Available from: https://reviewersmanual.joannabriggs.org/
https://reviewersmanual.joannabriggs.org... . To analyze cohort studies, 11 questions of the JBI Critical Appraisal Checklist for Analytical Cohort Studies were used: (i) both groups recruited from the same population; (ii) exposures similarly measured to identify exposed and unexposed groups; (iii) appropriately measured exposures; (iv) confounding factor identification; (v) strategies for dealing with confounding factors; (vi) participants free of outcomes at baseline; (vii) appropriately measured outcomes; (viii) sufficient time to study outcome occurrence; (ix) complete follow-ups/if not, described and explored reasons for it; (x) strategies to deal with incomplete follow-ups; and (xi) appropriate statistical analyses¹⁹19 Moola S, Munn Z, Tufanaru C, Aromataris E, Sears K, Sfetcu R, et al. Systematic reviews of etiology and risk. In: Aromataris E, Munn Z, editors. JBI manual for evidence synthesis. Adelaide (AU): Joanna Briggs Institute; 2020 [cited 2021 Mar 1]. Chapter 7. Available from: https://jbi-global-wiki.refined.site/space/MANUAL/3283910762/Chapter+7%3A+Systematic+reviews+of+etiology+and+risk
https://jbi-global-wiki.refined.site/spa... . Ecological studies were evaluated by the JBI Critical Appraisal Checklist for Analytical Cross Sectional Studies, modified according to criteria in Dufault and Klar²⁰20 Dufault B, Klar N. The quality of modern cross-sectional ecologic studies: a bibliometric review. Am J Epidemiol. 2011;174(10):1101-7. https://doi.org/10.1093/aje/kwr241
https://doi.org/10.1093/aje/kwr241... for the methodological evaluation of this type of study design, with the following questions: (i) explained chosen design and sample size; (ii) clearly defined inclusion and exclusion criteria; (iii) theme and method described in detail; (iv) objective and standardized definition criteria to determine the condition studied; (v) appropriately measured exposures; (vi) confounding factor identification; (vii) strategies to deal with confounding factors; (viii) appropriately measured outcomes; (ix) efforts to reduce the possibility of bias; (x) appropriate statistical analyses; (xi) strategies to deal with incomplete follow-ups; and (xii) highlighted limitations¹⁸18 Moola S, Munn Z, Tufanaru C, Aromataris &, Sears K, Sfetcu R, Currie M, Qureshi R, Mattis P, Lisy K, Mu P-F. Systematic reviews of etiology and risk . In: Aromataris E, Munn Z, editors. Joanna Briggs Institute Reviewer’s Manual. Adelaide (AU): The Joanna Briggs Institute; 2017 [cited 2018 Nov 12]. Chapter 7. Available from: https://reviewersmanual.joannabriggs.org/
https://reviewersmanual.joannabriggs.org... , ²⁰20 Dufault B, Klar N. The quality of modern cross-sectional ecologic studies: a bibliometric review. Am J Epidemiol. 2011;174(10):1101-7. https://doi.org/10.1093/aje/kwr241
https://doi.org/10.1093/aje/kwr241... .

RESULTS

We found 374 studies in the researched platforms, selecting 103 published within the study period and excluding two since they were official government documents for public policies, 23 for being duplicates, and nine because they were not indexed for full reading. Finally, 71 studies remained for analysis. We read their abstracts and browsed the entire articles, selecting 16 according to our eligibility criteria. Most studies were conducted in Europe (6/16), followed by Asia (3/16), North America (4/16), South America (2/16) – of which one was Brazilian, and Africa (1/16) ( Figure ). In total, seven were cross-sectional studies; eight, cohort; and one, ecological. To this, we added the average of 2.7 studies published annually in the years analyzed, with a minimum of one and a maximum of four papers published each year.

We collected our sample between June 2019 and April 2021 and all data were entered into a Microsoft Excel spreadsheet containing the authors, study population, year of publication, country of publication, and study design.

