ATTENTION TO SEXUALLY TRANSMITTED INFECTIONS AMONG WOMEN EXPERIENCING HOMELESSNESS: PERSPECTIVES OF STREET CLINIC NURSESABSTRACT
Objective: To analyze the care practices provided to women experiencing homelessness by Street Clinic nurses in the context of sexually transmitted infections.
Method: Descriptive, qualitative study analyzed in light of the concept of vulnerability. Remote semi-structured interviews were conducted between October 2022 and June 2024 with 12 nurses working in the Street Clinic program in the Northern region of Brazil.
Results: Vulnerability permeates nursing care in all its dimensions. In street-based practice, nurses employ different strategies for prevention, health promotion, diagnosis and treatment of sexually transmitted infections, as well as referrals and territorial interventions. A context of programmatic vulnerability is evident within the networked care provided to women experiencing homelessness.
Conclusion: Care practices aimed at women experiencing homelessness for the prevention of sexually transmitted infections are challenging and traverse multiple dimensions of vulnerability. The actions carried out by nurses in loco within the territory contribute to improving access to care for this population.
Descriptors:
Primary health care; Sexually transmitted infections; Nursing; Women’s health; Homeless people; Health vulnerability
RESUMO
Objetivo: Analisar as práticas de cuidado às mulheres em situação de rua de enfermeiros(as) do Consultório na Rua frente às infecções sexualmente transmissíveis.
Método: Estudo descritivo, qualitativo, analisado à luz do conceito de vulnerabilidade. Foram realizadas entrevistas semiestruturadas, por via remota, no período de outubro de 2022 a junho de 2024, com 12 enfermeiras(os) que atuavam no Consultório na Rua na região Norte do Brasil.
Resultados: A vulnerabilidade perpassa o cuidado da(o) enfermeira(o) em todas as suas dimensões. Na atuação nas ruas, utilizam-se diferentes estratégias de prevenção, promoção da saúde, diagnóstico e tratamento de infecções sexualmente transmissíveis, encaminhamentos e intervenções no território. Evidencia-se contexto de vulnerabilidade programática no cuidado em rede de atenção às mulheres em situação de rua.
Conclusão: As práticas de cuidado às mulheres em situação de rua na prevenção de infecções sexualmente transmissíveis é desafiadora e perpassa as dimensões da vulnerabilidade. As ações realizadas por enfermeiras(os) in loco no território contribuem para a acessibilidade ao cuidado dessa população.
DESCRITORES:
Atenção primária à saúde; Infecções sexualmente transmissíveis; Enfermagem; Saúde da mulher; Pessoas mal alojadas; Vulnerabilidade em saúde
RESUMEN
Objetivo: Analizar las prácticas de cuidado brindadas a mujeres en situación de calle por enfermeras de los Consultorios na Rua en el contexto de las infecciones de transmisión sexual.
Método: Estudio descriptivo y cualitativo, analizado a la luz del concepto de vulnerabilidad. Se realizaron entrevistas semiestructuradas de forma remota entre octubre de 2022 y junio de 2024 con 12 enfermeras que trabajan en el programa Consultorio na Rua en la región Norte de Brasil.
Resultados: La vulnerabilidad atraviesa el cuidado de enfermería en todas sus dimensiones. En la práctica realizada en la calle, las enfermeras emplean diferentes estrategias de prevención, promoción de la salud, diagnóstico y tratamiento de infecciones de transmisión sexual, además de derivaciones e intervenciones territoriales. Se evidencia un contexto de vulnerabilidad programática dentro del cuidado en red dirigido a mujeres en situación de calle.
Conclusión: Las prácticas de cuidado dirigidas a mujeres en situación de calle para la prevención de infecciones de transmisión sexual son desafiantes y atraviesan múltiples dimensiones de vulnerabilidad. Las acciones realizadas por las enfermeras in loco en el territorio contribuyen a mejorar el acceso a la atención para esta población.
Descriptores:
Atención primaria de salud; Infecciones de transmisión sexual; Enfermería; Salud de la mujer; Personas en situación de calle; Vulnerabilidad en salud
INTRODUCTION
In Brazil, 1 in every 1,000 people is experiencing homelessness, and women represent approximately 13% of this population group1. Life on the streets exposes women to challenging situations that affect the integrity of their bodies, their sexuality, and their health2.
