Rapid syphilis testing among young people: prevalence and associated factors^*

Abstract

Objective:  to analyze the prevalence of rapid syphilis testing among young people and its associated factors.

Method:  cross-sectional study, conducted in two Testing and Counseling Centers. It involved 301 young people, whose information was collected using a validated instrument and analyzed using descriptive statistics, chi-square tests, prevalence ratios, and logistic regression.

Results:  young people had a prevalence of 14.9% for rapid syphilis testing, with significant associations with sociodemographic factors (male gender, transgender identity, and non-heterosexual sexual orientation), socioeconomic factors (low income, independent living, and history of institutionalization), and behavioral factors (transactional sex, risky sexual practices, history of sexually transmitted infections, and drug use). Multivariate analysis confirmed higher odds of rapid syphilis testing among low-income, male youth with a history of sexually transmitted infections, reinforcing the vulnerability of these groups.

Conclusion:  In summary, the prevalence and factors associated with rapid syphilis testing among young people permeate an intersectional structure with multiple layers of vulnerabilities, encompassing sociodemographic, sociostructural, and behavioral dimensions.

Descriptors:
Syphilis; Young Adult; Sexual Behavior; Sexual Vulnerability; Sexually Transmitted Diseases; Prevalence

Highlights:

(1) The prevalence of rapid syphilis testing among young people was estimated at 14.9%.

(2) Male gender and previous STIs increase the risk of testing positive for syphilis in rapid tests.

(3) Socio-structural factors increase vulnerability to testing positive for syphilis in rapid tests.

(4) Risky sexual practices were associated with testing positive for syphilis in rapid tests.

(5) Low income and discrimination increase the chance of testing positive for syphilis in rapid tests.

Resumo

Objetivo:  analisar a prevalência da testagem rápida reagente para sífilis entre jovens e seus fatores associados.

Método:  estudo transversal, desenvolvido em dois Centros de Testagem e Aconselhamento. Envolveu 301 jovens, cujas informações foram coletadas por instrumento validado e analisadas por estatística descritiva, testagens de qui-quadrado, razão de prevalência e regressão logística.

Resultados:  os jovens apresentaram prevalência de 14,9% para a testagem rápida reagente para sífilis, com associações significativas aos fatores sociodemográficos (sexo masculino, identidade trans e orientação sexual não heterossexual), socioestruturais (baixa renda, moradia independente e histórico de institucionalização) e comportamentais (sexo transacional, práticas sexuais de risco, histórico de infecções sexualmente transmissíveis e consumo de drogas). A análise multivariada confirmou maiores chances de testagem rápida reagente para sífilis entre jovens com baixa renda, sexo masculino e histórico de Infecções sexualmente transmissíveis, o que reforça a vulnerabilidade desses grupos.

Conclusão:  em suma, a prevalência e os fatores associados à testagem rápida reagente para sífilis entre jovens permeiam uma estrutura interseccional com múltiplas camadas de vulnerabilidades, contemplando dimensões sociodemográficas, socioestruturais e comportamentais.

Descritores:
Sífilis; Adulto Jovem; Comportamento Sexual; Vulnerabilidade Sexual; Infecções Sexualmente Transmissíveis; Prevalência

Destaques:

(1) A prevalência da testagem rápida reagente para sífilis entre jovens foi estimada em 14,9%.

(2) Sexo masculino e IST prévias aumentam risco de testagem rápida reagente para sífilis.

(3) Fatores socioestruturais ampliam a vulnerabilidade à testagem rápida reagente para sífilis.

(4) Práticas sexuais de risco foram associadas à testagem rápida reagente para sífilis.

(5) Renda baixa e discriminação elevam chance de testagem rápida reagente para sífilis.

Resumen

Objetivo:  analizar la prevalencia de la prueba rápida reactiva para sífilis entre jóvenes y sus factores asociados.

Método:  estudio transversal, desarrollado en dos Centros de Pruebas y Asesoramiento. Involucró a 301 jóvenes, cuya información fue recolectada mediante un instrumento validado y analizada por estadística descriptiva, pruebas de chi-cuadrado, razón de prevalencia y regresión logística.

Resultados:  los jóvenes presentaron una prevalencia de 14,9% para la prueba rápida reactiva para sífilis, con asociaciones significativas con factores sociodemográficos (sexo masculino, identidad trans y orientación sexual no heterosexual), socioestructurales (bajos ingresos, vivienda independiente e historial de institucionalización) y conductuales (sexo transaccional, prácticas sexuales de riesgo, antecedente de infecciones de transmisión sexual y consumo de drogas). El análisis multivariado confirmó mayores probabilidades de prueba rápida reactiva para sífilis entre jóvenes con bajos ingresos, sexo masculino y antecedente de infecciones de transmisión sexual, lo que refuerza la vulnerabilidad de estos grupos.

Conclusión:  en suma, la prevalencia y los factores asociados a la prueba rápida reactiva para sífilis entre jóvenes atraviesan una estructura interseccional con múltiples capas de vulnerabilidades, contemplando dimensiones sociodemográficas, socioestructurales y conductuales.

Descriptores:
Sífilis; Adulto Joven; Conducta Sexual; Vulnerabilidad Sexual; Enfermedades de Transmisión Sexual; Prevalencia

Destacados:

(1) La prevalencia de la prueba rápida reactiva para sífilis entre jóvenes se estimó en 14,9%.

(2) El sexo masculino y las ITS previas aumentan el riesgo de prueba rápida reactiva para sífilis.

(3) Los factores socioestructurales amplían la vulnerabilidad a la prueba rápida reactiva para sífilis.

(4) Las prácticas sexuales de riesgo se asociaron con la prueba rápida reactiva para sífilis.

(5) Los bajos ingresos y la discriminación elevan la probabilidad de prueba rápida reactiva para sífilis.

Introduction

Syphilis is a sexually transmitted infection (STI) that must be reported, caused by Treponema pallidum and transmitted: from mother to fetus during pregnancy; at the time of delivery, through the bloodstream; or through sexual intercourse without proper use of a condom¹. With diagnosis available through the Unified Health System (SUS), the infection can be quickly detected and treated to prevent clinical progression, the emergence of complications, an increase in cases of congenital syphilis, and new cases of acquired infection². Even so, recent studies highlight the reemerging nature of the disease and a significant number of cases among young people, especially those under the age of 24^1)-(3.