Among the selected articles, we found the following vulnerability factors for their outcomes: alcohol use²¹21 Aldridge RW, Hayward AC, Hemming S, Yates SK, Ferenando G, Possas L, et al. High prevalence of latent tuberculosis and bloodborne virus infection in a homeless population. Thorax. 2018;73(6):557-64. https://doi.org/10.1136/thoraxjnl-2016-209579
https://doi.org/10.1136/thoraxjnl-2016-2... ; smoking²¹21 Aldridge RW, Hayward AC, Hemming S, Yates SK, Ferenando G, Possas L, et al. High prevalence of latent tuberculosis and bloodborne virus infection in a homeless population. Thorax. 2018;73(6):557-64. https://doi.org/10.1136/thoraxjnl-2016-209579
https://doi.org/10.1136/thoraxjnl-2016-2... , ²²22 Semunigus T, Tessema B, Eshetie S, Moges F. Smear positive pulmonary tuberculosis and associated factors among homeless individuals in Dessie and Debre Birhan towns, Northeast Ethiopia. Ann Clin Microbiol Antimicrob. 2016;15(1):50. https://doi.org/10.1186/s12941-016-0165-x
https://doi.org/10.1186/s12941-016-0165-... , ²⁵25 Hwang YW, Lee YJ, Kong SY. Epidemiology and clinical outcomes of tuberculosis among homeless persons visiting emergency department in public hospital. Am J Emerg Med. 2018;36(1):164-6. https://doi.org/10.1016/j.ajem.2017.07.049
https://doi.org/10.1016/j.ajem.2017.07.0... , ²⁸28 Nwana N, Marks SM, Lan E, Chang AH, Holcombe M, Morris SB. Treatment of latent Mycobacterium tuberculosis infection with 12 once weekly directly-observed doses of isoniazid and rifapentine among persons experiencing homelessness. PLoS One. 2019;14(3):e0213524. https://doi.org/10.1371/journal.pone.0213524
https://doi.org/10.1371/journal.pone.021... , ²⁹29 Amiri FB, Gouya MM, Saifi M, Rohani M, Tabarsi P, Sedaghat A, et al. Vulnerability of homeless people in Tehran, Iran, to HIV, tuberculosis and viral hepatitis. PLoS One. 2014;9(6):e98742. https://doi.org/10.1371/journal.pone.0098742
https://doi.org/10.1371/journal.pone.009... ; use of illicit drugs²¹21 Aldridge RW, Hayward AC, Hemming S, Yates SK, Ferenando G, Possas L, et al. High prevalence of latent tuberculosis and bloodborne virus infection in a homeless population. Thorax. 2018;73(6):557-64. https://doi.org/10.1136/thoraxjnl-2016-209579
https://doi.org/10.1136/thoraxjnl-2016-2... , ²⁴24 Ranzani OT, Carvalho CRR, Waldman EA, Rodrigues LC. The impact of being homeless on the unsuccessful outcome of treatment of pulmonary TB in São Paulo State, Brazil. BMC Med. 2016;14:41. https://doi.org/10.1186/s12916-016-0584-8
https://doi.org/10.1186/s12916-016-0584-... , ²⁶26 Dias M, Gaio R, Sousa P, Abranches M, Gomes M, Oliveira O, et al. Tuberculosis among the homeless: should we change the strategy? Int J Tuberc Lung Dis. 2017;21(3):327-32. https://doi.org/10.5588/ijtld.16.0597
https://doi.org/10.5588/ijtld.16.0597... , such as injectable ones²¹21 Aldridge RW, Hayward AC, Hemming S, Yates SK, Ferenando G, Possas L, et al. High prevalence of latent tuberculosis and bloodborne virus infection in a homeless population. Thorax. 2018;73(6):557-64. https://doi.org/10.1136/thoraxjnl-2016-209579
https://doi.org/10.1136/thoraxjnl-2016-2... , ²⁷27 Agarwal S, Nguyen DT, Graviss EA. Homelessness and mortality among persons with tuberculosis in Texas, 2010-2017. Public Health Rep. 2019;134(6):643-50. https://doi.org/10.1177/0033354919874087
https://doi.org/10.1177/0033354919874087... - which may have caused needle sharing²⁹29 Amiri FB, Gouya MM, Saifi M, Rohani M, Tabarsi P, Sedaghat A, et al. Vulnerability of homeless people in Tehran, Iran, to HIV, tuberculosis and viral hepatitis. PLoS One. 2014;9(6):e98742. https://doi.org/10.1371/journal.pone.0098742
https://doi.org/10.1371/journal.pone.009... , ³⁰30 Powell KM, VanderEnde DS, Holland DP, Haddad MB, Yarn B, Yamin AS, et al. Outbreak of drug-resistant Mycobacterium tuberculosis among homeless people in Atlanta, Georgia, 2008-2015. Public Health Rep. 2017;132(2):231-40. https://doi.org/10.1177/0033354917694008
https://doi.org/10.1177/0033354917694008... - and methamphetamine²⁹29 Amiri FB, Gouya MM, Saifi M, Rohani M, Tabarsi P, Sedaghat A, et al. Vulnerability of homeless people in Tehran, Iran, to HIV, tuberculosis and viral hepatitis. PLoS One. 2014;9(6):e98742. https://doi.org/10.1371/journal.pone.0098742
https://doi.org/10.1371/journal.pone.009... ; history of incarceration²¹21 Aldridge RW, Hayward AC, Hemming S, Yates SK, Ferenando G, Possas L, et al. High prevalence of latent tuberculosis and bloodborne virus infection in a homeless population. Thorax. 2018;73(6):557-64. https://doi.org/10.1136/thoraxjnl-2016-209579
https://doi.org/10.1136/thoraxjnl-2016-2... , ²⁹29 Amiri FB, Gouya MM, Saifi M, Rohani M, Tabarsi P, Sedaghat A, et al. Vulnerability of homeless people in Tehran, Iran, to HIV, tuberculosis and viral hepatitis. PLoS One. 2014;9(6):e98742. https://doi.org/10.1371/journal.pone.0098742
https://doi.org/10.1371/journal.pone.009... ; immigration²⁶26 Dias M, Gaio R, Sousa P, Abranches M, Gomes M, Oliveira O, et al. Tuberculosis among the homeless: should we change the strategy? Int J Tuberc Lung Dis. 2017;21(3):327-32. https://doi.org/10.5588/ijtld.16.0597
https://doi.org/10.5588/ijtld.16.0597... , ³²32 Munn MS, Duchin JS, Kay M, Pecha M, Thibault CS, Narita M. Analysis of risk factors for tuberculous infection following exposure at a homeless shelter. Int J Tuberc Lung Dis. 2015;19(5):570-5. https://doi.org/10.5588/ijtld.14.0648
https://doi.org/10.5588/ijtld.14.0648... , ³³33 Streit F, Bartels C, Kuczius T, Cassier C, Gardemann J, Schaumburg F. Prevalence of latent tuberculosis in homeless persons: a single-centre cross-sectional study, Germany. PLoS One. 2019;14(3):e0214556. https://doi.org/10.1371/journal.pone.0214556
https://doi.org/10.1371/journal.pone.021... ; psychological disorders²⁴24 Ranzani OT, Carvalho CRR, Waldman EA, Rodrigues LC. The impact of being homeless on the unsuccessful outcome of treatment of pulmonary TB in São Paulo State, Brazil. BMC Med. 2016;14:41. https://doi.org/10.1186/s12916-016-0584-8
https://doi.org/10.1186/s12916-016-0584-... , ²⁸28 Nwana N, Marks SM, Lan E, Chang AH, Holcombe M, Morris SB. Treatment of latent Mycobacterium tuberculosis infection with 12 once weekly directly-observed doses of isoniazid and rifapentine among persons experiencing homelessness. PLoS One. 2019;14(3):e0213524. https://doi.org/10.1371/journal.pone.0213524
https://doi.org/10.1371/journal.pone.021... , ³⁰30 Powell KM, VanderEnde DS, Holland DP, Haddad MB, Yarn B, Yamin AS, et al. Outbreak of drug-resistant Mycobacterium tuberculosis among homeless people in Atlanta, Georgia, 2008-2015. Public Health Rep. 2017;132(2):231-40. https://doi.org/10.1177/0033354917694008
https://doi.org/10.1177/0033354917694008... ; prostitution²⁹29 Amiri FB, Gouya MM, Saifi M, Rohani M, Tabarsi P, Sedaghat A, et al. Vulnerability of homeless people in Tehran, Iran, to HIV, tuberculosis and viral hepatitis. PLoS One. 2014;9(6):e98742. https://doi.org/10.1371/journal.pone.0098742
https://doi.org/10.1371/journal.pone.009... , including among men who have sex with men; illiteracy²²22 Semunigus T, Tessema B, Eshetie S, Moges F. Smear positive pulmonary tuberculosis and associated factors among homeless individuals in Dessie and Debre Birhan towns, Northeast Ethiopia. Ann Clin Microbiol Antimicrob. 2016;15(1):50. https://doi.org/10.1186/s12941-016-0165-x
https://doi.org/10.1186/s12941-016-0165-... , ²⁹29 Amiri FB, Gouya MM, Saifi M, Rohani M, Tabarsi P, Sedaghat A, et al. Vulnerability of homeless people in Tehran, Iran, to HIV, tuberculosis and viral hepatitis. PLoS One. 2014;9(6):e98742. https://doi.org/10.1371/journal.pone.0098742
https://doi.org/10.1371/journal.pone.009... ; malnutrition²²22 Semunigus T, Tessema B, Eshetie S, Moges F. Smear positive pulmonary tuberculosis and associated factors among homeless individuals in Dessie and Debre Birhan towns, Northeast Ethiopia. Ann Clin Microbiol Antimicrob. 2016;15(1):50. https://doi.org/10.1186/s12941-016-0165-x
https://doi.org/10.1186/s12941-016-0165-... ; HIV coinfection²¹21 Aldridge RW, Hayward AC, Hemming S, Yates SK, Ferenando G, Possas L, et al. High prevalence of latent tuberculosis and bloodborne virus infection in a homeless population. Thorax. 2018;73(6):557-64. https://doi.org/10.1136/thoraxjnl-2016-209579
https://doi.org/10.1136/thoraxjnl-2016-2... , ²²22 Semunigus T, Tessema B, Eshetie S, Moges F. Smear positive pulmonary tuberculosis and associated factors among homeless individuals in Dessie and Debre Birhan towns, Northeast Ethiopia. Ann Clin Microbiol Antimicrob. 2016;15(1):50. https://doi.org/10.1186/s12941-016-0165-x
https://doi.org/10.1186/s12941-016-0165-... , ²⁴24 Ranzani OT, Carvalho CRR, Waldman EA, Rodrigues LC. The impact of being homeless on the unsuccessful outcome of treatment of pulmonary TB in São Paulo State, Brazil. BMC Med. 2016;14:41. https://doi.org/10.1186/s12916-016-0584-8
https://doi.org/10.1186/s12916-016-0584-... ; and other chronic diseases, such as diabetes²⁷27 Agarwal S, Nguyen DT, Graviss EA. Homelessness and mortality among persons with tuberculosis in Texas, 2010-2017. Public Health Rep. 2019;134(6):643-50. https://doi.org/10.1177/0033354919874087
https://doi.org/10.1177/0033354919874087... , ²⁸28 Nwana N, Marks SM, Lan E, Chang AH, Holcombe M, Morris SB. Treatment of latent Mycobacterium tuberculosis infection with 12 once weekly directly-observed doses of isoniazid and rifapentine among persons experiencing homelessness. PLoS One. 2019;14(3):e0213524. https://doi.org/10.1371/journal.pone.0213524
https://doi.org/10.1371/journal.pone.021... , chronic renal failure²⁷27 Agarwal S, Nguyen DT, Graviss EA. Homelessness and mortality among persons with tuberculosis in Texas, 2010-2017. Public Health Rep. 2019;134(6):643-50. https://doi.org/10.1177/0033354919874087
https://doi.org/10.1177/0033354919874087... , ²⁸28 Nwana N, Marks SM, Lan E, Chang AH, Holcombe M, Morris SB. Treatment of latent Mycobacterium tuberculosis infection with 12 once weekly directly-observed doses of isoniazid and rifapentine among persons experiencing homelessness. PLoS One. 2019;14(3):e0213524. https://doi.org/10.1371/journal.pone.0213524
https://doi.org/10.1371/journal.pone.021... , and hepatitis B and C²¹21 Aldridge RW, Hayward AC, Hemming S, Yates SK, Ferenando G, Possas L, et al. High prevalence of latent tuberculosis and bloodborne virus infection in a homeless population. Thorax. 2018;73(6):557-64. https://doi.org/10.1136/thoraxjnl-2016-209579
https://doi.org/10.1136/thoraxjnl-2016-2... , ²⁸28 Nwana N, Marks SM, Lan E, Chang AH, Holcombe M, Morris SB. Treatment of latent Mycobacterium tuberculosis infection with 12 once weekly directly-observed doses of isoniazid and rifapentine among persons experiencing homelessness. PLoS One. 2019;14(3):e0213524. https://doi.org/10.1371/journal.pone.0213524
https://doi.org/10.1371/journal.pone.021... , ²⁹29 Amiri FB, Gouya MM, Saifi M, Rohani M, Tabarsi P, Sedaghat A, et al. Vulnerability of homeless people in Tehran, Iran, to HIV, tuberculosis and viral hepatitis. PLoS One. 2014;9(6):e98742. https://doi.org/10.1371/journal.pone.0098742
https://doi.org/10.1371/journal.pone.009... .