When compared with the general population, women experiencing homelessness present worse physical and mental health conditions and, consequently, a higher risk of premature death2-4, as well as a greater risk of acquiring sexually transmitted infections (STIs), gynecological problems, unintended pregnancy, and unsafe abortion2-3,5.
From this perspective, women experiencing homelessness have distinct sexual and reproductive health needs, which pose challenges for health services and systems4. Consistent use of prevention methods has the potential to reduce STI transmission. However, barriers persist in accessing health services and prevention measures among people experiencing homelessness (PEH)6-9.
The “Consultório na Rua” (“CnaR”, Street Clinic) strategy, established in 2011 by the National Primary Care Policy, aims to expand access to the health care network for people experiencing homelessness and to provide health care through the development of bonds, qualified listening, dialogical relationships, intersectoral collaboration, interdisciplinary work, and shared care3,10. It is composed of multiprofessional teams whose distinguishing feature is in loco work carried out directly in street settings, with the challenge of addressing health needs and promoting care and health actions for PEH3,10. Within the multiprofessional team, nursing work specifically encompasses comprehensive care for individuals, families, and the community, involving clinical, managerial, educational, and investigative activities aimed at promoting, maintaining, and restoring individual and collective health11.
A scoping review highlights that nurses’ knowledge, attitudes, and practices significantly contribute to improving access to health services for PEH, particularly in the context of education, sexual and reproductive health promotion, and STI prevention12. Brazilian studies addressing care for this population within the CnaR exist; however, they do not explore gender issues and are concentrated in state capitals of the Southeast region10,13. The present study aims to analyze the care practices directed at women experiencing homelessness by CnaR nurses in the context of STI prevention and management in the Northern region of Brazil.
METHOD
This is a qualitative study that followed the guidelines established by the Consolidated Criteria for Reporting Qualitative Research (COREQ)14. The theoretical framework was based on the concept of vulnerability, in which the likelihood of individuals’ exposure to HIV and subsequent illness from AIDS results from a set of individual, collective, and contextual factors that increase susceptibility to infection and disease. The individual dimension of vulnerability includes biological, behavioral, and affective aspects that heighten susceptibility to adverse health outcomes. The social component relates to the influence of socioeconomic and cultural contexts. The programmatic dimension refers to how policies, programs, health services, and the distribution of resources for prevention and control shape the response to STIs/HIV15 The care provided by CnaR nurses is understood as an element of the programmatic vulnerability of women experiencing homelessness to STIs/AIDS16.
The study was conducted in CnaR services in the Northern region of Brazil, across eight municipalities in six states: Acre, Amapá, Amazonas, Pará, Rondônia, and Tocantins. These services aim to provide care for people experiencing homelessness, sex workers, migrants, Warao Indigenous peoples, and other groups in situations of vulnerability, considering their regional specificities
Nurses who had been working in the CnaR for more than six months and who had experience in providing primary care to women experiencing homelessness were included in the study. Professionals who were on medical leave or vacation were excluded. Participant selection followed a convenience sampling strategy, and data collection took place between October 2022 and June 2024.
Recruitment of potential participants was carried out by sending emails to state and municipal health departments in the Northern region of Brazil, requesting the contact information of the Street Clinic coordinators. After receiving institutional responses, the contact information of nurses working in each team was requested, and individual invitations were then sent electronically. Additionally, invitations to participate in the study were posted on the social media pages (Instagram® and Facebook®) of CnaR teams. The message sent to potential participants included an introduction of the research team, the name of the affiliated institution, the objective of the study, information that the interview would be conducted online, a statement ensuring data confidentiality, and the Free and Informed Consent Form (FICF).
After expressing interest and digitally signing the FICF, the interview date and time were scheduled according to the participant’s availability. In total, invitations were sent to 19 potential participants, of whom 14 agreed to take part. However, in three cases there was no further response, resulting in a total of 12 interviews conducted. One of the researchers scheduled the semi-structured interviews, which were held remotely and recorded via Google Meet®. The interviews were conducted by two nurse researchers, both holding doctoral degrees, and a nursing undergraduate student trained for this activity. It is noteworthy that the interviewers had no prior contact with the services or with the participants. Each interview lasted an average of 50 minutes and was conducted only once with each participant.