With regard to early diagnosis strategies, there is rapid testing (RT) for syphilis⁴, which consists of an immunochromatographic method capable of detecting antibodies against Treponema pallidum from small blood samples, preferably obtained by finger prick, which promotes speed and ease of collection, even in environments with poor working infrastructure^4)-(5. The result, available in a few minutes, can be classified as reactive or non-reactive for syphilis. A non-reactive result implies reinforcement of preventive measures and possible repetition of RT in 30 days, if there is clinical suspicion or recent risk. On the other hand, reactive results require confirmation by a non-treponemal test, such as the Venereal Disease Research Laboratory (VDRL) test, in order to distinguish active infection from serological scarring⁵.

Comprising adolescence and young adulthood, youth occurs between the ages of 15 and 24, a period in which people experience discoveries in different aspects, which in turn shape social relationships and contribute to behaviors, including sexual behaviors⁶. From this perspective, studies emphasize that people’s sexual expression has been emerging earlier and earlier and is commonly associated with deficits in knowledge about STIs and difficulties for parents and health professionals in addressing the issue in the population, according to the conditions of vulnerability to syphilis among young people^6)-(7.

Globally, the Global Burden of Disease study showed that, although syphilis is not the most prevalent STI in absolute numbers, its age-standardized rate showed continuous growth between 1990 and 2021, with Brazil standing out as the country with the highest increase in this rate among the countries analyzed⁸.

In this context, it is noted that between 2011 and 2022, Brazil reported more than 1.1 million cases of acquired syphilis, of which 36% occurred in young people. Between 2020 and 2021, the national detection rate rose from 59.1 to 78.5 cases per 100,000 inhabitants, a trend also observed in the Northeast region, where rates jumped from 29.9 to 47.3 cases per 100,000 inhabitants. Paraíba, a state in the Northeast, showed growth similar to the regional pattern, although without exceeding the national average². In addition, it is worth noting that the data on mandatory notifications for syphilis in Paraíba follow the global trend⁹, i.e., they have decreased since the beginning of the COVID-19 pandemic, which certainly does not reflect a reduction in the occurrence of infection, but rather fragility in diagnosis, underreporting, and, consequently, lack of timely treatment¹⁰.

This study, in addition to highlighting the importance of RT for syphilis in the context of public health⁵, emphasizes the vulnerability of a specific age group (young people aged 15 to 24) to syphilis, differing from other studies that mainly address general populations, pregnant women, or key groups linked primarily to gender identity and/or sexual orientation, according to a systematic review of the literature¹¹.

Combined with the scientific need to contribute to the Sustainable Development Goals (SDGs) of the 2030 Agenda of the United Nations (UN)¹², the production of studies on the prevalence of acquired syphilis among young people finds solid justification both in the global and Brazilian epidemiological scenario^2),(8 and in the dynamics of health research⁷.

Given the above, the objective of this study was to analyze the prevalence of RT reactive for syphilis among young people and its associated factors.

Method

Study type or design

Cross-sectional study, developed from an excerpt of the primary research entitled “HIV in the young population: subsidies for tackling the epidemic based on the analysis of socio-structural and behavioral factors”, reported according to the recommendations of Strengthening the Reporting of OBservational studies in Epidemiology (STROBE)¹³_.

Study location

Developed in two Testing and Counseling Centers in two municipalities in health macro-regions I and II, in the state of Paraíba, Brazil. These services operate on a walk-in basis or by referral from other services, in the morning and afternoon shifts, serving 134 of the state’s 223 municipalities and offering sexual health promotion, prevention, diagnosis, and treatment services.

Period

Data collection took place from February to July 2021.

Population

The population consisted of young people aged between 15 and 24 years old.

Sample definition

The sample was defined by calculation for finite populations, considering the average monthly estimate of RT performed in the services investigated (Macro-region I Headquarters - N=500; Macro-region II Headquarters - N=320); significance level of 5%; confidence interval 95%CI; and an anticipated Prevalence (P) value based on the detection rate of HIV/AIDS cases in the recommended age group, focusing on the original research (Macro-region I Headquarters with P = 23.0%; Macro-region I Headquarters with P = 8.6%); which defined the sample as 301 young people, of whom 200 are from Macro-region I Headquarters and 101 from Macro-region II Headquarters.

Selection criteria

Participants were selected using non-probabilistic sampling, adopting convenience criteria based on the specific characteristics of the study site. People whose serological status for syphilis was unknown at the time of the primary survey and who sought out Testing and Counseling Centers in order to undergo RT for any STI were included. In addition, those who had a disability that prevented them from responding to the questionnaire were excluded.

Instrument used and study variables

The instrument was developed and validated by researchers from the Center for Studies on HIV, Health, and Sexuality (NEHAS)¹⁴. It consists of 45 questions divided into four sections: 1 - Interview identification; 2 - Sociodemographic variables (age, gender, aspects related to sexuality, self-declared race, years of schooling); 3 - Socio-structural variables (work, current relationship status, housing conditions, family income - the minimum wage of R$ 1,100.00 (in force in 2021) was considered, history of institutionalization, discrimination, psychiatric treatment, and victimization by sexual violence); and 4 - Behavioral variables (coitarca, history of STIs, consent in sexual relations, aspects related to sexual practices, transactional sex, drug use)¹⁴.

Data collection

Data collection took place during morning and afternoon shifts, according to the availability of the researchers, varying according to the days of the week, until the desired sample was obtained.

As established in the inclusion and exclusion criteria, young people who sought out the Testing and Counseling Centers were informed about the study and invited to participate. Acceptance required the signing of the Free and Informed Consent Form or the Free and Informed Assent Form for minors under 18 years of age. Consequently, they participated in individualized interviews in a private setting, guided by the data collection instrument¹⁴ with a face-to-face approach by a researcher trained to conduct it. It should be noted that this process preceded the participant’s RT.

Data processing and analysis

The data of interest in this study were transferred from the original research database and organized in a Microsoft Excel^® spreadsheet for compilation and recategorization using the Statistical Package for the Social Sciences (SPSS) version 20.0.

To analyze the characteristics of the participants, absolute and relative frequencies were calculated, as well as measures of central tendency and dispersion.

To analyze prevalence, the number of RT reagents for syphilis was divided by the total sample (n= 301). To calculate Pearson’s chi-square (X²) and prevalence ratio (PR), the association between the outcome RT reactive for syphilis and the associated factors was considered. It should be noted that for these analyses, data referring to the categories “ignored”, “did not want to answer”, and “did not know how to answer” were excluded.

For the multivariate analysis, we chose to use the logistic regression model, adopting backward selection to select the variables that best explained the phenomenon under study, considering a significance level of 5% (p < 0.05)¹⁵.