In all analyzed studies, most patients with tuberculosis were Black or mixed-race men²⁴24 Ranzani OT, Carvalho CRR, Waldman EA, Rodrigues LC. The impact of being homeless on the unsuccessful outcome of treatment of pulmonary TB in São Paulo State, Brazil. BMC Med. 2016;14:41. https://doi.org/10.1186/s12916-016-0584-8
https://doi.org/10.1186/s12916-016-0584-... , ²⁸28 Nwana N, Marks SM, Lan E, Chang AH, Holcombe M, Morris SB. Treatment of latent Mycobacterium tuberculosis infection with 12 once weekly directly-observed doses of isoniazid and rifapentine among persons experiencing homelessness. PLoS One. 2019;14(3):e0213524. https://doi.org/10.1371/journal.pone.0213524
https://doi.org/10.1371/journal.pone.021... , ³⁰30 Powell KM, VanderEnde DS, Holland DP, Haddad MB, Yarn B, Yamin AS, et al. Outbreak of drug-resistant Mycobacterium tuberculosis among homeless people in Atlanta, Georgia, 2008-2015. Public Health Rep. 2017;132(2):231-40. https://doi.org/10.1177/0033354917694008
https://doi.org/10.1177/0033354917694008... , ³²32 Munn MS, Duchin JS, Kay M, Pecha M, Thibault CS, Narita M. Analysis of risk factors for tuberculous infection following exposure at a homeless shelter. Int J Tuberc Lung Dis. 2015;19(5):570-5. https://doi.org/10.5588/ijtld.14.0648
https://doi.org/10.5588/ijtld.14.0648... , with a mean age of 49.8 years (SD ± 5.2). The literature shows that average homelessness length related to a higher occurrence of tuberculosis and latent tuberculosis infection²¹21 Aldridge RW, Hayward AC, Hemming S, Yates SK, Ferenando G, Possas L, et al. High prevalence of latent tuberculosis and bloodborne virus infection in a homeless population. Thorax. 2018;73(6):557-64. https://doi.org/10.1136/thoraxjnl-2016-209579
https://doi.org/10.1136/thoraxjnl-2016-2... , ²²22 Semunigus T, Tessema B, Eshetie S, Moges F. Smear positive pulmonary tuberculosis and associated factors among homeless individuals in Dessie and Debre Birhan towns, Northeast Ethiopia. Ann Clin Microbiol Antimicrob. 2016;15(1):50. https://doi.org/10.1186/s12941-016-0165-x
https://doi.org/10.1186/s12941-016-0165-... , ²⁹29 Amiri FB, Gouya MM, Saifi M, Rohani M, Tabarsi P, Sedaghat A, et al. Vulnerability of homeless people in Tehran, Iran, to HIV, tuberculosis and viral hepatitis. PLoS One. 2014;9(6):e98742. https://doi.org/10.1371/journal.pone.0098742
https://doi.org/10.1371/journal.pone.009... .