Data collection was concluded when the themes brought up by participants during the interviews began to repeat and no new insights emerged, as perceived by the researcher during the continuous process of data analysis. Content saturation indicated that the empirical material was sufficient to meet the study’s objectives17. The data collection instrument consisted of a semi-structured guide divided into two parts: the first included sociodemographic variables such as age, self-reported race, level of education (specialization, master’s, doctorate), and length of experience in the CnaR. The second part comprised open-ended questions related to nursing care for women experiencing homelessness in the context of STIs, with guiding questions such as: “How is the approach to STIs carried out in the CnaR?” and “What is the nurse’s care practice for women experiencing homelessness diagnosed with an STI?” A pilot test was conducted with two participants to assess the clarity, relevance, and sequence of the instrument. The test allowed evaluation of the adequacy of the questions to the participants’ reality. No difficulties in understanding or need for adjustments were identified. Therefore, the responses obtained in the pilot test were retained and incorporated into the study’s analytical corpus.
After data collection, the interviews were transcribed. To ensure participant confidentiality, each interview was identified with the letter “E” followed by a cardinal number corresponding to the order in which the interviews were conducted. The data were analyzed using content analysis according to the model described by Morse and Field18, developed in sequential stages: apprehension, synthesis, theorization, and recontextualization. The results were interpreted in light of the concept of vulnerability15, which made it possible to understand how individual, collective, and structural factors influence care. Through content analysis, three categories were defined: “Nurses’ perceptions of the vulnerabilities of women experiencing homelessness regarding STIs and HIV,” “Care practices in the prevention and management of STIs” and a third category titled “Challenges in nursing care within the Street Clinic: reflections of programmatic vulnerability”.
The study was approved by a Research Ethics Committee. All ethical procedures were rigorously followed in accordance with Resolution 466/2012 of the “Conselho Nacional de Saúde” (Brazilian National Health Council) for research involving human subjects, ensuring confidentiality, anonymity, and the right to withdraw at any time without any disadvantage to participants. Access to the data was restricted exclusively to the research team, and sharing with third parties was prohibited. Digital files were stored on a computer and kept in an encrypted institutional folder throughout the analysis process. In this way, all ethical principles were ensured in accordance with current regulations and the General Data Protection Law (Law No. 13.709/2018), guaranteeing respect for participants’ dignity and rights.
RESULTS
A total of 12 nurses participated in the study, with a mean age of 35 years, nine of whom were women. Seven participants identified as mixed race (“parda”), four as white, and one as Black. Regarding marital status, seven were married or in a stable union. The average time since graduation was 10 years. Ten nurses held a specialization in different areas of nursing, seven of them in public/community health, and two held a master’s degree.
The results of the content analysis of the interviews are presented according to three categories: “Nurses’ perceptions of the vulnerabilities of women experiencing homelessness regarding STIs and HIV,” “Care practices in the prevention and management of STIs” and “Challenges in nursing care within the Street Clinic: reflections of programmatic vulnerability”.
Nurses’ perceptions of the vulnerabilities of women experiencing homelessness regarding STIs and HIV
Participants from different municipalities mentioned the high incidence of STIs among PEH, especially syphilis and HIV, affecting individuals across groups - men and women, young people and older adults - and expressed growing concern about the increasing number of HIV cases:
We have a high incidence of syphilis, and it’s not limited to a specific group: men, women, young people, older adults (E3).
(...) we have a high rate of STIs [among people experiencing homelessness], most of them syphilis and HIV, and they even receive follow-up care in specialized services (E4).
Here in the state, we have a very high incidence of sexually transmitted infections, especially HIV (E8).
A particular feature of the Northern region stands out: the need to provide care for Indigenous peoples and migrants, especially those coming from Venezuela, forming groups that move in flows toward different state capitals:
Most of the immigrants living on the streets come from Venezuela, Indigenous people. I think 90% are from the Warao ethnic group. In fact, we have a [CnaR] team that was created especially for them (...) (E1).
Some go to Roraima. From Roraima to Manaus. From Manaus to Belém. Then Maranhão. From there they continue on to other cities in the Northeast and Southeast. And they go back and forth (E4).