Ethical aspects

This study followed the ethical precepts for research involving human subjects set forth in Resolution No. 466/12 of the National Health Council; it was approved by the Research Ethics Committee of the Health Sciences Center of the Federal University of Paraíba - Opinion No. 3,935,713 (03/26/2020), and the necessary procedures were conducted to ensure the protection of information accessible to the research team and anonymity at the time of publication of the results.

Results

Of the 382 young people approached by researchers during data collection, 301 agreed to participate. The participants had a mean age of 20.83 years (standard deviation ± 2.3), whose sociodemographic characterization indicated a predominance of the 20-24 age group (212/70.4%), male gender (155/51.5%); self-declared non-white skin color white (217/72.1%); cisgender (291/96.6%), heterosexual (175/58.1%), with more than eight years of schooling (259/86%), and 86% (163) were not currently studying.

Regarding factors intrinsic to the socio-structural dimension, there was a predominance of young people in stable relationships (172/57.3%), with family incomes between one and two minimum wages (111/37.2%), who do not work (166/55.1%) and share housing only with family members (152/50.5%). They also reported victimization due to discrimination based on sexual orientation (104/34.7%) and gender identity (57/18.9%), mainly in schools and universities (86/82.7% and 11/19.6%, respectively). In addition, sexual violence was reported (84/27.9%) - perpetrated mainly by strangers (29/35%), history of psychiatric treatment (61/20.3%), and imprisonment or institutionalization (10/3.3%).

In the behavioral profile of young people, the following characteristics were observed to be predominant: sexual intercourse before the age of 15 (153/50.8%) - a practice not consented to by a portion of young people (15/5%); condom use “sometimes” (167/55.4%); practicing oral sex (237/78.7%) and vaginal sex (214/71.1%); and alcohol consumption (174/57.8%), of which a portion (68/39.5%) reported having stopped using condoms when under the influence of alcohol; another stated that they did not remember whether or not they used condoms on such occasions (11/6.4%).

There were reports of transactional sex (29/9.6%), insertive anal sex (114/37.9%) and receptive anal sex (124/41.2%), previous diagnosis of STIs (63/20.9%), difficulty in acquiring (32/10.6%) or negotiating condoms (103/34.2%), and illicit drug use was also reported (103/34.2%).

Regarding prevalence and associations inherent to the results, a prevalence of RT reactive for syphilis was identified in a portion of young people (45/14.9%) and an association with sociodemographic, sociostructural, and behavioral factors.

Regarding sociodemographic factors, the outcome for syphilis-reactive RT was associated with variables related to sex, gender identity, and sexual orientation (Table 1). In this dimension (Table 1), males had an OR of 3.8 (95% CI: 1.9-7.5) times higher for RT reactive for syphilis, while young people whose gender identity was trans male or trans female had PRs of 8.0 (95% CI: 1.7-36.9) and 10.1 (95% CI: 4.4-23.1), respectively. Furthermore, being homosexual or pansexual showed, respectively, an OR of 4.4 (95% CI: 2.3-8.4) and 4.8 (95% CI: 1.6-14.2), indicating greater vulnerability to syphilis-reactive RT in these groups.

Table 1
Prevalence (P*), prevalence ratio (PR^†), and chi-square test of association between the outcome of rapid syphilis testing and sociodemographic factors among young people (n = 301). João Pessoa, PB, Brazil, 2021

Variables		Rapid syphilis test reagent (N)		P* (%)	PR† [95.0%CI‡]	X² p-value §
		Yes	No
Age group	15-19 years	08	81	9.0	1	0.060
	20-24 years	37	175	17.5	1.9 [0.9; 4.0]
Sex	Female	09	137	6.2	1	0.001||
	Male	36	119	23.2	3.8 [1.9; 7.5]
Self-declared color	White	12	72	14.3	1	0.841
	Not white	33	184	15.2	1.00 [0.6; 1.9]
Years of study	≤ 8 years	04	38	9.5	1	0.288
	> 8 years	41	218	15.8	1.7 [0.6; 4.4]
Study	Yes	19	119	13.8	1	0.597
	No	26	137	16.0	1.2 [0.6; 2.0]
Gender identity	Man	30	116	20.5	3.3 [1.6; 6.7]	0.001||
	Woman	09	136	6.2	1
	Trans man	01	1	50.0	8.0 [1.7; 36.9]
	Trans woman	05	3	62.5	10.1 [4.4; 23.1]
Sexual orientation	Heterosexual	12	163	6.9	1	0.001||
	Homosexual	24	55	30.4	4.4 [2.3; 8.4]
	Bisexual	06	32	15.8	2.0 [0.9; 5.7]
	Pansexual	03	6	33.3	4.8 [1.6; 14.2]

• *P = Prevalence; ^†PR = Prevalence ratio; ^‡CI = Confidence interval; ^§X² p value = p value of the Chi-square test for proportion comparison; ^||p-value <0.05 = Association between rapid syphilis testing and the corresponding variable

In terms of socioeconomic factors, a statistical association was found between RT reactivity for syphilis and the following variables: family income, with whom they share their home, victimization due to discrimination based on gender identity and sexual orientation, and having been arrested or institutionalized. Thus, it should be noted that a household income below the minimum wage increased the OR to 2.3 (95% CI: 1.2-4.6) times for syphilis-reactive RT. In addition, living only with friends or alone presented, respectively, PR 3.9 (95% CI: 1.9-8.0) and 3.2 (95% CI: 1.6-6.3). A similar phenomenon occurs with young people who had a history of imprisonment/institutionalization, with an OR of 2.8 (95% CI: 1.7-6.4) (Table 2).

Table 2
Prevalence (P*), prevalence ratio (PR^†), and chi-square test of association between the outcome of rapid syphilis testing and socioeconomic factors among young people (n = 301). João Pessoa, PB, Brazil, 2021

Variables		Rapid syphilis test reagent (N)		P* (%)	PR† [95.0%CI‡]	X² p value §
		Yes	No
Household income	≤ 1 MW||	23	70	24.7	2.3 [1.2; 4.6]	0.008¶
	1 to 2 MW||	12	99	10.8	1.0 [0.5; 2.2]
	> 2 MW||	10	84	10.6	1
Works	Yes	20	115	14.8	1	0.953
	No	25	141	15.1	1.0 [0.6; 1.7]
Who do you share your home with?	Only with friends	08	13	38.1	3.9 [1.9; 8.0]	0.001¶
	Alone	12	26	31.6	3.2 [1.6; 6.3]
	Only with partner	07	37	15.9	1.6 [0.7; 3.7]
	Only with family members	15	137	9.9	1
	Partner and friends or family members	03	43	6.5	0.7 [0.2; 2.2]
Relationship status	Fixed	17	155	9.9	1	0.051
	Casual	11	33	25.0	2.5 [1.3; 5.0]
	With more than one partnership	02	12	14.3	1.4 [0.3; 5.6]
	No relationship	15	55	21.4	2.1 [1.1; 4.1]
Discrimination based on gender identity	Yes	15	42	26.3	2.1 [1.2; 3.7]	0.008¶
	No	30	214	12.3	1
Discrimination based on sexual orientation	Yes	29	75	27.9	3.4 [1.9; 6.0]	0.001¶
	No	16	179	8.2	1
Victimization due to sexual violence	Yes	16	68	19.0	1.4 [0.8; 2.5]	0.215
	No	29	188	13.4	1
Has been incarcerated or institutionalized	Yes	04	6	40.0	2.8 [1.7; 6.4]	0.024¶
	No	41	250	14.1	1
History of psychiatric treatment	Yes	11	50	18.0	1.3 [0.7; 2.3]	0.450
	No	34	206	14.2	1