Table 3 shows the outcomes related to the occurrence of tuberculosis and latent tuberculosis infection: incomplete treatment²²22 Semunigus T, Tessema B, Eshetie S, Moges F. Smear positive pulmonary tuberculosis and associated factors among homeless individuals in Dessie and Debre Birhan towns, Northeast Ethiopia. Ann Clin Microbiol Antimicrob. 2016;15(1):50. https://doi.org/10.1186/s12941-016-0165-x
https://doi.org/10.1186/s12941-016-0165-... , ²⁴24 Ranzani OT, Carvalho CRR, Waldman EA, Rodrigues LC. The impact of being homeless on the unsuccessful outcome of treatment of pulmonary TB in São Paulo State, Brazil. BMC Med. 2016;14:41. https://doi.org/10.1186/s12916-016-0584-8
https://doi.org/10.1186/s12916-016-0584-... , ²⁵25 Hwang YW, Lee YJ, Kong SY. Epidemiology and clinical outcomes of tuberculosis among homeless persons visiting emergency department in public hospital. Am J Emerg Med. 2018;36(1):164-6. https://doi.org/10.1016/j.ajem.2017.07.049
https://doi.org/10.1016/j.ajem.2017.07.0... , ²⁷27 Agarwal S, Nguyen DT, Graviss EA. Homelessness and mortality among persons with tuberculosis in Texas, 2010-2017. Public Health Rep. 2019;134(6):643-50. https://doi.org/10.1177/0033354919874087
https://doi.org/10.1177/0033354919874087... , ²⁸28 Nwana N, Marks SM, Lan E, Chang AH, Holcombe M, Morris SB. Treatment of latent Mycobacterium tuberculosis infection with 12 once weekly directly-observed doses of isoniazid and rifapentine among persons experiencing homelessness. PLoS One. 2019;14(3):e0213524. https://doi.org/10.1371/journal.pone.0213524
https://doi.org/10.1371/journal.pone.021... , ³⁰30 Powell KM, VanderEnde DS, Holland DP, Haddad MB, Yarn B, Yamin AS, et al. Outbreak of drug-resistant Mycobacterium tuberculosis among homeless people in Atlanta, Georgia, 2008-2015. Public Health Rep. 2017;132(2):231-40. https://doi.org/10.1177/0033354917694008
https://doi.org/10.1177/0033354917694008... , ³¹31 Gómez LM, Paniagua-Saldarriaga LA, Richert Q, Keynan Y, Montes F, López L, et al. Homelessness and HIV: a combination predictive of poor tuberculosis treatment outcomes and in need of innovative strategies to improve treatment completion. Am J Trop Med Hyg. 2019;100(4):932-9. https://doi.org/10.4269/ajtmh.18-0305
https://doi.org/10.4269/ajtmh.18-0305... , ³⁴34 Dolla C, Padmapriyadarsini C, Menon AP, Muniyandi M, Adinarayanan S, Sekar G, et al. Tuberculosis among the homeless in Chennai city, South India. Trans R Soc Trop Med Hyg. 2017;111(10):479-81. https://doi.org/10.1093/trstmh/trx081
https://doi.org/10.1093/trstmh/trx081... , ³⁵35 Korzeniewska-Koseła M, Kuś J, Lewandowska K, Siemion-Szcześniak I. Tuberculosis in homeless persons in Poland. Przegl Epidemiol. 2015;69(3):445-51. or its failure²2 Quinn PJ, Markey BK, Carter ME, Donnelly WJ, Leonard F. Microbiologia veterinária e doenças infecciosas. Vol. 5. Porto Alegre, RS: Artmed; 2005. , ²⁴24 Ranzani OT, Carvalho CRR, Waldman EA, Rodrigues LC. The impact of being homeless on the unsuccessful outcome of treatment of pulmonary TB in São Paulo State, Brazil. BMC Med. 2016;14:41. https://doi.org/10.1186/s12916-016-0584-8
https://doi.org/10.1186/s12916-016-0584-... , ²⁶26 Dias M, Gaio R, Sousa P, Abranches M, Gomes M, Oliveira O, et al. Tuberculosis among the homeless: should we change the strategy? Int J Tuberc Lung Dis. 2017;21(3):327-32. https://doi.org/10.5588/ijtld.16.0597
https://doi.org/10.5588/ijtld.16.0597... , death²²22 Semunigus T, Tessema B, Eshetie S, Moges F. Smear positive pulmonary tuberculosis and associated factors among homeless individuals in Dessie and Debre Birhan towns, Northeast Ethiopia. Ann Clin Microbiol Antimicrob. 2016;15(1):50. https://doi.org/10.1186/s12941-016-0165-x
https://doi.org/10.1186/s12941-016-0165-... , ²⁴24 Ranzani OT, Carvalho CRR, Waldman EA, Rodrigues LC. The impact of being homeless on the unsuccessful outcome of treatment of pulmonary TB in São Paulo State, Brazil. BMC Med. 2016;14:41. https://doi.org/10.1186/s12916-016-0584-8
https://doi.org/10.1186/s12916-016-0584-... , ²⁵25 Hwang YW, Lee YJ, Kong SY. Epidemiology and clinical outcomes of tuberculosis among homeless persons visiting emergency department in public hospital. Am J Emerg Med. 2018;36(1):164-6. https://doi.org/10.1016/j.ajem.2017.07.049
https://doi.org/10.1016/j.ajem.2017.07.0... , ²⁷27 Agarwal S, Nguyen DT, Graviss EA. Homelessness and mortality among persons with tuberculosis in Texas, 2010-2017. Public Health Rep. 2019;134(6):643-50. https://doi.org/10.1177/0033354919874087
https://doi.org/10.1177/0033354919874087... , ³⁰30 Powell KM, VanderEnde DS, Holland DP, Haddad MB, Yarn B, Yamin AS, et al. Outbreak of drug-resistant Mycobacterium tuberculosis among homeless people in Atlanta, Georgia, 2008-2015. Public Health Rep. 2017;132(2):231-40. https://doi.org/10.1177/0033354917694008
https://doi.org/10.1177/0033354917694008... , ³¹31 Gómez LM, Paniagua-Saldarriaga LA, Richert Q, Keynan Y, Montes F, López L, et al. Homelessness and HIV: a combination predictive of poor tuberculosis treatment outcomes and in need of innovative strategies to improve treatment completion. Am J Trop Med Hyg. 2019;100(4):932-9. https://doi.org/10.4269/ajtmh.18-0305
https://doi.org/10.4269/ajtmh.18-0305... , ³⁴34 Dolla C, Padmapriyadarsini C, Menon AP, Muniyandi M, Adinarayanan S, Sekar G, et al. Tuberculosis among the homeless in Chennai city, South India. Trans R Soc Trop Med Hyg. 2017;111(10):479-81. https://doi.org/10.1093/trstmh/trx081
https://doi.org/10.1093/trstmh/trx081... , development of treatment-resistance²²22 Semunigus T, Tessema B, Eshetie S, Moges F. Smear positive pulmonary tuberculosis and associated factors among homeless individuals in Dessie and Debre Birhan towns, Northeast Ethiopia. Ann Clin Microbiol Antimicrob. 2016;15(1):50. https://doi.org/10.1186/s12941-016-0165-x
https://doi.org/10.1186/s12941-016-0165-... , ²⁵25 Hwang YW, Lee YJ, Kong SY. Epidemiology and clinical outcomes of tuberculosis among homeless persons visiting emergency department in public hospital. Am J Emerg Med. 2018;36(1):164-6. https://doi.org/10.1016/j.ajem.2017.07.049
https://doi.org/10.1016/j.ajem.2017.07.0... , and occurrence of extrapulmonary tuberculosis²²22 Semunigus T, Tessema B, Eshetie S, Moges F. Smear positive pulmonary tuberculosis and associated factors among homeless individuals in Dessie and Debre Birhan towns, Northeast Ethiopia. Ann Clin Microbiol Antimicrob. 2016;15(1):50. https://doi.org/10.1186/s12941-016-0165-x
https://doi.org/10.1186/s12941-016-0165-... , ²⁶26 Dias M, Gaio R, Sousa P, Abranches M, Gomes M, Oliveira O, et al. Tuberculosis among the homeless: should we change the strategy? Int J Tuberc Lung Dis. 2017;21(3):327-32. https://doi.org/10.5588/ijtld.16.0597
https://doi.org/10.5588/ijtld.16.0597... , ²⁷27 Agarwal S, Nguyen DT, Graviss EA. Homelessness and mortality among persons with tuberculosis in Texas, 2010-2017. Public Health Rep. 2019;134(6):643-50. https://doi.org/10.1177/0033354919874087
https://doi.org/10.1177/0033354919874087... . The main diagnostic tools were sputum cytology²²22 Semunigus T, Tessema B, Eshetie S, Moges F. Smear positive pulmonary tuberculosis and associated factors among homeless individuals in Dessie and Debre Birhan towns, Northeast Ethiopia. Ann Clin Microbiol Antimicrob. 2016;15(1):50. https://doi.org/10.1186/s12941-016-0165-x
https://doi.org/10.1186/s12941-016-0165-... , ²⁴24 Ranzani OT, Carvalho CRR, Waldman EA, Rodrigues LC. The impact of being homeless on the unsuccessful outcome of treatment of pulmonary TB in São Paulo State, Brazil. BMC Med. 2016;14:41. https://doi.org/10.1186/s12916-016-0584-8
https://doi.org/10.1186/s12916-016-0584-... , ²⁶26 Dias M, Gaio R, Sousa P, Abranches M, Gomes M, Oliveira O, et al. Tuberculosis among the homeless: should we change the strategy? Int J Tuberc Lung Dis. 2017;21(3):327-32. https://doi.org/10.5588/ijtld.16.0597
https://doi.org/10.5588/ijtld.16.0597... , ²⁷27 Agarwal S, Nguyen DT, Graviss EA. Homelessness and mortality among persons with tuberculosis in Texas, 2010-2017. Public Health Rep. 2019;134(6):643-50. https://doi.org/10.1177/0033354919874087
https://doi.org/10.1177/0033354919874087... , ²⁹29 Amiri FB, Gouya MM, Saifi M, Rohani M, Tabarsi P, Sedaghat A, et al. Vulnerability of homeless people in Tehran, Iran, to HIV, tuberculosis and viral hepatitis. PLoS One. 2014;9(6):e98742. https://doi.org/10.1371/journal.pone.0098742
https://doi.org/10.1371/journal.pone.009... , ³¹31 Gómez LM, Paniagua-Saldarriaga LA, Richert Q, Keynan Y, Montes F, López L, et al. Homelessness and HIV: a combination predictive of poor tuberculosis treatment outcomes and in need of innovative strategies to improve treatment completion. Am J Trop Med Hyg. 2019;100(4):932-9. https://doi.org/10.4269/ajtmh.18-0305
https://doi.org/10.4269/ajtmh.18-0305... , thoracic X-rays²⁴24 Ranzani OT, Carvalho CRR, Waldman EA, Rodrigues LC. The impact of being homeless on the unsuccessful outcome of treatment of pulmonary TB in São Paulo State, Brazil. BMC Med. 2016;14:41. https://doi.org/10.1186/s12916-016-0584-8
https://doi.org/10.1186/s12916-016-0584-... , ²⁷27 Agarwal S, Nguyen DT, Graviss EA. Homelessness and mortality among persons with tuberculosis in Texas, 2010-2017. Public Health Rep. 2019;134(6):643-50. https://doi.org/10.1177/0033354919874087
https://doi.org/10.1177/0033354919874087... , ³³33 Streit F, Bartels C, Kuczius T, Cassier C, Gardemann J, Schaumburg F. Prevalence of latent tuberculosis in homeless persons: a single-centre cross-sectional study, Germany. PLoS One. 2019;14(3):e0214556. https://doi.org/10.1371/journal.pone.0214556
https://doi.org/10.1371/journal.pone.021... , culture²⁷27 Agarwal S, Nguyen DT, Graviss EA. Homelessness and mortality among persons with tuberculosis in Texas, 2010-2017. Public Health Rep. 2019;134(6):643-50. https://doi.org/10.1177/0033354919874087
https://doi.org/10.1177/0033354919874087... , ²⁹29 Amiri FB, Gouya MM, Saifi M, Rohani M, Tabarsi P, Sedaghat A, et al. Vulnerability of homeless people in Tehran, Iran, to HIV, tuberculosis and viral hepatitis. PLoS One. 2014;9(6):e98742. https://doi.org/10.1371/journal.pone.0098742
https://doi.org/10.1371/journal.pone.009... , molecular examination²⁷27 Agarwal S, Nguyen DT, Graviss EA. Homelessness and mortality among persons with tuberculosis in Texas, 2010-2017. Public Health Rep. 2019;134(6):643-50. https://doi.org/10.1177/0033354919874087
https://doi.org/10.1177/0033354919874087... , and clinical diagnosis²⁷27 Agarwal S, Nguyen DT, Graviss EA. Homelessness and mortality among persons with tuberculosis in Texas, 2010-2017. Public Health Rep. 2019;134(6):643-50. https://doi.org/10.1177/0033354919874087
https://doi.org/10.1177/0033354919874087... .