The nurses highlighted the issue of multiple sexual partnerships and the dynamics of gender relations. People experiencing homelessness often move between shelters and street settings, where they engage in panhandling and sexual activities, even when they may have a steady partner, whether on the street or in the shelter.
I believe that these [sexual partnerships] can have a very significant impact on sexual health, on women’s health. Because many times the men go out ‘to work,’ which means to beg on the streets, and they end up having sexual relations elsewhere (E8).
And we noticed that the men stay at home or remain in a base location. And the women go out to collect [money] on the streets (E11).
I think that most women really always have a partner, and they are always dominated by them. So, for us to be able to reach her, we have to reach him first, right? (E12).
The participants’ statements reveal that women experiencing homelessness face violence not only from their partners but also from other groups.
Both violence and the risk of physical violence, sexual violence, the risk of encountering someone with whom they do not have a good relationship - we have people, including women, who stay in one territory but cannot go to another. They cannot cross into another territory because they are marked (E3).
Women who experience multiple forms of violence on the streets. And it is very common - sexual, physical, and moral violence - including perpetrated by public agents (E4).
The nurses identified women in different situations within CnaR care, such as sex workers and transgender women, and reported using diverse strategies for sexual health care and STI prevention. These strategies aimed both to identify the particularities of each group and to address the unique needs of each individual.
(...) the [women] who engage in sex work are aware of condom use, (...) those who work as sex professionals inside the nightclubs here in X [city] and the girls who engage in sex work on the corner. And also the trans woman sex worker (E3).
We carry boxes of condoms in the car; we arrive distributing them when the woman accepts, and also for the men. Women are more interested in condoms than men” (E4).
We advise them: ‘Look, you have to use condoms.’ We make them available; on every route we take, we bring condoms and distribute them (E8).
The main methods we use are barrier methods, both male and female, but there is greater demand for male condoms (E9).
They seek to provide both internal and external condoms, although the people experiencing homelessness who receive care show a preference for the external option.
They [men experiencing homelessness] only use male condoms. They do not accept the female condom at all, not even the women. They say it’s not good, that it’s uncomfortable (E1).
We work mostly with male condoms because they don’t like the female one. (...) the male condom they take in large quantities. Many are concerned about protecting themselves, not only regarding contraception but also STI prevention (E2).
The female condom doesn’t have much demand; we have a large supply, but they don’t like it. They say it’s too big, that it’s ugly, that it’s very difficult. Even when we offer it, they prefer to take the male one (E3).
They take condoms when we pass by distributing them, and they take a lot of male condoms. We also have the female one, but the women don’t like using it (E6).
They highlighted the difficulties faced by women in negotiating condom use with their sexual partners as a prevention strategy.
All of them understand the importance of using condoms, but sometimes, due to the man’s imposition, they end up not using them. (...) because if she doesn’t do what he says, he won’t pay [for the sexual encounter], and then she won’t receive the money, even though she needs it. So she ends up giving in. (...) Others say they would even use it, but the partner doesn’t want to (E3).
We end up distributing condoms directly to the woman, into her hands. This became a strategy to ensure care, because we realized that the way we used to work [delivering boxes of condoms to the person responsible for the territory] did not give women access. (...) there was reuse of condoms (E4).
They use male condoms; they say their partners prefer them (E8).
Care practices in the prevention and management of STIs
Counseling was one of the main tools used by the nurses, a moment in which they took advantage of their interaction with women experiencing homelessness to implement strategies aimed at reducing the risk of STI transmission, address knowledge about transmission, and emphasize the importance of adhering to prevention measures. In street settings, they reported the possibility of conducting consultations and performing rapid tests for HIV, syphilis, and hepatitis B and C, as well as referring individuals to specialized services in the event of a reactive result. During these encounters, health promotion and disease prevention actions were also carried out with women experiencing homelessness.
We provide guidance regarding Pap smears, routine exams, and testing for HIV, syphilis, and hepatitis (E2).
We carry out testing, distribute condoms, and provide counseling to them (E5).
When we go out on our route, we offer all the available health services. We offer rapid testing; consultations with the physician, who is a general practitioner; wound care; psychological support. During these actions, we end up identifying people who are HIV-positive, and when we do, we refer them to the specialty center (E7).
