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HIV, tuberculosis and co-infection among migrant populations living in Portugal
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Os migrantes no seu percurso migratório, e no país de acolhimento, são expostos a diversos fatores que podem conferir maior vulnerabilidade ao VIH e à tuberculose (TB). Contudo, a vulnerabilidade a estas infeções nos migrantes tem sido pouco explorada em estudos recentes e em dados oficiais, particularmente no contexto Português.
Esta tese pretende contribuir para o conhecimento sobre a carga das infeções VIH, TB e VIH-TB em populações migrantes em Portugal, e sobre a vulnerabilidade destas populações a estas infeções. Os objetivos específicos estabelecidos são: 1) descrever a prevalência e determinar fatores sociodemográficos, socioeconómicos e comportamentais relacionados com o VIH, TB e coinfecção VIH-TB em migrantes; 2) descrever as características clínicas e genómicas de migrantes com coinfecção VIH-TB; 3) compreender as especificidades e barreiras aos cuidados de saúde da TB em migrantes infetados com TB ou coinfecção VIH-TB. Este trabalho baseia-se numa revisão sistemática da literatura, num estudo transversal de base comunitária, na análise de dados clínicos e genómicos, e num estudo misto com profissionais de saúde.
Em migrantes oriundos da África Subsariana observou-se uma elevada proporção de infeção por VIH (5.4%) e de infeção por TB no passado (4.1%). A revisão sistemática da literatura mostrou também uma maior prevalência de VIH-TB em migrantes face aos nacionais em países Europeus, sobretudo em migrantes da Africa subsariana. Muitos migrantes relataram uso inconsistente do preservativo (82.5%), múltiplos parceiros (23.5%), e sexo comercial (10.8%). Cerca de metade (49.7%) nunca fez teste para o VIH, e mais de um terço (35%) dos VIH-positivos desconhecia o seu estatuto serológico. A infeção por VIH foi associada à idade (1.07 [IC95%:1.03-1.11]), à violência por parte de um parceiro (2.77 [IC95%:1.08-7.10]), e ao uso consistente do preservativo (0.23 [IC95%:0.09-0.58]). Os participantes que tiveram TB no passado foram sobretudo homens (3.42 [IC95%:1.29-9.06]), e VIH-positivos (11.48 [IC95%:4.55-28.94]). Os migrantes co-infetados mais jovens tenderam a ser diagnosticados simultaneamente para as duas infeções, contrariamente aos mais velhos. Nos migrantes co-infetados verificou-se também uma maior proporção de estirpes não-B do VIH comparativamente aos nacionais, relacionadas com uma maior carga viral. Os profissionais dos cuidados de saúde primários relataram que a falta de conhecimento sobre a TB nos migrantes é um obstáculo ao seu diagnóstico precoce. O tratamento é frequentemente interrompido devido a deslocações ao país de origem e à falta de apoio social no país de acolhimento. Também o acesso e uso de cuidados de saúde da TB pelos migrantes são frequentemente dificultados por fatores socioeconómicos, administrativos, e pela reduzida proteção social.
Os resultados deste trabalho mostram que as populações migrantes são vulneráveis ao VIH e à TB em Portugal, particularmente devido ao seu desconhecimento sobre as mesmas e sobre os serviços de saúde, às suas condições económicas, e às dificuldades de acesso à prevenção e a cuidados de saúde. Intervenções futuras são necessárias em proximidade com as comunidades, ao nível da proteção social, da educação para a prevenção, e no acesso aos serviços de saúde, devendo-se também fomentar a cooperação internacional para responder adequadamente a estes problemas de saúde global.
