# Trends and clusters of tuberculosis treatment interruption among people experiencing homelessness in Brazil: influence of individual, social and programmatic factors

## TL;DR

This study examines how tuberculosis treatment interruptions among homeless people in Brazil have changed over time and identifies regional patterns influenced by social and program factors.

## Contribution

The paper introduces a novel ecological analysis combining trend and clustering methods to explore treatment interruption disparities among homeless populations.

## Key findings

- Treatment interruption increased significantly in specific demographic and regional groups, such as men and those in the North and Midwest regions.
- Four clusters of states were identified, each showing distinct socioeconomic and programmatic characteristics related to treatment outcomes.
- Higher inequality and weaker primary healthcare were linked to worse tuberculosis treatment outcomes in the worst-performing cluster.

## Abstract

To analyze temporal trends and state-level clusters of tuberculosis treatment interruption indicators among the homeless population in Brazil.

This is an ecological study, in which treatment interruption among homeless people with tuberculosis was assessed from 2015 to 2023. Joinpoint regression was used for trend analysis, stratified by sociodemographic and epidemiological variables. State clusters were identified by k-means clustering analysis, based on socioeconomic and programmatic indicators.

Tuberculosis treatment interruption increased among: men (average quarterly percent change - AQPC=0.15; 95% confidence interval - 95%CI 0.04-0.29), individuals aged 40-59 years (AQPC=0.38; 95%CI 0.25-0.53), tobacco users (AQPC=0.72; 95%CI 0.61-0.82), beneficiaries of social programs (AQPC=4.59; 95%CI 3.69-6.02), those without directly observed treatment (AQPC=0.49; 95%CI 0.39-0.63), without HIV coinfection (AQPC=0.38; 95%CI 0.30-0.51), and in the North (AQPC=1.51; 95%CI 0.96-2.21) and Midwest (AQPC=0.83; 95%CI 0.17-1.59) regions. According to the cluster analysis, cluster A had the lowest treatment interruption rate, low AIDS incidence, and better programmatic indicators. Cluster B had high poverty and low level of education and income, but strong primary health care performance. Cluster C stood out for its higher human development, better social indicators, and lower inequality. Cluster D concentrated the worst outcomes: higher treatment interruption, greater inequality, higher AIDS incidence, and weaker primary health care.

Socioeconomic and programmatic inequalities were evident in access and attachment to tuberculosis treatment among people experiencing homelessness in Brazil.

Analisar as tendências temporais e os agrupamentos estaduais dos indicadores de interrupção do tratamento da tuberculose na população em situação de rua no Brasil.

Estudo ecológico da interrupção do tratamento da tuberculose na população em situação de rua, de 2015 a 2023. Realizaram-se análises de tendência por regressão joinpoint, estratificadas por variáveis sociodemográficas e epidemiológicas. Aplicou-se análise pelo método k-means para identificar agrupamentos estaduais do desfecho, segundo indicadores socioeconômicos e programáticos.

Houve aumento da interrupção do tratamento para: sexo masculino (variação percentual trimestral média - VPTM=0,15; intervalo de confiança de 95% - IC95% 0,04-0,29), 40-59 anos (VPTM=0,38; IC95% 0,25-0,53), uso de tabaco (VPTM=0,72; IC95% 0,61-0,82), recebimento de benefícios sociais (VPTM=4,59; IC95% 3,69-6,02), ausência de tratamento diretamente observado (VPTM=0,49; IC95% 0,39-0,63), ausência de coinfecção com HIV (VPTM=0,38; IC95% 0,30-0,51), região Norte (VPTM=1,51; IC95% 0,96-2,21) e região Centro-Oeste (VPTM=0,83; IC95% 0,17-1,59). Pela análise de agrupamento, o grupo A apresentou a menor taxa de interrupção, baixa incidência de aids e melhores indicadores programáticos. O grupo B teve elevada pobreza e baixa escolaridade e renda, mas bom desempenho da atenção primária. O grupo C se destacou pelo maior desenvolvimento humano, melhores indicadores sociais e menor desigualdade. Já o grupo D concentrou os piores resultados: maior interrupção do tratamento, desigualdade, incidência de aids e fragilidade na atenção primária.

Notaram-se desigualdades socioeconômicas e programáticas no acesso e na vinculação ao tratamento da tuberculose entre as pessoas em situação de rua no Brasil.