They always ask us to perform rapid STI tests. We work with HIV, syphilis, hepatitis B, and hepatitis C (E8).
The provision of Pre-Exposure Prophylaxis (PrEP) to women sex workers was another action highlighted by the participants. These actions included carrying out interventions in nightclubs with the aim of engaging in dialogue with them, informing them, and encouraging their use of PrEP as a preventive measure against HIV/AIDS. The nurses emphasized that these interventions were part of a continuous process, with several stages - from the initial explanation to identifying those interested - while underscoring the importance of respecting the women’s autonomy throughout this process. They also highlighted the success of offering PrEP in primary health care units.
We created a schedule precisely to introduce the topic of PrEP to the homeless population, specifically to these women [sex workers]. So we are now starting two interventions inside the nightclubs (...). These are nightclubs where only prostitution takes place. (...) One day will be for explaining, another day for us to start thinking about how PrEP will be used. Another day we will ‘select’ the girls to start using it. Actually, I don’t know if ‘select’ is the right word, because they also have to want it (E3).
We offer PrEP; we interact with the primary health care units (UBS) that provide it, right? And we are already able to include them in this service. In fact, some patients - mainly sex workers - are already enrolled to use PrEP (E8).
The nurses highlighted the importance of the syndromic approach when caring for women experiencing homelessness who present with symptoms such as pain, genital itching, vaginal discharge, among others. During these encounters, they performed rapid tests, provided medication when needed, and referred women for medical consultations. They emphasized that immediate intervention in street settings is essential, taking advantage of the opportunity to offer treatment in loco whenever possible.
When they present an STI-related issue - ‘Oh, I’m feeling pain,’ ‘I have itching in my genital area,’ or ‘I have discharge’ - we immediately proceed with the rapid tests and with medication when needed (...) and request that they undergo a medical evaluation (E2).
The clinical assessment is extremely important in this regard, based on the reports of symptoms. If I identify something, some other suspicion - for example, when it is related to gonorrhea - we try to take them to the health unit, when possible, for evaluation by another professional, a physician; or, following protocol, I provide treatment. We make treatment available right there on the street. (...) I am able to perform a clinical exam, when they allow me, and I provide immediate treatment (E9).
(...) [among people experiencing homelessness] there are many STIs, a lot of syphilis. We provide a great deal of syphilis treatment, rapid testing, we identify it and immediately begin treatment (E12).
Challenges in nursing care within the Street Clinic: reflections of programmatic vulnerability
Barriers to accessing health services and long waiting times for specialized care were evident, with repercussions for morbidity and mortality among people experiencing homelessness due to the worsening of their clinical conditions.
The network itself shows its flaws, its gaps. Administrative and bureaucratic failures, the impossibility of scheduling a specialized consultation, of scheduling a specialized exam, even when the exam or consultation needs to be urgent… Because this person is with me today, and in a week they may already have died on the street. So it’s complicated for us to try to secure a consultation or a specialized exam for six months from now. Six months from now, this person may no longer be with us (E2).
The nurses also reported difficulties with adherence to STI treatment due to adverse events associated with the medications. For women experiencing homelessness, challenges in adherence and treatment discontinuation are intensified, given the lack of housing and shelter, which results in inadequate conditions for care.
The treatment for HIV and AIDS, we know it is difficult and causes several adverse effects, which hurt and greatly affect the person’s health. For them it is even harder. They have nowhere to stay, nowhere to take shelter during this period. So most of them start treatment and end up stopping because of this, because the discomfort, the harm, is too painful for them to endure while living on the street (E7).
There are some women with HIV, and we follow up with them to get their medication, right? To check whether they are picking up their medication. We try to accompany them to the service to see if they go, because many give up on treatment (E8).
In addition, they emphasized the difficulty women experiencing homelessness face in adhering to treatments that require regularity and continuous care, given the context of social vulnerability in which they live and the dynamics of street life and territorial mobility.
On the street, they don’t have a schedule, they don’t have a sense of time. So how is a person experiencing homelessness supposed to follow a treatment that requires care, timing, and regularity? This makes their participation and acceptance of treatment much more difficult. That’s when we ended up losing some women to these diseases (E7).