Migrant populations are exposed to several factors throughout their migratory journey and at the host country that can render an increased vulnerability to HIV and tuberculosis (TB). However, migrants’ vulnerability to these infectious diseases has been little explored in recent studies and in official reports, particularly regarding the Portuguese context. This thesis aims to contribute to improve knowledge on the burden of HIV, TB and HIV-TB co-infection among migrant populations in Portugal, and on the vulnerability of these populations to these infectious diseases. The specific objectives proposed are: 1) to describe prevalence and determine sociodemographic, socioeconomic and behavioural factors related to HIV, TB and HIV-TB co-infection among migrants; 2) to describe clinical and genomic characteristics of migrants with HIV-TB co-infection; 3) to understand the specificities and barriers to TB care among migrants infected with TB or HIV-TB. The accomplishment of these objectives is based on a systematic review of literature, on a cross sectional community-based study, on the analysis of clinical and genomic data, and on a mixed-methods study with healthcare providers. High proportion of HIV infection (5.4%) and of a past TB infection (4.1%) were observed among sub-Saharan African migrants. Data from the systematic review of literature have also shown a higher prevalence of HIV-TB among migrants compared to nationals in European countries, particularly among those from sub-Saharan African countries. Many migrants reported inconsistent condom use (82.5%), multiple partners (23.5%) and engagement in commercial sex (10.8%). About half (49.7%) was never tested for HIV. Over a third (35%) of HIV-positive participants were not aware of their HIV status. HIV infection was associated with increasing age (1.07 [IC95%:1.03-1.11]), violence from a partner (2.77 [IC95%:1.08-7.10]), and consistent condom use (0.23 [IC95%:0.09-0.58]). Those who had TB in the past were more likely to be men (3.42 [IC95%1.29-9.06]) and HIV-positive (11.48 [IC95%:4.55-28.94]). Younger co-infected migrants were more likely to be simultaneously diagnosed for both infections, contrarily to older migrants. A higher proportion of non-B HIV strains were also observed among co-infected migrants compared to nationals, which was also related to a higher viral load. Primary healthcare providers referred that migrants’ unawareness about TB is an obstacle to its early diagnosis. Treatment is also frequently interrupted due to travels to their country of origin and due to lack of social support in the host country. Access and use of TB care by migrants is also frequently hampered by socioeconomic and administrative hurdles and by limited social protection. The findings from this work show that migrant populations remain vulnerable to HIV and TB in Portugal, particularly due to their unawareness about these infections and the healthcare services, due to their economic situation, and due to difficulties in accessing preventive measures and health care. Future interventions are needed in proximity with the communities, at social protection level, in the education for prevention, and in the access to healthcare services, also promoting international cooperation to appropriately respond to these global health issues.
Migrant populations are exposed to several factors throughout their migratory journey and at the host country that can render an increased vulnerability to HIV and tuberculosis (TB). However, migrants’ vulnerability to these infectious diseases has been little explored in recent studies and in official reports, particularly regarding the Portuguese context. This thesis aims to contribute to improve knowledge on the burden of HIV, TB and HIV-TB co-infection among migrant populations in Portugal, and on the vulnerability of these populations to these infectious diseases. The specific objectives proposed are: 1) to describe prevalence and determine sociodemographic, socioeconomic and behavioural factors related to HIV, TB and HIV-TB co-infection among migrants; 2) to describe clinical and genomic characteristics of migrants with HIV-TB co-infection; 3) to understand the specificities and barriers to TB care among migrants infected with TB or HIV-TB. The accomplishment of these objectives is based on a systematic review of literature, on a cross sectional community-based study, on the analysis of clinical and genomic data, and on a mixed-methods study with healthcare providers. High proportion of HIV infection (5.4%) and of a past TB infection (4.1%) were observed among sub-Saharan African migrants. Data from the systematic review of literature have also shown a higher prevalence of HIV-TB among migrants compared to nationals in European countries, particularly among those from sub-Saharan African countries. Many migrants reported inconsistent condom use (82.5%), multiple partners (23.5%) and engagement in commercial sex (10.8%). About half (49.7%) was never tested for HIV. Over a third (35%) of HIV-positive participants were not aware of their HIV status. HIV infection was associated with increasing age (1.07 [IC95%:1.03-1.11]), violence from a partner (2.77 [IC95%:1.08-7.10]), and consistent condom use (0.23 [IC95%:0.09-0.58]). Those who had TB in the past were more likely to be men (3.42 [IC95%1.29-9.06]) and HIV-positive (11.48 [IC95%:4.55-28.94]). Younger co-infected migrants were more likely to be simultaneously diagnosed for both infections, contrarily to older migrants. A higher proportion of non-B HIV strains were also observed among co-infected migrants compared to nationals, which was also related to a higher viral load. Primary healthcare providers referred that migrants’ unawareness about TB is an obstacle to its early diagnosis. Treatment is also frequently interrupted due to travels to their country of origin and due to lack of social support in the host country. Access and use of TB care by migrants is also frequently hampered by socioeconomic and administrative hurdles and by limited social protection. The findings from this work show that migrant populations remain vulnerable to HIV and TB in Portugal, particularly due to their unawareness about these infections and the healthcare services, due to their economic situation, and due to difficulties in accessing preventive measures and health care. Future interventions are needed in proximity with the communities, at social protection level, in the education for prevention, and in the access to healthcare services, also promoting international cooperation to appropriately respond to these global health issues.
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Saúde pública Sida HIV Tuberculose Co-infeção VIH-TB Migrantes Vulnerabilidade