Among the 16 publications analyzed, 10 described the association between tuberculosis comorbidities and HIV. In Semunigus et al.²²22 Semunigus T, Tessema B, Eshetie S, Moges F. Smear positive pulmonary tuberculosis and associated factors among homeless individuals in Dessie and Debre Birhan towns, Northeast Ethiopia. Ann Clin Microbiol Antimicrob. 2016;15(1):50. https://doi.org/10.1186/s12941-016-0165-x
https://doi.org/10.1186/s12941-016-0165-... , the proportion of coinfection reached 55.5%. According to Dias et al.²⁶26 Dias M, Gaio R, Sousa P, Abranches M, Gomes M, Oliveira O, et al. Tuberculosis among the homeless: should we change the strategy? Int J Tuberc Lung Dis. 2017;21(3):327-32. https://doi.org/10.5588/ijtld.16.0597
https://doi.org/10.5588/ijtld.16.0597... , HIV-positive people were 2.1 times more likely to have an unfavorable outcome. Moreover, 32.6% of participants showed some comorbidity. In Ranzani et al.²⁴24 Ranzani OT, Carvalho CRR, Waldman EA, Rodrigues LC. The impact of being homeless on the unsuccessful outcome of treatment of pulmonary TB in São Paulo State, Brazil. BMC Med. 2016;14:41. https://doi.org/10.1186/s12916-016-0584-8
https://doi.org/10.1186/s12916-016-0584-... , 17.3% of homeless persons were HIV positive. According to Agarwal et al.²⁷27 Agarwal S, Nguyen DT, Graviss EA. Homelessness and mortality among persons with tuberculosis in Texas, 2010-2017. Public Health Rep. 2019;134(6):643-50. https://doi.org/10.1177/0033354919874087
https://doi.org/10.1177/0033354919874087... , 16% of participants with tuberculosis were HIV positive and the chance ratio for mortality in these individuals was 3.57 higher than for those who were HIV negative. In Hwang et al.²⁵25 Hwang YW, Lee YJ, Kong SY. Epidemiology and clinical outcomes of tuberculosis among homeless persons visiting emergency department in public hospital. Am J Emerg Med. 2018;36(1):164-6. https://doi.org/10.1016/j.ajem.2017.07.049
https://doi.org/10.1016/j.ajem.2017.07.0... , 5.7% showed tuberculosis+HIV coinfections. In Amiri et al.²⁹29 Amiri FB, Gouya MM, Saifi M, Rohani M, Tabarsi P, Sedaghat A, et al. Vulnerability of homeless people in Tehran, Iran, to HIV, tuberculosis and viral hepatitis. PLoS One. 2014;9(6):e98742. https://doi.org/10.1371/journal.pone.0098742
https://doi.org/10.1371/journal.pone.009... , 1.2% of HP were HIV positive and had a latent tuberculosis infection, a similar proportion (1.8%) to the one in Nwana et al.²⁸28 Nwana N, Marks SM, Lan E, Chang AH, Holcombe M, Morris SB. Treatment of latent Mycobacterium tuberculosis infection with 12 once weekly directly-observed doses of isoniazid and rifapentine among persons experiencing homelessness. PLoS One. 2019;14(3):e0213524. https://doi.org/10.1371/journal.pone.0213524
https://doi.org/10.1371/journal.pone.021... Gomez et al.³¹31 Gómez LM, Paniagua-Saldarriaga LA, Richert Q, Keynan Y, Montes F, López L, et al. Homelessness and HIV: a combination predictive of poor tuberculosis treatment outcomes and in need of innovative strategies to improve treatment completion. Am J Trop Med Hyg. 2019;100(4):932-9. https://doi.org/10.4269/ajtmh.18-0305
https://doi.org/10.4269/ajtmh.18-0305... found that 20.6% of HP had comorbidities. Vieira et al.²³23 Vieira AL, Oliveira O, Gomes M, Gaio R, Duarte R. Tuberculosis incidence rate among the homeless population: the impact of socio-demographic and health-related variables. Pulmonology. 2018;24(5):309-11. https://doi.org/10.1016/j.pulmoe.2018.05.001
https://doi.org/10.1016/j.pulmoe.2018.05... report that a 100-case increase of HIV+tuberculosis coinfection in the general population raises the incidence of tuberculosis among homeless persons to 14 cases per 100,000 inhabitants. The only HIV+ patient in Dolla et al.³⁴34 Dolla C, Padmapriyadarsini C, Menon AP, Muniyandi M, Adinarayanan S, Sekar G, et al. Tuberculosis among the homeless in Chennai city, South India. Trans R Soc Trop Med Hyg. 2017;111(10):479-81. https://doi.org/10.1093/trstmh/trx081
https://doi.org/10.1093/trstmh/trx081... died.