We follow them on the street itself; for syphilis and some other STIs, we provide treatment right there, even to ensure that it gets done. And even then, sometimes we can’t guarantee it - they leave places easily, they wander and don’t stay in the same location for long. But by going into the territory, we can ensure they receive treatment. When they have to go to the health unit, it’s more difficult. So we prefer to go to them to guarantee treatment (E11).
The worst part is when we don’t get results - when we start syphilis treatment and we can’t follow through and don’t see outcomes. It’s frustrating. You search, you look for them, and the next week you can’t find them. Then you have to start all over again. We couldn’t resolve it (E12).
In caring for women experiencing homelessness, nurses demonstrated efforts to mobilize community resources, carrying out solidarity actions to gather basic supplies that were not provided by health services and/or social assistance.
Beyond our professional work, we also manage to go further. What does ‘going further’ mean? Bringing clothing, giving a basic food basket, buying medication when it’s not available in the public system. We manage this through a support network of donors, through groups of friends (...). This is what it means to go beyond the professional role. It’s understanding that these are people in need, and when the system cannot provide a response or ensure comprehensive care, we try, in our own way, to make it happen (E2).
There are cultural considerations in the provision of care that must be taken into account during assistance, such as the offer of rapid tests, particularly when addressing the specific needs of the Warao ethnic group.
They [Warao] are guided by their own magic, so it is very complicated even to perform an HIV test, that rapid test. Because it requires drawing blood, it was difficult to show them that I wasn’t a sorcerer! And they would say: ‘Look, I’m not going to take the test because I don’t have any blood left’ (E1).
The nurses also highlighted language as a barrier in providing care to immigrants and Indigenous peoples. The strategies used by these professionals included relying on interpreters, including Warao children, who more easily learned Portuguese. At times, translation was required from Portuguese to Spanish and then from Spanish to Warao, illustrating the communication challenges-an essential element of care. They also mentioned using other linguistic resources, such as miming and gestures.
I think the first thing would be to develop a communication strategy. (...) for us to study at least the most common words in the Warao language, so that we can understand at least those related to health. So that we can communicate not only through gestures, because sometimes that’s complicated (E1).
It’s very complicated because the older ones don’t speak Spanish, they only speak Warao, and usually it’s their chief! Communication ends up being more complicated, because it goes from Portuguese to Spanish, from Spanish to Warao, and from Warao back to Spanish, and from Spanish back to Portuguese, you know? (E3).
Sometimes they say they understood what we said, but when we ask them to repeat it - for example, instructions about a medication - they say everything the opposite of what we said. So communication is a major barrier to providing care (E4).
And half of them, let’s say, can speak Spanish; the other half speak Warao, which is their native Indigenous language. And for those who speak Warao, it’s complicated to communicate. We need an interpreter, who is sometimes the little kids, the younger ones. They already speak a bit of Portuguese. Some of them know a little Spanish. So they speak, they translate, and there’s a lot of miming involved (E6).
DISCUSSION
The prevention and management practices for STIs carried out by nurses in the CNaR in the Northern region of Brazil revealed contexts that cut across the individual, social, and programmatic dimensions of vulnerability experienced by women living on the streets. As members of the teams, nurses draw on training and work processes that integrate knowledge from the basic biological sciences, psychology, and the social sciences - an important foundation for delivering differentiated care to this population. Studies highlight tailored approaches that consider the diversity of sexual practices that may occur, recognize the presence of psychoactive substance use in different contexts, and identify inconsistent use of barrier methods, transactional sex, and unprotected sexual encounters resulting from situations of sexual abuse, all of which increase these women’s vulnerability to STIs2,5-7,9,19. Nurses in this study perceive distinct care contexts for women experiencing homelessness in the region, where there is a high proportion of Indigenous peoples. It is noteworthy that 0.2% of Indigenous people in Brazil are experiencing homelessness, with higher rates in the Northern region (0.5%), which also has the highest proportion of people experiencing homelessness who were born in another country (33%)1.
The Northern region of Brazil presents particular characteristics regarding PEH, influenced by geographic, social, and cultural contexts. The vast territorial extension and the presence of international borders facilitate migratory flows and increase the vulnerability of marginalized groups20. These borders may also function as corridors for human trafficking and sexual exploitation, especially of women and adolescents, heightening vulnerability to STIs21.