• *P = Prevalence; ^†PR = Prevalence ratio; ^‡CI = Confidence interval; ^§X² p value = p value of the Chi-square test for proportion comparison; ^||MW = Minimum wage of R$ 1,100.00, Brazil, effective in 2021; ^¶p-value <0.05 = Association between rapid syphilis testing and the corresponding variable

Regarding behavioral factors, syphilis-reactive RT was associated with non-consent during first sexual intercourse, condom use frequency, transactional sex, vaginal sex, insertive and receptive anal sex, history of STIs, and illicit drug use (Table 3). Thus, it was observed that non-consensual first sexual intercourse increased the OR by 2.3 (95% CI: 1.1-5.1) for syphilis-reactive RT, as did the following sexual practices: transactional sex increased the OR by 3.8 (95% CI: 2.2-6.4), insertive anal sex increased the OR by 2.6 (95% CI: 1.5-4.6), and receptive anal sex increased the OR by 1.7 (95% CI: 1.1-3.0). In addition, young people who did not engage in vaginal sex had an OR 3.8 (95% CI: 2.2-6.6) times higher for syphilis-reactive RT (Table 3).

Table 3
Prevalence (P*), prevalence ratio (PR^†), and chi-square test of association between the outcome of rapid syphilis testing and behavioral factors among young people (n = 301). João Pessoa, PB, Brazil, 2021

Variables		Rapid syphilis test reagent (N)		P* (%)	PR† [95.0%CI‡]	X² p-value §
		Yes	No
Coitarca (n= 294)	≤ 15 years	25	128	16.3	1.1 [0.6; 2.0]	0.608
	> 15 years	20	121	14.2	1
First consensual sexual intercourse (n= 298)	Yes	40	243	14.1	1	0.043||
	No	05	10	33.3	2.3 [1.1; 5.1]
Difficulty in obtaining condoms (n= 299)	Yes	08	24	25.0	1.8 [0.9; 3.5]	0.096
	No	37	230	13.9	1
Frequency of condom use (n= 297)	Always	21	40	34.4	5.9 [2.1; 16.3]	0.001||
	Sometimes	20	147	12.0	2.0 [0.7; 5.8]
	Never	04	65	5.8	1
Difficulty negotiating condom use (n= 294)	Always	03	28	9.7	1	0.265
	Sometimes	15	57	20.8	2.1 [0.6; 6.9]
	Never	27	164	14.1	1.4 [0.4; 4.5]
Transactional sex	Yes	13	16	44.8	3.8 [2.2; 6.4]	0.001||
	No	32	240	11.8	1
Practices vaginal sex (n=297)	Yes	18	196	8.4	1	0.001||
	No	27	56	32.5	3.8 [2.2; 6.6]
Practice oral sex (n=297)	Yes	38	199	16	1.3 [0.6; 2.9]	0.399
	No	7	53	11.7	1
Practicing insertive anal sex (n=297)	Yes	28	86	24.6	2.6 [1.5; 4.6]	0.001||
	No	17	166	9.3	1
Practicing receptive anal sex (n=297)	Yes	25	99	20.2	1.7 [1.1; 3.0]	0.041||
	No	20	153	11.6	1
History of STIs¶ (n= 289)	Yes	30	33	47.6	7.1 [4.1; 12.5]	0.001||
	No	15	211	6.6	1
Consumes alcoholic beverages	Yes	31	143	17.8	1.6 [0.9; 2.9]	0.103
	No	14	113	11.0	1
Consumes illicit drugs	Yes	23	80	22.3	2.0 [1.2; 3.4]	0.010||
	No	22	176	11.1	1

• *P = Prevalence; ^†PR = Prevalence ratio; ^‡CI = Confidence interval; ^§X² p value = p value of the chi-square test for proportion comparison; ^||p-value <0.05 = Association between rapid syphilis testing and the corresponding variable; ^¶STI = Sexually transmitted infections

In this context, a previous history of STIs and illicit drug use increased the OR by 7.1 (95% CI: 4.1-12.5) and 2.0 (95% CI: 1.2-3.4), respectively, for RT reactive for syphilis. Regarding condom use frequency, those who reported always using condoms had an OR 5.9 (95%CI 2.1-16.3) times higher for syphilis-reactive RT compared to young people who reported using condoms sometimes or never (Table 3).

Based on logistic regression analysis, being young, aged 15 to 19 years, constitutes a protective effect against syphilis-reactive RT when compared to young people aged 20 to 24 years. However, those with an income below the minimum wage or between one and two minimum wages were 2.9 and 2.4 times more likely to be RT reactive for syphilis, respectively, compared to young people with an income above three minimum wages. Similarly, being male increased the chances of RT reactive for syphilis threefold compared to females, and having a history of STIs represented an 8.4 times greater chance of RT reactive for syphilis compared to those who did not report such a history (Table 4).

Table 4
Logistic regression model considering factors associated with rapid syphilis testing among young people (n = 301). João Pessoa, PB, Brazil, 2021

Variables	Coefficient	Standard error	Odds ratio	Confidence interval (95%)	p value*
Age group 15-19 years old	-0.78	0.34	0.45	[0.23 - 0.89]	0.02†
Male gender	1.11	0.43	3.06	[1.31 - 7.11]	0.01†
Family income ≥ 3 minimum wages‡					0.01†
Family income ≤ 1 minimum wage‡	1.09	0.42	2.98	[1.31 - 6.80]	0.01†
Family income between 1-2 minimum wages‡	0.90	0.46	2.47	[1.01 - 6.09]	0.04†
Previous diagnosis of STI§	2.13	0.36	8.46	[4.11 - 17.42]	0.01†
R² (Nagelkerke) ||					70.5%
Hosmer-Lemeshow test (p-value)					0.20

• *p-value = p value of the logistic regression model; ^†p<0.05 = Association between rapid syphilis testing and the factors investigated; ^‡SM = Current minimum wage = R$ 1,100.00, Brazil, 2021; ^§STI = Sexually Transmitted Infection; ^||R² (Nagelkerke) = Measures the performance of the model based on the variables used

Discussion

The sociodemographic profile presented in this study is similar to that found in the national^16)-(17 and international^7),(18)-(23 literature related to the prevalence of young males^{16)-(19),(21)-(22}, cisgender⁷, heterosexual^7),(16, aged 20 to 24 years²⁰, non-white^16),(19),(23, and with more than eight years of schooling in their samples¹⁶. The only variable that stood out was “currently studying”, as most studies focusing on young people tend to address the university setting, which consequently influenced the variable in question²⁴.