Regarding biases, most studies showed dissimilar recruited groups²⁴24 Ranzani OT, Carvalho CRR, Waldman EA, Rodrigues LC. The impact of being homeless on the unsuccessful outcome of treatment of pulmonary TB in São Paulo State, Brazil. BMC Med. 2016;14:41. https://doi.org/10.1186/s12916-016-0584-8
https://doi.org/10.1186/s12916-016-0584-... , ²⁵25 Hwang YW, Lee YJ, Kong SY. Epidemiology and clinical outcomes of tuberculosis among homeless persons visiting emergency department in public hospital. Am J Emerg Med. 2018;36(1):164-6. https://doi.org/10.1016/j.ajem.2017.07.049
https://doi.org/10.1016/j.ajem.2017.07.0... , ³⁶36 Pendzich J, Maksymowicz-Mazur W, Pawłowska J, Filipczyk Ł, Kulawik I, Zientek J, Kozielski J. Tuberculosis among the homeless and inmates kept in custody and in penitentiary institutions in the Silesia region. Pneumonol Alergol Pol. 2015;83(1):23-9. doi: 10.5603/PiAP.2015.0003. PMID: 25577530. , confounding factor identification²⁶26 Dias M, Gaio R, Sousa P, Abranches M, Gomes M, Oliveira O, et al. Tuberculosis among the homeless: should we change the strategy? Int J Tuberc Lung Dis. 2017;21(3):327-32. https://doi.org/10.5588/ijtld.16.0597
https://doi.org/10.5588/ijtld.16.0597... , ²⁷27 Agarwal S, Nguyen DT, Graviss EA. Homelessness and mortality among persons with tuberculosis in Texas, 2010-2017. Public Health Rep. 2019;134(6):643-50. https://doi.org/10.1177/0033354919874087
https://doi.org/10.1177/0033354919874087... , ²⁹29 Amiri FB, Gouya MM, Saifi M, Rohani M, Tabarsi P, Sedaghat A, et al. Vulnerability of homeless people in Tehran, Iran, to HIV, tuberculosis and viral hepatitis. PLoS One. 2014;9(6):e98742. https://doi.org/10.1371/journal.pone.0098742
https://doi.org/10.1371/journal.pone.009... , ³⁰30 Powell KM, VanderEnde DS, Holland DP, Haddad MB, Yarn B, Yamin AS, et al. Outbreak of drug-resistant Mycobacterium tuberculosis among homeless people in Atlanta, Georgia, 2008-2015. Public Health Rep. 2017;132(2):231-40. https://doi.org/10.1177/0033354917694008
https://doi.org/10.1177/0033354917694008... , ³³33 Streit F, Bartels C, Kuczius T, Cassier C, Gardemann J, Schaumburg F. Prevalence of latent tuberculosis in homeless persons: a single-centre cross-sectional study, Germany. PLoS One. 2019;14(3):e0214556. https://doi.org/10.1371/journal.pone.0214556
https://doi.org/10.1371/journal.pone.021... , strategies to deal with these factors²⁶26 Dias M, Gaio R, Sousa P, Abranches M, Gomes M, Oliveira O, et al. Tuberculosis among the homeless: should we change the strategy? Int J Tuberc Lung Dis. 2017;21(3):327-32. https://doi.org/10.5588/ijtld.16.0597
https://doi.org/10.5588/ijtld.16.0597... , ²⁷27 Agarwal S, Nguyen DT, Graviss EA. Homelessness and mortality among persons with tuberculosis in Texas, 2010-2017. Public Health Rep. 2019;134(6):643-50. https://doi.org/10.1177/0033354919874087
https://doi.org/10.1177/0033354919874087... , ²⁹29 Amiri FB, Gouya MM, Saifi M, Rohani M, Tabarsi P, Sedaghat A, et al. Vulnerability of homeless people in Tehran, Iran, to HIV, tuberculosis and viral hepatitis. PLoS One. 2014;9(6):e98742. https://doi.org/10.1371/journal.pone.0098742
https://doi.org/10.1371/journal.pone.009... , ³⁰30 Powell KM, VanderEnde DS, Holland DP, Haddad MB, Yarn B, Yamin AS, et al. Outbreak of drug-resistant Mycobacterium tuberculosis among homeless people in Atlanta, Georgia, 2008-2015. Public Health Rep. 2017;132(2):231-40. https://doi.org/10.1177/0033354917694008
https://doi.org/10.1177/0033354917694008... , ³²32 Munn MS, Duchin JS, Kay M, Pecha M, Thibault CS, Narita M. Analysis of risk factors for tuberculous infection following exposure at a homeless shelter. Int J Tuberc Lung Dis. 2015;19(5):570-5. https://doi.org/10.5588/ijtld.14.0648
https://doi.org/10.5588/ijtld.14.0648... or incomplete participant follow-ups²⁵25 Hwang YW, Lee YJ, Kong SY. Epidemiology and clinical outcomes of tuberculosis among homeless persons visiting emergency department in public hospital. Am J Emerg Med. 2018;36(1):164-6. https://doi.org/10.1016/j.ajem.2017.07.049
https://doi.org/10.1016/j.ajem.2017.07.0... , ²⁶26 Dias M, Gaio R, Sousa P, Abranches M, Gomes M, Oliveira O, et al. Tuberculosis among the homeless: should we change the strategy? Int J Tuberc Lung Dis. 2017;21(3):327-32. https://doi.org/10.5588/ijtld.16.0597
https://doi.org/10.5588/ijtld.16.0597... , ³⁶36 Pendzich J, Maksymowicz-Mazur W, Pawłowska J, Filipczyk Ł, Kulawik I, Zientek J, Kozielski J. Tuberculosis among the homeless and inmates kept in custody and in penitentiary institutions in the Silesia region. Pneumonol Alergol Pol. 2015;83(1):23-9. doi: 10.5603/PiAP.2015.0003. PMID: 25577530. . Few studies indicated their limitations²⁴24 Ranzani OT, Carvalho CRR, Waldman EA, Rodrigues LC. The impact of being homeless on the unsuccessful outcome of treatment of pulmonary TB in São Paulo State, Brazil. BMC Med. 2016;14:41. https://doi.org/10.1186/s12916-016-0584-8
https://doi.org/10.1186/s12916-016-0584-... , ²⁶26 Dias M, Gaio R, Sousa P, Abranches M, Gomes M, Oliveira O, et al. Tuberculosis among the homeless: should we change the strategy? Int J Tuberc Lung Dis. 2017;21(3):327-32. https://doi.org/10.5588/ijtld.16.0597
https://doi.org/10.5588/ijtld.16.0597... , ²⁸28 Nwana N, Marks SM, Lan E, Chang AH, Holcombe M, Morris SB. Treatment of latent Mycobacterium tuberculosis infection with 12 once weekly directly-observed doses of isoniazid and rifapentine among persons experiencing homelessness. PLoS One. 2019;14(3):e0213524. https://doi.org/10.1371/journal.pone.0213524
https://doi.org/10.1371/journal.pone.021... , ²⁹29 Amiri FB, Gouya MM, Saifi M, Rohani M, Tabarsi P, Sedaghat A, et al. Vulnerability of homeless people in Tehran, Iran, to HIV, tuberculosis and viral hepatitis. PLoS One. 2014;9(6):e98742. https://doi.org/10.1371/journal.pone.0098742
https://doi.org/10.1371/journal.pone.009... , ³¹31 Gómez LM, Paniagua-Saldarriaga LA, Richert Q, Keynan Y, Montes F, López L, et al. Homelessness and HIV: a combination predictive of poor tuberculosis treatment outcomes and in need of innovative strategies to improve treatment completion. Am J Trop Med Hyg. 2019;100(4):932-9. https://doi.org/10.4269/ajtmh.18-0305
https://doi.org/10.4269/ajtmh.18-0305... , ³⁴34 Dolla C, Padmapriyadarsini C, Menon AP, Muniyandi M, Adinarayanan S, Sekar G, et al. Tuberculosis among the homeless in Chennai city, South India. Trans R Soc Trop Med Hyg. 2017;111(10):479-81. https://doi.org/10.1093/trstmh/trx081
https://doi.org/10.1093/trstmh/trx081... and those that did showed flaws in how they described their methodology and results²⁹29 Amiri FB, Gouya MM, Saifi M, Rohani M, Tabarsi P, Sedaghat A, et al. Vulnerability of homeless people in Tehran, Iran, to HIV, tuberculosis and viral hepatitis. PLoS One. 2014;9(6):e98742. https://doi.org/10.1371/journal.pone.0098742
https://doi.org/10.1371/journal.pone.009... , ³⁰30 Powell KM, VanderEnde DS, Holland DP, Haddad MB, Yarn B, Yamin AS, et al. Outbreak of drug-resistant Mycobacterium tuberculosis among homeless people in Atlanta, Georgia, 2008-2015. Public Health Rep. 2017;132(2):231-40. https://doi.org/10.1177/0033354917694008
https://doi.org/10.1177/0033354917694008... , ³²32 Munn MS, Duchin JS, Kay M, Pecha M, Thibault CS, Narita M. Analysis of risk factors for tuberculous infection following exposure at a homeless shelter. Int J Tuberc Lung Dis. 2015;19(5):570-5. https://doi.org/10.5588/ijtld.14.0648
https://doi.org/10.5588/ijtld.14.0648... , ³⁶36 Pendzich J, Maksymowicz-Mazur W, Pawłowska J, Filipczyk Ł, Kulawik I, Zientek J, Kozielski J. Tuberculosis among the homeless and inmates kept in custody and in penitentiary institutions in the Silesia region. Pneumonol Alergol Pol. 2015;83(1):23-9. doi: 10.5603/PiAP.2015.0003. PMID: 25577530. .