The present study identified challenges related to condom use, particularly internal condoms, which reflects individual vulnerability, considering risk perception, adoption of self-protection measures, personal attitudes, experiences of sexuality, and the ability to negotiate safer sexual practices15. Gender relations permeate the social dimension of vulnerability15, as being a woman and experiencing homelessness amplifies socially shared stigmas, where gender intersectionality reinforces other forms of exclusion22. Difficulties faced by women experiencing homelessness in negotiating condom use highlight gender inequality - historically unfavorable to women - which undermines their autonomy in decision-making, including the negotiation of protected sex4.
Condom use is low among sexually active PEH, with only 18.4% reporting consistent use in all sexual encounters19. The use of internal condoms among women experiencing homelessness is even lower, reaching only 8%8. There is clear evidence of limited knowledge about STI transmission and prevention among this population8, as well as limited understanding of the benefits of barrier methods in preventing these infections9, which reinforces the role and actions of CnaR nurses in health education. Nurses can contribute to strengthening sexual health empowerment by supporting women’s participation in decision-making, enhancing their capacity for sexual negotiation and communication, and improving their understanding of HIV and STI risk and the use of prevention methods23.
The in loco work of nurses enabled access to care for women experiencing homelessness, as well as the implementation of interventions in areas of greater social vulnerability. In the work of CnaR teams, knowledge of the territory, itinerant practices, and the promotion of accessibility to health services - through actions grounded in health promotion and equity - support the provision of comprehensive care10. It is essential to understand the collective as a shared space, recognizing how it is constructed through interactions among people in the various contexts in which they live, within everyday situations where they are exposed (or made vulnerable) to STIs/HIV24. The in loco work of nurses in the CnaR has the potential to decode the dynamics of exposure scenes embedded in territorial contexts, which carry specific sociocultural characteristics and programmatic conditions within the “SUS” (Brazilian Unified Health System) and the Unified Social Assistance System that are unique to each locality24.
Among the actions implemented by nurses to reduce the risk of STI transmission, counseling, nursing consultations, syndromic management, and rapid testing stood out. Counseling is an essential listening tool that helps establish bonds and respects individuals equitably, aiming to ensure continuity of care and comprehensive health attention. However, for these objectives to be achieved, professionals must be adequately prepared to practice empathetic listening and promote positive reframing of sexuality25.
Failures in STI testing have been identified in the sexual and reproductive health care of women living in Amazonian border regions20. Evidence shows that a portion of sexually active people experiencing homelessness go long periods without testing, do not receive post-test counseling5, and do not use any form of STI prevention6. Additionally, some women experiencing homelessness have never undergone STI testing, reinforcing the importance of nurses’ in loco actions. It is important to highlight that PrEP and antiretroviral treatment for people living with HIV are essential for HIV prevention and reducing transmission among people experiencing homelessness5. There is evidence of PrEP adherence among part of this population, as well as interest in using it as a prevention strategy5. Therefore, implementing health education actions to increase knowledge and adherence to PrEP5 is an important strategy that can be carried out by nurses in the CnaR.
An intervention study conducted in the United States identified the impact of nurses’ actions through the implementation of motivational interviewing techniques and shared decision-making strategies, with the development of individualized care plans and mutually agreed-upon goals for HIV prevention among young people (16-25 years) experiencing homelessness. The intervention focused on promoting HIV prevention behaviors, such as PrEP, HIV/STI testing, avoiding sexual practices under the influence of substances, and condom use. After the intervention, increased adherence to PrEP was observed, although no significant changes were found regarding nPEP use, condom adherence, avoiding sex under the influence of substances, or HIV/STI outcomes19.
Within the scope of nurses’ actions, individuals with reactive diagnostic results for STIs are referred to secondary care services. Primary health care serves as the entry point for people experiencing homelessness into the health system, through the CnaR10. The work of the CnaR includes matrix support, referral, and counter-referral to ensure comprehensive care, based on interdisciplinary and networked practices to better address the needs of people experiencing homelessness, especially in managing more complex cases3,10.
Programmatic vulnerability was evident through barriers in accessing health services, referral to specialized care, continuity of care, and access to supplies and basic living conditions during treatment - elements necessary for restoring health. A shortage of services for PEH was identified, as well as challenges in coordinating with other health services13. This highlights the need to restructure services and strengthen articulation with other components of the care network to advance health assistance for this population, with the aim of overcoming institutional exclusion and the stigma experienced by these individuals26.