Young males assume the greatest risk not only for syphilis-reactive RT but also for other STIs^21)-(22. That said, vulnerability may be linked to behaviors such as seeking sexual partners through the internet, early age at first intercourse, higher frequency of sexual intercourse, low adoption of self-care practices, and preservation of sexual health, when compared to females^{17)-(18),(21)-(22}.

Young people aged 20 to 24 are more vulnerable to reactive RT for syphilis and other STIs, especially females, due to the convergence of unfavorable sociodemographic and economic factors, transactional sexual practices, and inconsistent condom use^25)-(26. In this scenario, persistent misinformation about sexual health and exposure to risky behaviors amplify this vulnerability, which is fundamental for access to adequate information and collective analysis of the factors that interfere in this process²⁷.

Beyond individual factors, the bi- and multivariate analyses presented in this study suggest the vulnerability of population groups linked to the LGBTQIAPN+ community, as they point to a higher risk of syphilis-reactive RT in males, transsexuals, homosexuals, or pansexuals. This sociodemographic situation may be linked to misinformation caused by a cascade of events based on structural and historical prejudice experienced by this group, whose impacts are perceived in access to health services, the availability of resources and information to prevent risky sexual behavior, STIs, and promote sexual health^28)-(30.

Furthermore, socio-structural variables reflect complex patterns of vulnerability in this population group, with emphasis on intersectionalities between economic conditions, situations of violence, and mental health³¹. These conditions are well established in the literature when viewed separately³², however, evidence of the current situation, with its intersectionalities, in prevalence studies linked to the risk of reactive RT for syphilis is still under-explored.

In this context, despite the potential for social transformation in educational environments in terms of respect and human dignity, schools and universities perpetuate a prejudiced structure, which creates spaces for the reproduction of LGBTphobic violence^29),(33. Another factor intrinsic to the socio-structural vulnerability of these young people is linked to a history of deprivation of liberty, particularly relevant in peripheral youth populations, which affects how young people relate to each other (by engaging in risky sexual behaviors), their insertion into the labor market, and how they perceive access to health care³⁴.

Furthermore, reports of sexual violence against adolescents and young people are present from large urban centers to rural communities³⁵, where the predominance of unknown perpetrators, as pointed out in this study, contrasts partially with a study conducted in the interior of Piauí, which identified intimate partners and friends as the main perpetrators, suggesting that this is the reality of specific contexts of urban violence or underreporting of intra-family cases³⁶.

Family income is a socio-structural factor inherent to access to health and information, since the higher the income, the better the access to health services and actions³⁷. That said, studies show that the lower the family income, the greater the likelihood of inconsistent condom use and, consequently, the greater the risk for STIs^31),(37)-(38.

As for the variables “not currently working” and “not currently studying”, the literature explains that young people experience typical aspects of emerging adulthood, permeated by social markers such as gender, education, and work experience, in addition to being affected by the precariousness of the labor market²³. This condition, in addition to limiting opportunities for personal and social development, exposes these young people to multiple situations of vulnerability. Such factors are associated with contexts of greater social isolation, difficulty in accessing information and health services, and the adoption of risky behaviors, which makes this young population especially susceptible to STIs²³.

In our sample, at least half of the young people reported living only with family members, which, based on the literature, constitutes a protective factor against STIs^39)-(40. However, those who live with friends and/or alone represented a higher risk for syphilis-reactive RT and other STIs, since young people have greater freedom and little supervision, thus engaging in risky sexual behaviors³⁹. Furthermore, it should be noted that the age group (15-19 years) understood as a protective factor against syphilis-reactive RT in this study can be explained by living with family members, high supervision, and late sexual debut⁴⁰.

Regarding behavioral factors, it is observed that the relational context of young people determines behavioral patterns that directly influence the dynamics of sexual protection and creates different scenarios of epidemiological vulnerability²⁴. However, the estimated risk of STIs based on the relationship status assumed by young people is not yet a scientific consensus. That said, behavioral analyses show that casual partners are more prone to prophylactic negligence-whether due to forgetfulness or deliberate disregard-while stable relationships favor the progressive replacement of condoms with interpersonal trust criteria^21),(24),(41. In this sense, both models can increase exposure to syphilis and other STIs, as the reduction in consistent use of physical barriers facilitates transmission during sexual practices, regardless of subjective perception of safety²⁴.

A review of the scope showed that sexual initiation among young people occurs, on average, at age 15²⁴. In this context, the first sexual experience assumes epidemiological relevance, since the absence of condoms and/or lack of consent increase risky behaviors and vulnerability to STIs^21),(24. Thus, unprotected or non-consensual intercourse is an important factor in the exposure and perpetuation of these infections among young people^21),(42.

With regard to the aforementioned dimension of knowledge, it is clear that coercion and sexual abuse are not only related to unwanted pregnancy, but also to the risk of STIs. In turn, the incidence of non-consensual sexual relations is an indicator of gender inequalities and prevailing patterns of masculinity³¹. Thus, it can be seen that coerced and forced sexual initiation is associated with inconsistent condom use, recent experiences of violence, and mental health outcomes among young people, a situation that highlights the multiple layers of vulnerability among young people, especially females^31),(42.

It is currently recognized that transactional sex translates into a factor of behavioral vulnerability, social, economic, and/or structural interfaces^21),(24. In this sense, one study pointed out that street youth often neglect condom use during transactional sex due to pressure from intimate partners, immediate financial needs, and fear of violence, which describes a scenario conducive to the transmission of syphilis and other STIs⁴³.

The aforementioned dynamic is reproduced in different contexts: among South African university students, 1.4% of the 918 surveyed reported engaging in this practice⁴⁴; while among American high school adolescents, the prevalence reached 7.4%, with males being 2.5 times more likely to engage in this practice⁴⁵. Additionally, structural factors such as poverty, social exclusion, and limited access to health services perpetuate cycles of vulnerability and hinder both prevention and early diagnosis of these infections^24),(43.

