Factors associated with unsuccessful tuberculosis treatment among homeless persons in Brazil: A retrospective cohort study from 2015 to 2020.

Background: Tuberculosis (TB) is a preventable and a curable disease. In Brazil, TB treatment outcomes are particularly worse among homeless populations who are either of black race, malnourished or living with HIV/AIDS and other comorbidities. This study therefore evaluated factors associated with unsuccessful TB treatment among homeless population (HP) compared to those with shelter. Methodology/Principal findings: The study population was composed of 284,874 people diagnosed with TB in Brazil between 2015 and 2020 and reported in the Information System for Notifiable Diseases (SINAN), among which 7,749 (2.72%) were homeless and 277,125 (97.28%) were sheltered. Cox regression analysis was performed with both populations to identify factors associated with unsuccessful TB treatment, and significant predictors of TB treatment outcomes. Results show that HP are more susceptible to unfavorable outcomes when compared to sheltered people (Hazard Ratio (HR): 2.04, 95% CI 1.82–2.28). Among the HP, illicit drug use (HR: 1.38, 95% CI 1.09–1.74), mental disorders (HR: 2.12, 95% CI 1.08–4.15) and not receiving directed observed treatment (DOT) (HR: 18.37, 95% CI 12.23–27.58) are significant predictors of poor treatment outcomes. The use of illicit drugs (HR: 1.53, 95% CI 1.21–1.93) and lack of DOT (HR: 17.97, 95% CI 11.71–27.59) are associated with loss to follow-up, while lack of DOT (HR: 15.66, 95% CI 4.79–51.15) was associated with mortality among TB patients. Conclusion/significance: Homeless population living in Brazil are twice at risk of having an unsuccessful treatment, compared to those who are sheltered, with illicit drugs use, mental disorders and lack of DOT as risk factors for unsuccessful TB outcomes. Our findings reinforce the arguments for an intersectoral and integral approach to address these determinants of health among the vulnerable homeless populations. Author summary: Tuberculosis is one of the world's most deadly disease and is responsible for 4,000 deaths daily. People living in impoverished conditions, especially those who are homeless are among the worst affected. In Brazil, the population of homeless persons is rising. This population is affected by socioeconomic issues such as worst jobs, structural racism, lack of civil rights, limited access to health care service and stigmatization. Our study therefore investigated the reasons why tuberculosis treatments are unsuccessful among homeless people in Brazil in comparison to populations with shelter. We found out that homeless population living in Brazil are twice at risk of having an unsuccessful treatment, compared to those who are with shelter. In addition, we found that homeless population who use illicit drugs and had mental illness were the most affected. Also, the non-implementation of directly observed treatment is a major reason why most patients do not complete their treatment, and a major predictor of death among these homeless populations. Since tuberculosis is a preventable and curable disease and diagnosis and treatment are freely available in the Unified Health System (SUS, Sistema Único de Saúde) of Brazil, it therefore becomes important to understand and address these barriers that have limited the access of homeless populations to existing health services. [ABSTRACT FROM AUTHOR]