DISCUSSION

We can observe a recurrence between alcohol, tobacco, and illicit drug consumption results – factors of individual susceptibility and social vulnerability (due to the stigma associated with addiction) – whether to escape the reality of suffering or to seek an improvement in general well-being³⁷37 Zuim RCB, Trajman A. Itinerário terapêutico de doentes com tuberculose vivendo em situação de rua no Rio de Janeiro. Physis. 2018;28(2):e280205. https://doi.org/10.1590/S0103-73312018280205
https://doi.org/10.1590/S0103-7331201828... , ³⁸38 Hino P, Santos JO, Rosa AS. Pessoas que vivenciam situação de rua sob o olhar da saúde. Rev Bras Enferm. 2018;71 Supl 1:732-40. https://doi.org/10.1590/0034-7167-2017-0547
https://doi.org/10.1590/0034-7167-2017-0... . Thus, this vulnerability overlap may increase exposure to tuberculosis and HIV in the study population. Gender, age, coinfection by other communicable diseases, and history of incarceration are also factors which arouse discrimination in our society, albeit at different levels.

Since it is a very important global public health problem (even listed among the Sustainable Development Goals), some methodological flaws in these studies draw our attention, such as their small sample size, weakening their results and conclusions; lack of direct access to tuberculosis-positive patients²⁹29 Amiri FB, Gouya MM, Saifi M, Rohani M, Tabarsi P, Sedaghat A, et al. Vulnerability of homeless people in Tehran, Iran, to HIV, tuberculosis and viral hepatitis. PLoS One. 2014;9(6):e98742. https://doi.org/10.1371/journal.pone.0098742
https://doi.org/10.1371/journal.pone.009... ; underestimation of the actual number of homeless persons²⁴24 Ranzani OT, Carvalho CRR, Waldman EA, Rodrigues LC. The impact of being homeless on the unsuccessful outcome of treatment of pulmonary TB in São Paulo State, Brazil. BMC Med. 2016;14:41. https://doi.org/10.1186/s12916-016-0584-8
https://doi.org/10.1186/s12916-016-0584-... , ²⁶26 Dias M, Gaio R, Sousa P, Abranches M, Gomes M, Oliveira O, et al. Tuberculosis among the homeless: should we change the strategy? Int J Tuberc Lung Dis. 2017;21(3):327-32. https://doi.org/10.5588/ijtld.16.0597
https://doi.org/10.5588/ijtld.16.0597... and of the incidence and prevalence of tuberculosis in this population²⁶26 Dias M, Gaio R, Sousa P, Abranches M, Gomes M, Oliveira O, et al. Tuberculosis among the homeless: should we change the strategy? Int J Tuberc Lung Dis. 2017;21(3):327-32. https://doi.org/10.5588/ijtld.16.0597
https://doi.org/10.5588/ijtld.16.0597... , ³⁴34 Dolla C, Padmapriyadarsini C, Menon AP, Muniyandi M, Adinarayanan S, Sekar G, et al. Tuberculosis among the homeless in Chennai city, South India. Trans R Soc Trop Med Hyg. 2017;111(10):479-81. https://doi.org/10.1093/trstmh/trx081
https://doi.org/10.1093/trstmh/trx081... ; and a sample composed only of people with tuberculosis²⁴24 Ranzani OT, Carvalho CRR, Waldman EA, Rodrigues LC. The impact of being homeless on the unsuccessful outcome of treatment of pulmonary TB in São Paulo State, Brazil. BMC Med. 2016;14:41. https://doi.org/10.1186/s12916-016-0584-8
https://doi.org/10.1186/s12916-016-0584-... , excluding extrapulmonary forms of the illness.

Individual Vulnerability

Constant drug use can lead to the development of mental disorders, as stated in the last World Drug Report in 2020 from the United Nations Office of Drugs and Crime (UNODC). In total, two publications²⁴24 Ranzani OT, Carvalho CRR, Waldman EA, Rodrigues LC. The impact of being homeless on the unsuccessful outcome of treatment of pulmonary TB in São Paulo State, Brazil. BMC Med. 2016;14:41. https://doi.org/10.1186/s12916-016-0584-8
https://doi.org/10.1186/s12916-016-0584-... , ³⁰30 Powell KM, VanderEnde DS, Holland DP, Haddad MB, Yarn B, Yamin AS, et al. Outbreak of drug-resistant Mycobacterium tuberculosis among homeless people in Atlanta, Georgia, 2008-2015. Public Health Rep. 2017;132(2):231-40. https://doi.org/10.1177/0033354917694008
https://doi.org/10.1177/0033354917694008... described the variable “mental disorder,” evincing its constant occurrence in the study samples. The break with family members either due to maladaptation to their structural model, a history of violence and harassment or unacceptance of reprehensible forms of sustenance and their own addiction, expose these people to social and individual vulnerability since they are unable to count on their families at a difficult time³⁹39 Lindner LC. “Dando uma moral”: moralidades, prazeres e poderes no caminho da cura da tuberculose na população em situação de rua no município de São Paulo [tese]. São Paulo: Faculdade de Saúde Pública da Universidade de São Paulo; 2016. , ⁴⁰40 Oliveira RG. Práticas de saúde em contextos de vulnerabilização e negligência de doenças, sujeitos e territórios: potencialidades e contradições na atenção à saúde de pessoas em situação de rua. Saude Soc. 2018;27(1):37-50. https://doi.org/10.1590/S0104-12902018170915
https://doi.org/10.1590/S0104-1290201817... .

Social Vulnerability

The State attempts to reduce social vulnerability by implementing income transfer programs to decrease the number of people below the poverty line and give them better feeding conditions⁴¹41 Lopes AJ, Jansen U, Capone D, Jansen JM. História natural e apresentação clínica. Rev Hosp Univ Pedro Ernesto. 2006;5(2):40-5. . This important measure is considered programmatic and affects social vulnerability and should be expanded as it can reduce the vulnerability of people below the poverty line. Since vulnerability dimensions may overlap or intersect, this helps to broaden the epidemiological view on the ways of getting sick and alert managers to health issues, resulting in a more qualified confrontation of these problems in HP.

Producing vulnerable and non-integrable lives forces HP to continuously live with access barriers to education, work, and health care and services, among others, in addition to their invisibility, which can lead some of them to engage in activities such as prostitution, association with trafficking, theft, and labor analogous to slavery.

Social vulnerability also involves characteristics marked by lower social classes, residence, and Black ethnicity, among others. Studies showed a 63.6% proportion of Black and mixed-race people among their results. The average age of participants is 49.8 years (SD ± 5.2), probably due to their greater spatial mobility, when compared to women or people of different age groups such as older adults, who move less through the streets, exposing themselves less in their journeys⁴²42 San Pedro A, Oliveira RM. Tuberculose e indicadores socioeconômicos: Revisão sistemática da literatura. Rev Panam Salud Publica. 2013;33(4):294-301. .