The present study also identified women’s resistance to treatment adherence and to engaging with the CnaR team as a barrier. Women experiencing homelessness face significant challenges in adhering to treatment, such as lack of stable housing, lack of financial resources, social stigma, discrimination in health services, and difficulty maintaining a regular health-care routine27. Additionally, the geographic mobility of PEH must be considered, as it makes continuity of care even more challenging19.
The lack of connection between women experiencing homelessness and health professionals represents a barrier to the use of STI prevention methods8. Stigma and prejudice lead to delayed access to health services and worsening health conditions2-3. Another barrier relates to women’s lack of knowledge about the availability of health services2. Nurses must recognize and support women experiencing homelessness as active participants in seeking health services, improving their care experience28.
It is essential to build bonds, establish horizontal care relationships, and provide high-quality professional assistance free from stigma and prejudice, while recognizing each person’s singularities3,10,13,28. Such an approach is crucial, as women will only return to health-care settings if they feel safe and protected, with the assurance that their dignity will be preserved28.
The specificities of the Northern region of Brazil and the challenges identified in caring for Indigenous peoples in urban areas and immigrants experiencing homelessness must be considered. Migratory flows have repercussions for the health system, including structural problems related to fragile infrastructure, shortages of trained professionals, and work overload29, all of which intensify conditions of programmatic vulnerability15. It is also important to highlight ethnic-cultural aspects, such as language barriers, which further limit the quality of health care29.
Greater investment in services aimed at PEH can serve as a valuable tool for improving access to health care, reducing barriers to care, and contributing to the elimination of disparities in the care of women experiencing homelessness8. Considering the health inequities in Brazil and the need for increased health investments in the Northern region30 - combined with the demands generated by growing migratory movements, which often overload local health systems29 - the potential of the CnaR becomes evident in promoting comprehensive care, equity, and the defense of rights, strengthening citizenship10. When identifying health vulnerabilities, challenges and opportunities also emerge for building a more just and supportive society24.
The study presents limitations, such as the remote conduction of interviews and the impossibility of observing nurses’ care practices. On the other hand, conducting the study remotely made it possible to learn about different realities in the care of women experiencing homelessness in the Northern region. Another limitation concerns the fact that the study did not assess the experiences of the women themselves, which could have offered a broader understanding of issues related to STI prevention and treatment. This limitation highlights the need for future studies that incorporate multiple perspectives and include the voices of the women themselves.
CONCLUSION
The work of nurses in the CnaR in the Northern region in the prevention and management of STIs/HIV among women is challenging and intersects with the dimensions of individual, social, and programmatic vulnerability. Within the scope of actions carried out in loco in territories of greater vulnerability, nurses provided welcoming care and counseling, implemented health-education strategies that include multiple forms of STI prevention, offered rapid testing, conducted syndromic management of STIs, and referred individuals to higher-complexity services within the health-care network. The findings of this study enable a critical and reflective analysis of the health and social realities of a marginalized population that requires specific care, supporting the development of strategies to improve access to health services. It is necessary to consider that factors such as health disparities, vulnerability, and gender issues influence the actions implemented and must be taken into account in their planning.
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NOTES
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ORIGIN OF THE ARTICLE
Article extracted from the trabalho de conclusão de curso - Práticas de cuidados de Enfermeiros com mulheres em situação de rua no contexto da saúde sexual e reprodutiva, presented to the Curso Enfermagem, Universidade Federal de Juiz de Fora, in 2023.
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FUNDING INFORMATION
This study was financed by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brazil (CAPES) - Finance Code 001, and by the National Council for Scientific and Technological Development (CNPq) through the Call for Proposals No. 21/2023, under Process No. 445651/2023-7, awarded to N.G.B.
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Ethics Committee in Research of the Universidade Federal de Juiz de Fora, n. 5.390.304/2022, Certificate of Presentation for Ethical Appreciation 56604922.3.0000.5147.
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TRANSLATED BY
Ricardo H D Giammattei.
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DATA AVAILABILITY
All data supporting the findings of this study are included within the article.
Edited by
All data supporting the findings of this study are included within the article.