Among the sexual practices engaged in by young people, anal sex emerges as a factor of greater predisposition to reactive TR for syphilis and other STIs²⁴, due to a combination of aspects such as: greater fragility of the rectal epithelium to infections; lower perception of risk, whose feeling of invulnerability enables the adoption of risky sexual behaviors; and deficits in access to adequate information and health services⁴⁶.

It is well established in the literature that a history of STIs indicates previous exposure to risky behaviors, which tend to be repeated over time^21),(24. Literature reviews demonstrate a significant association between a history of STIs and a higher risk of reactive RT for syphilis and other infections, corroborating the persistence of behavioral vulnerabilities^21),(24. In this sense, the phenomenon is detailed by studies that have shown that people with a history of STIs are 1.8 times more likely to acquire other STIs²⁷, while a previous diagnosis of two other STIs increases the probability of syphilis infection by 5.83 times⁴⁷.

In another context, the association between alcohol and/or illicit drug use and unsafe sexual practices among young people is a critical factor in the transmission of syphilis and other STIs. One study found that the use of psychoactive substances alters judgment patterns and reduces risk perception during social interactions-at festive events, young people are less concerned about the subsequent risks and, consequently, engage in risky sexual behavior⁴⁸.

The frequency of condom use is a key factor in the prevention of STIs, as it is widely recognized that unprotected sex increases the risk of acquiring these infections². However, the results of this study diverge from the literature by suggesting that young people who use condoms more regularly are, paradoxically, more likely to test positive for syphilis. This phenomenon has precedents in international research, based on a US cohort that associated frequent condom use with syphilis test reactivity²⁵. These findings require further investigation to clarify potential confounding factors, considering the scientific consensus on the effectiveness of condoms as a preventive method and the possible influence of information biases resulting from underreporting or omission by participants.

Based on the evidence presented, public policies aimed at preventing STIs and promoting sexual health among young people should prioritize multilevel interventions that combine health education, community strategies, and the use of digital technologies^49)-(50. In this context, the Impact Triad^® experience demonstrates that peer-navigation-based approaches, which use trained community leaders to disseminate information and facilitate access to health services, significantly increase STI testing, condom use, and adherence to pre-exposure prophylaxis, in addition to strengthening social support and reducing discrimination among young people from minority groups⁵⁰.

At the same time, systematic reviews show that mobile health (mHealth) platforms, such as text messages, voice calls, and interactive apps, are well accepted by young people because they offer privacy, convenience, and adapted language. Therefore, it is additionally recommended that public policies integrate face-to-face and digital actions, promote the active participation of young people in the development of strategies, train health professionals and communities to address sensitive issues, and invest in continuous and intersectoral educational campaigns to enable universal and equitable access to sexual health prevention and care⁴⁹.

In nursing and health practice, the findings call for priority screening for key groups among young people, educational interventions based on digital technologies, and the integration of psychosocial assessments into nursing protocols. Multidisciplinary action should combine TR (nursing and other health professionals duly trained for this purpose), coordination of protection networks (social assistance), and trauma management (psychology), with a focus on reducing inequalities in access to health and maximizing the promotion of sexual health.

Despite the limitations of this study, as the primary study focused exclusively on HIV, its analyses were limited to variables related to this infection. This methodological limitation resulted in the absence of specific data on VDRL, a crucial test for quantifying the serological burden of syphilis. The possibility of participant selection bias is assumed, since these are young people who sought care and are already familiar with Testing and Counseling Centers. Furthermore, convenience sampling in urban centers may underestimate the reality of young people in rural communities.

Conclusion

The prevalence of syphilis-reactive RT in young people was estimated at 14.9%, a context that points to an intersectional structure permeated by multiple layers of vulnerabilities that associate the phenomenon with sociodemographic factors (male, transgender male or female, homosexual or pansexual), socio-structural (low family income, independent housing, and history of institutionalization), and behavioral (first non-consensual sexual intercourse, transactional sex, risky sexual practices, history of STIs, and drug use).

Furthermore, with regard to syphilis-reactive RT among young people, the logistic regression model showed that, while the 15-19 age group was a protective factor compared to the 20-24 age group, low income (less than two minimum wages) and male gender increased the chances of reactive RT. Notably, a previous history of STIs emerged as an important risk factor, increasing the chances of RT reactivity for the disease by 8.4 times.

Caution is advised when generalizing the results, particularly regarding the apparent ineffectiveness of condoms, which may reflect memory bias or underreporting of risky practices. Therefore, future studies should incorporate longitudinal designs and representative samples from different socioeconomic contexts.

Data Availability Statement

Datasets related to this article will be available upon request to the corresponding author.

Acknowledgments

We would like to thank Luciana Maria Bernardo Nóbrega, Juliana Kelly Batista da Silva, Renata Olívia Gadelha Romero, Andrea Carla Almeida de Araújo, and Wanderlice Felinto Cardoso for their collaboration in the data collection stage.