History of incarceration was frequent among the reviewed studies. The prison system, tasked with rehabilitating and reinserting convicts into society, fails to do so due to the stigma inmates carry after their sentences are fulfilled either by society in general or by absent family support or unemployment. Thus, many lack the monetary resources to continue their lives, resorting to homelessness and sometimes engaging in illegal activities, which are incapable of breaking the recidivism cycle⁴³43 Chagas B. Estigma e reinserção do preso na sociedade. Revista OAB Olinda. 2018;1:110-28. .

According to a ranking conducted by the World Prison Brief (2021)⁴⁴44 World Prison Brief [database]. About World Prison Brief. London (UK); Institute for Crime & Justice Policy Research at Birbeck University of London; 2000 [cited 2018 Nov 10]. Available from: https://www.prisonstudies.org/about-us
https://www.prisonstudies.org/about-us... , Brazil has the third largest prison population in the world, a fact intrinsically linked to structural racism and, consequently, to the systematic marginalization of Black and mixed-race people, who comprise 61.7% of inmates⁴⁵45 Câmara dos Deputados (BR), Comissão de Direitos Humanos e Minorias. Sistema carcerário brasileiro: negros e pobres na prisão. Brasília, DF: CDHM; 2018 [cited 2018 Nov 10]. Available from: https://www2.camara.leg.br/atividade-legislativa/comissoes/comissoes-permanentes/cdhm/noticias/sistema-carcerario-brasileiro-negros-e-pobres-na-prisao
https://www2.camara.leg.br/atividade-leg... . Thus, we can observe that these vulnerability factors related to social, racial, and economic impacts are perpetuated in the most vulnerable populations.

Programmatic Vulnerability

This dimension, related to access to State public and institutional equipment, proved to be an important dimension to analyze vulnerable populations’ susceptibilities to tuberculosis and HIV in epidemiological studies⁴⁶46 Muñoz Sánchez AI, Bertolozzi MR. Pode o conceito de vulnerabilidade apoiar a construção do conhecimento em Saúde Coletiva? Cienc Saude Coletiva. 2007;12(2):319-24. https://doi.org/10.1590/S1413-81232007000200007
https://doi.org/10.1590/S1413-8123200700... , as it evinces the precariousness and fragility of these resources. Incomplete treatment and the development of resistance to medication are included in this dimension, as they show the failure of the health system to provide adequate therapy, information, and structure to treat these patients⁴⁷47 Paiva V, Ayres JR, Buchalla CM. Vulnerabilidade e direitos humanos: prevenção e promoção da saúde. Livro I: Da doença à cidadania. Curitiba, PR: Juruá Editora; 2012. . Among its consequences is coinfection with other diseases since homelessness and environmental exposure enhance the risks for some chronic and infectious diseases³⁸38 Hino P, Santos JO, Rosa AS. Pessoas que vivenciam situação de rua sob o olhar da saúde. Rev Bras Enferm. 2018;71 Supl 1:732-40. https://doi.org/10.1590/0034-7167-2017-0547
https://doi.org/10.1590/0034-7167-2017-0... once priority issues for the maintenance of life, such as safety and food, are more urgent than health care. Due to access barriers, health care is relegated to the background or received only when opportune³⁸38 Hino P, Santos JO, Rosa AS. Pessoas que vivenciam situação de rua sob o olhar da saúde. Rev Bras Enferm. 2018;71 Supl 1:732-40. https://doi.org/10.1590/0034-7167-2017-0547
https://doi.org/10.1590/0034-7167-2017-0... , ⁴⁸48 Hino P, Monroe AA, Takahashi RF, Souza KMJ, Figueiredo TMRM, Bertolozzi MR. Tuberculosis control from the perspective of health professionals working in street clinics. Rev Lat Am Enfermagem. 2018;26:e3095. https://doi.org/10.1590/1518-8345.2691.3095
https://doi.org/10.1590/1518-8345.2691.3... .

CONCLUSION

According to the Institute of Applied Economic Research, Brazil had more than 100,000 homeless persons in 2016⁴⁹49 Natalino MAC. Estimativa da população em situação de rua no Brasil. Brasília, DF: IPEA; 2016 [cited 2018 Nov 10]. (Texto para Discussão; 2246). Available from: http://repositorio.ipea.gov.br/bitstream/11058/7289/1/td_2246.pdf
http://repositorio.ipea.gov.br/bitstream... . Due to the Brazilian socioeconomic perspective, including the covid-19 pandemic allied to the current economic and political scenario, Brazil witnessed an increase in poverty and the number of HP⁵⁰50 Sant’Anna E. Para 43% dos brasileiros, número de moradores de rua aumentou. Folha de São Paulo. 4 jan 2020 [cited 2020 Feb 10]. Available from: https://www1.folha.uol.com.br/cotidiano/2020/01/para-43-dos-brasileiros-numero-de-moradores-de-rua-aumentou.shtml
https://www1.folha.uol.com.br/cotidiano/... . Among its consequences, we can observe, in the short term, an increase of tuberculosis in HP and other vulnerable populations, such as low-income families, favela dwellers or residents of precarious housing⁵¹51 Pereira AGL, Medronho R de A, Escosteguy CC, Valencia LIO, Magalhães MAFM. Spatial distribution and socioeconomic context of tuberculosis in Rio de Janeiro, Brazil. Rev Saude Publica. 2015;49:48. https://doi.org/10.1590/S0034-8910.2015049005470
https://doi.org/10.1590/S0034-8910.20150... since Brazil already has experienced an increase in poverty and misery, as have other Latin American countries⁵⁰50 Sant’Anna E. Para 43% dos brasileiros, número de moradores de rua aumentou. Folha de São Paulo. 4 jan 2020 [cited 2020 Feb 10]. Available from: https://www1.folha.uol.com.br/cotidiano/2020/01/para-43-dos-brasileiros-numero-de-moradores-de-rua-aumentou.shtml
https://www1.folha.uol.com.br/cotidiano/... , ⁵²52 Naciones Unidas, Comisión Económica para América Latina y e l Caribe. El COVID-19 y la crisis socioeconómica em América Latina y Caribe. Rev CEPAL. 2020;(32 ed espec):7-8. .

Our perspective of the concept of vulnerability allowed us to assess that the results found in the analyzed publications evinced the social and programmatic factors associated with tuberculosis and HIV in HP, highlighting the different dimensions of life and healthcare precarization. Thus, this concept was a fundamental support to classify and understand the different susceptibilities permeating HP’s life and hindering the treatment of tuberculosis and HIV, as well as treatment failures due to discontinuity and, consequently, the appearance of drug-resistant strains.

Even with established protocols, guidelines, ordinances, and technical standards to prevent and treat HP’s health, we noticed that the execution of the action plans outlined by government strategies shows important flaws, evincing weaknesses in the health system and public policies aimed at HP, and the stigma and social prejudices health services reproduce. Thus, some lives are more exposed to vulnerability situations and consequently show less access to prevention and protection and are more susceptible to violence from the State and society than others. This is due to various crossings marking these lives as more vulnerable and often unrecognized and invisible.

Recommendations

Based on the results of this review, we recommend greater attention and investment in improving prevention actions and interventions for tuberculosis and tuberculosis+HIV in HP since primary care to routinely assess homeless persons’ vulnerabilities. We also suggest that managers and technicians evaluate the need to change and adjust primary care protocols for HP and integrally distribute resources to the demands which are already known and shown in this study. Political effort and commitment are also necessary to distribute resources destined to health, social policies, and HP assistance.

Systematizing vulnerability factors can support hypotheses for future research and subsidize public health and social policies to cope with tuberculosis and HIV in HP. Our findings, when compared to other systematic reviews, seem to advance the literature by its discussion from a perspective of the concept of vulnerability, unprecedented in national publications, for homeless persons and the prevalence of tuberculosis and tuberculosis+HIV.

Limitations

This study has limitations since, even if its two researchers conducted a wide search of the published studies, a number of texts may yet be digitally unavailable on the surveyed platforms; due to the quick dynamic of publishing, some studies may have escaped search and data collection.

REFERENCES

Publication Dates

History