High-risk sexual behavior and HIV/STDs cascade of care in migrants: results from an Italian dedicated outpatient clinic

Introduction: Ethnical segregation and migration influence sexual health. Differences in sexual networks and the risk of sexually transmitted diseases (STDs) between racial/ethnic minorities and the native population have been described in the literature. Methodology: We collected data on sexual behavior and physical examination. Basing on CDC 2015 guidelines on STDs, anamnesis, and clinical features, screening for HIV/STDs was proposed. Results: We enrolled 209 migrants, the median age was 32.5 (26-40) years, and 146 (69.9%) were male. The most represented nationalities were Nigerian, Senegalese, and Somali, with 85 (40.7%), 68 (32.5%), and 16 (7.7%) people, respectively. Twenty-two (10.5%) patients referred perianal/genital lesions, 6 (2.9%) abdominal/pelvic discomfort, and 183 (87.6%) were asymptomatic. Almost all symptomatic patients accepted the tests. 52/183 (28.4%) asymptomatic subjects accepted the tests, and only 24/52(46.2%) performed them. Among symptomatic patients were 6 (24%) HBsAg positivities and one (4%) HCV infection. Four (16%) people had latent syphilis; in 12 (48%) people, HPV-related genital warts were present, 7 (28%) people had Molluscum contagiosum, and 6 (24%) women had pelvic inflammatory diseases. Among patients referring no symptoms, there were 10 (41.7%) HBsAg positivities, one (4.2%) HIV infection, four (16.7%) latent syphilis, one (4.2%) HPVrelated genital infection, and one (4.2%) PID. Being Nigerian and having symptoms were associated with a more high acceptance of the STDs test. Having a high-risk behavior was significantly associated with the development of at least one STD. Conclusions: migrants have high-risk sexual behavior. Despite this, they have a low perception of HIV/STDs risk and healthcare needs. Particular attention should be given to improve access to HIV/STDs services that provide screening and treatment and increase the perception of healthcare needs.


Introduction
Sexually transmitted diseases (STDs) are defined as local or systemic infections, acquired through sexual contacts or objects used in such occasions. In the 21st century, there is still an unacceptably high global incidence of STDs. Around the world, more than one million STDs are acquired every day. The burden of morbidity and mortality worldwide, resulting from sexually, genitally, and extra-genitally transmitted pathogens, compromises the quality of life and sexual and reproductive health, newborn, and child health [1]. Moreover, it is widely recognized that STDs facilitate the sexual transmission of HIV. For example, syphilis increases HIV infection risk by three-fold or more. However, there has been no reduction of new HIV infections rates among young people and adults between 2010 and 2015, threatening future progress towards the goal of ending the AIDS epidemic by 2030 [2]. The prevalence and incidence of STDs significantly change regarding underserved populations. Among these, social determinants such as segregation, migration, and healthcare provision and use can influence STDs spread. As a consequence, epidemiological differences between population subgroups can be highlighted, due to healthcare disparities, with a possible impact on other communities. Furthermore, race and ethnicity seem to represent a substantial element for higher STDs rates than the rest of the population [3]. Published studies showed how HIV/STDs prevalence among racial and ethnic minorities are from 5.4 to 17.8 times higher in respect of Caucasian. Furthermore, young black men and women seem to be at risk regardless of their behavior [4,5]. The CDC surveillance also highlighted the significant difference inherent in ethnicity regarding STDs [6]. The high migratory flows, mostly from Africa to Italy in the last years, increasingly require more attention from healthcare providers to underserved populations such as migrants.
We report our experience and the cascade of care of STDs among migrants referring to our dedicated outpatient clinic in Sassari, Italy.

Study conduction
We conducted a survey among illegal migrants admitted to our dedicated outpatient clinic from July to September 2019.
The anamnesis on sexual behavior, and the data on clinical examination were collected to identify the prevalence of individuals with high-risk sexual patterns or STDs suspicion. The screening for HIV/STDs was purposed based on both the 2015 CDC guidelines on STDs [7]. Screening purpose was also based on the anamnesis regarding sexual behavior, and physical examination. High-risk sexual behavior was defined as having multiple partners, chosen or not, without the use of condoms.

Statistical analysis
Data distribution was evaluated with the Kolmogorov-Smirnov test. Data were elaborated as numbers on total (percentages), and median (IQR) when appropriate.
Categorical variables were evaluated with the Pearson Chi-square test. Univariate analysis was conducted to evaluate factors associated with the acceptance of STDs screening and with the presence of STDs. Independent variables resulting in a p-value < 0.2 at univariate analysis were included in the model. The significance level was defined as a p-value < 0.05.

Ethical issues
This research was conducted according to the Helsinki Declaration. Data were collected anonymously, and all patients signed informed consent.
The patients' demographic characteristics, clinical features, and diagnoses have been summarized in Table 1. After the first evaluation, further investigation with blood tests for HBV, HCV, HIV, syphilis both for the symptomatic and the asymptomatic patients was proposed. People with anal or genital lesions were proposed for dermatovenerologist consultation, in order to  (Table 2), being Nigerian and having symptoms were significantly associated with the level of STDs test acceptance. Instead, only having a high-risk behavior was significantly associated with the development of at least one STD (Table 3).

Discussion
Migrants represent a fragile population, widely studied in literature for a broad spectrum of heathcare needs [8,9]. STDs are among the most crucial world health problems, and their disparities in underserved populations, such as migrants, have been widely discussed in the literature [10]. In any population, the spread of infectious diseases depends on the possibility of contact between susceptible and infected people, and migration could concur with this mechanism. Migrants who attend to healthcare services in our area have a high-risk sexual behavior. Despite this, they seem to have a low perception of HIV/STDs risk and healthcare needs. Migration may represent a central condition that could concur with STDs diffusion. Multiple factors, such as ethnic segregation, lower economic status, education level, and differences in sexual patterns, have been reported in migrants compared to non-migrants, turning the former into a higher risk [11]. It is also described that mixing different subpopulations may  represent a risk factor in the transmission of STDs from a community member to a member of another, who could, in turn, involve all his community in STDs spread [12]. This is why the assessment of high-risk sexual behavior among migrants could represent the first step for creating a successful approach in prevention measures. Furthermore, particular attention should be given to improve knowledge and access to HIV and STDs prevention, screening, and treatment. A right counseling approach is required among this particular population, given the necessity to increase the perception of healthcare needs. In fact, in our cohort, a low rate of patients accepted HIV/STDs screening, including people with symptomatic genital/perianal lesions, who sometimes did not come back to start the treatment. Some limitations should be addressed regarding our study. Particularly, only a limited time has been analyzed. Furthermore, asylum seekers were not included in our cohort. This means that no migrants admitted to the facilities ware part of the study population, and these results could be indicative only for a specific subgroup of migrants. In conclusion, our study highlights the need to improve information among migrants on sexual health and to reduce the barriers encountered by the clinicians in healthcare provision in such challenging settings.