References

• ¹ RXiong S, Liu Z, Zhang X, Huang S, Ding X, Zhou J, et al. Resurgence of syphilis: focusing on emerging clinical strategies and preclinical models. J Transl Med. 2023;21(1):917. https://doi.org/10.1186/s12967-023-04685-4
  » https://doi.org/10.1186/s12967-023-04685-4
• ² Ministério da Saúde (BR), Secretaria de Vigilância em Saúde, Departamento de HIV/aids, Tuberculose, Hepatites Virais e Infecções Sexualmente Transmissíveis. Boletim epidemiológico: sífilis 2024 - número especial [Internet]. Brasília-DF: Ministério da Saúde; 2024 [cited 2025 Jun 08]. 59 p. Available from: Available from: https://www.gov.br/aids/pt-br/central-de-conteudo/boletins-epidemiologicos/2024/boletim_sifilis_2024_e.pdf/view
  » https://www.gov.br/aids/pt-br/central-de-conteudo/boletins-epidemiologicos/2024/boletim_sifilis_2024_e.pdf/view
• ³ Llata E, Cuffe KM, Picchetti V, Braxton JR, Torrone EA. Demographic, Behavioral, and Clinical Characteristics of Persons Seeking Care at Sexually Transmitted Disease Clinics-14 Sites, STD Surveillance Network, United States, 2010-2018. MMWR Surveill Summ. 2021;70(7):ss7007a1. https://doi.org/10.15585/mmwr.ss7007a1
  » https://doi.org/10.15585/mmwr.ss7007a1
• ⁴ Ngounouh CT, Nguwoh PS, Fokam J, Essomba RG, Halilou I, Bit Younouss AA, et al. Diagnostic performance of the Hightop Rapid Diagnostic Test for the detection of anti-Treponema pallidum antibodies in Cameroon: a laboratory-based cross-sectional and comparative study. BMJ Open. 2025;15:e093330. https://doi.org/10.1136/bmjopen-2024-093330
  » https://doi.org/10.1136/bmjopen-2024-093330
• ⁵ Ministério da Saúde (BR), Secretaria de Vigilância em Saúde, Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Manual técnico para o diagnóstico da Sífilis [Internet]. Brasília: Ministério da Saúde; 2021 [cited 2025 Jun 08]. 70 p. Available from: Available from: https://www.gov.br/saude/pt-br/assuntos/saude-de-a-a-z/s/sifilis/publicacoes/manual-tecnico-para-o-diagnostico-da-sifilis.pdf
  » https://www.gov.br/saude/pt-br/assuntos/saude-de-a-a-z/s/sifilis/publicacoes/manual-tecnico-para-o-diagnostico-da-sifilis.pdf
• ⁶ Hegde A, Chandran S, Pattnaik JI. Understanding adolescent sexuality: A developmental perspective. J Psychosex Health. 2022;4(4):237-42. https://doi.org/10.1177/26318318221107598
  » https://doi.org/10.1177/26318318221107598
• ⁷ Naranjo-Márquez M, Bocchino A, Gilart E, Cotobal-Calvo EM, Procentese F, Palazón-Fernández JL. Risk determinants of sexual behaviors: dating apps, history of sexually transmitted infections, substance use, and pornography consumption in health science students. Nurs Rep. 2025;15(3):83. https://doi.org/10.3390/nursrep15030083
  » https://doi.org/10.3390/nursrep15030083
• ⁸ Deng M, Chen J, Wang Z, Zheng R, Pang W, Sun R, et al. Trends in the incidence of common sexually transmitted infections at the global, regional and national levels, 1990-2021: results of the Global Burden of Disease 2021 study. Trop Med Health. 2025;53:70. https://doi.org/10.1186/s41182-025-00744-2
  » https://doi.org/10.1186/s41182-025-00744-2
• ⁹ Chen L, Wang L, Xing Y, Xie J, Su B, Geng M, et al. Persistence and variation of the indirect effects of COVID-19 restrictions on the spectrum of notifiable infectious diseases in China: analysis of national surveillance among children and adolescents from 2018 to 2021. JMIR Public Health Surveill. 2024;10:e47626. https://doi.org/10.2196/47626
  » https://doi.org/10.2196/47626
• ¹⁰ Secretaria de Estado da Saúde da Paraíba. Boletim Epidemiológico da sífilis no. 04/2023 [Internet]. João Pessoa: Secretaria de Estado da Saúde; 2023 [cited 2024 Mar 14]. Available from: Available from: https://paraiba.pb.gov.br/diretas/saude/arquivos-1/vigilancia-em-saude/boletim-sifilis-setembro-2023.pdf
  » https://paraiba.pb.gov.br/diretas/saude/arquivos-1/vigilancia-em-saude/boletim-sifilis-setembro-2023.pdf
• ¹¹ Zhang Y, Tapa J, Johnson CC, Phillips TR, Fairley CK, Ameyan W, et al. HIV, hepatitis, and syphilis self-testing among adolescents and young adults: a systematic review and meta-analysis. J Infect Public Health. 2025;18:102764. https://doi.org/10.1016/j.jiph.2025.102764
  » https://doi.org/10.1016/j.jiph.2025.102764
• ¹² United Nations. Transforming our world: the 2030 Agenda for Sustainable Development [Internet]. New York, NY: United Nations; 2015 [cited 2023 Oct 23]. Available from: Available from: https://documents-dds-ny.un.org/doc/UNDOC/GEN/N15/291/89/PDF/N1529189.pdf?OpenElement
  » https://documents-dds-ny.un.org/doc/UNDOC/GEN/N15/291/89/PDF/N1529189.pdf?OpenElement
• ¹³ von Elm E, Egger M, Altman DG, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335(7624):806-8. https://doi.org/10.1136/bmj.39335.541782.AD
  » https://doi.org/10.1136/bmj.39335.541782.AD
• ¹⁴ Romero ROG, Medeiros ACT, Silva JKB, Santos JM, Leadebal ODCP, Nogueira JA. Construction and validation of an instrument to evaluate sociostructural and behavioral characteristics associated with HIV infection in young people. Esc Anna Nery. 2024;28:e20230043. https://doi.org/10.1590/2177-9465-EAN-2023-0043pt
  » https://doi.org/10.1590/2177-9465-EAN-2023-0043pt
• ¹⁵ Fernandes AAT, Figueiredo FDB, Rocha ECD, Nascimento WDS. Read this article if you want to learn logistic regression. Rev Sociol Polit. 2021;28:e20287406. https://doi.org/10.1590/1678-987320287406en
  » https://doi.org/10.1590/1678-987320287406en
• ¹⁶ Holzmann APF, Monção RA, Cordeiro PEG, Sena JV, Grandi JL, Barbosa DA. Factors associated with the diagnosis of acquired syphilis in users of a testing and counseling center. Rev Pesqui Cuid Fundam Online. 2022;14:e11233. https://doi.org/10.9789/2175-5361.rpcfo.v14.11233
  » https://doi.org/10.9789/2175-5361.rpcfo.v14.11233
• ¹⁷ Moreira GBC, Martins GGBS, Péret ISA, Pires LCS, Ribeiro LFC, Santos LI. Adolescents and sexually transmitted infections: risk behaviors and contextual factors that contribute to increased incidence in Brazil. Rev Interdiscip Ciênc Méd [Internet]. 2021 [cited 2024 Mar 14];5(1):59-66. Available from: Available from: https://revista.fcmmg.br/index.php/RICM/article/view/120
  » https://revista.fcmmg.br/index.php/RICM/article/view/120
• ¹⁸ Ebuenyi ID, Chikezie UE, Nwoke EA. Psychosocial correlates of risky sexual behaviour amongst students in Niger Delta University, Bayelsa. Pan Afr Med J. 2021;38:273. https://doi.org/10.11604/pamj.2021.38.7.27312
  » https://doi.org/10.11604/pamj.2021.38.7.27312
• ¹⁹ Bonett S, Tam V, Singapur A, Min J, Koenig HC, Wood SM. Incidence of syphilis infection and syphilis-related care utilization among adolescents and young adults living with HIV. Int J STD AIDS. 2022;33(2):136-43. https://doi.org/10.1177/09564624211048774
  » https://doi.org/10.1177/09564624211048774
• ²⁰ Musonda P, Halwiindi H, Kaonga P, Ngoma-Hazemba A, Simpungwe M, Mweemba M, et al. HIV, syphilis and sexual-risk behaviours’ prevalence among in- and out-of-school adolescent girls and young women in Zambia: a cross-sectional survey study. PLOS One. 2024;19(6):e0294545. https://doi.org/10.1371/journal.pone.0294545
  » https://doi.org/10.1371/journal.pone.0294545
• ²¹ Silva RS, Bossonario PA, Ferreira MEL, Andrade RLP, Bonfim RO, Alencar V, et al. Factors associated with inconsistent condom use among young people: a systematic review. Rev Gaúcha Enferm. 2024;45:e2030207. https://doi.org/10.1590/1983-1447.2024.2030207.pt
  » https://doi.org/10.1590/1983-1447.2024.2030207.pt
• ²² Xu J, Luo Y, Dong H, Zhao G. The Effects of Internet Exposure on Sexual Risk Behavior Among Sexually Experienced Male College Students in China: Cross-sectional Study. JMIR Public Health Surveill . 2022;8(5):e31847. https://doi.org/10.2196/31847
  » https://doi.org/10.2196/31847
• ²³ Silva DT, Makeneni S, Wall H, Bauermeister JA, Wood S. Measuring quality STI care among adolescent female primary care patients in Philadelphia. Sex Transm Infect. 2023;99(4):272-5. https://doi.org/10.1136/sextrans-2022-055623
  » https://doi.org/10.1136/sextrans-2022-055623
• ²⁴ Moreira WC, Nóbrega LMB, Silva JKB, Medeiros LB, Nogueira JA, Oriá MOB, et al. Behavioral aspects and the risk of sexually transmitted infections in young people: a scoping review. Rev Rene. 2024;25:e93261. https://doi.org/10.15253/2175-6783.20242593261
  » https://doi.org/10.15253/2175-6783.20242593261
• ²⁵ Tao YT, Gao TY, Li HY, Ma YT, Li HJ, Wang XY, et al. Global, regional, and national trends of syphilis from 1990 to 2019: the 2019 global burden of disease study. BMC Public Health. 2023;23(1):754. https://doi.org/10.1186/s12889-023-15510-4
  » https://doi.org/10.1186/s12889-023-15510-4
• ²⁶ Gichane MW, Rosenberg NE, Zimmer C, Pettifor AE, Maman S, Maseko B, et al. Individual and Relationship-Level Correlates of Transactional Sex Among Adolescent Girls and Young Women in Malawi: A Multilevel Analysis. AIDS Behav. 2022;26(3):822-32. https://doi.org/10.1007/s10461-021-03442-2
  » https://doi.org/10.1007/s10461-021-03442-2
• ²⁷ Westin MR, Martínez YF, Silva AP, Greco M, Marques LM, Campos GB, et al. Prevalence of syphilis and sexual behavior and practices among adolescents MSM and TrTGW in a Brazilian multi-center cohort for daily use of PrEP. Cad Saude Publica. 2023;39(1):e00118721. https://doi.org/10.1590/0102-311XEN118721
  » https://doi.org/10.1590/0102-311XEN118721
• ²⁸ Wiginton JM, Maksut JL, Scheim A, Zlotorzynska M, Sanchez TH, Baral SD. Intersecting Sexual Behavior and Gender Identity Stigmas Among Transgender Women in the United States: Burden and Associations with Sexual Health. AIDS Behav . 2023;27(9):3064-79. https://doi.org/10.1007/s10461-023-04028-w
  » https://doi.org/10.1007/s10461-023-04028-w
• ²⁹ Chilliak S, Martin-Storey A, Déry M, Temcheff CE, Lapalme M. When we go to ask for help, they don’t understand how to help us: Understanding how youth with childhood histories of conduct problems link sexuality and gender to school-based service use. Psychol Sch. 2024;61(5):2160-84. https://doi.org/10.1002/pits.23157
  » https://doi.org/10.1002/pits.23157
• ³⁰ McCormack H, Dickson M, Harrington T, Garay M, Whybrow R, Mooney-Somers J, et al. Sexual healthcare to meet the needs of sexuality and gender diverse Aboriginal young people: imagined possibilities. Cult Health Sex. 2025;27(6):685-700. https://doi.org/10.1080/13691058.2024.2394649
  » https://doi.org/10.1080/13691058.2024.2394649
• ³¹ Silva-Santisteban A, Apedaile D, Perez-Brumer A, Leon SR, Huerta L, Leon F, et al. HIV vulnerabilities and psychosocial health among young transgender women in Lima, Peru: results from a bio-behavioural survey. J Int AIDS Soc. 2024;27:e26299. https://doi.org/10.1002/jia2.26299
  » https://doi.org/10.1002/jia2.26299
• ³² Barcelos MRB, Lima EDFA, Dalla MDB, Vargas TB, Barroso JAM, Souza MP, et al. Evaluation of actions to address acquired syphilis between 2016 and 2019, in a southeast Brazilian state capital city. J Hum Growth Dev. 2022;32(2):258-67. https://doi.org/10.36311/jhgd.v32.12955
  » https://doi.org/10.36311/jhgd.v32.12955
• ³³ Amadori A, Sherwood SH, Russell ST, Brighi A. Risks and protective factors associated to homophobic cyberbullying among youth. Aggress Behav. 2025;51(3):e70034. https://doi.org/10.1002/ab.70034
  » https://doi.org/10.1002/ab.70034
• ³⁴ Haider MR, Kingori C, Brown MJ, Battle-Fisher M, Chertok IA. Illicit drug use and sexually transmitted infections among young adults in the US: evidence from a nationally representative survey. Int J STD AIDS . 2020;31(13):1238-46. https://doi.org/10.1177/0956462420950603
  » https://doi.org/10.1177/0956462420950603
• ³⁵ Reidy DE, Bhochhibhoya S, Baumler ER, Markham CM, Peskin MF, Shegog R, et al. The longitudinal association between sexual violence victimization and sexual risk behavior in adolescence. Prev Med Rep. 2023;35:102387. https://doi.org/10.1016/j.pmedr.2023.102387
  » https://doi.org/10.1016/j.pmedr.2023.102387
• ³⁶ Moreira WC, Silva PP, Moura NS, Cirino IP, Barreto MTS, Lima LHO. Analysis of cases of sexual violence of adolescent students. Enferm Glob. 2022;21(3):250-300. https://doi.org/10.6018/eglobal.491001
  » https://doi.org/10.6018/eglobal.491001
• ³⁷ Kops NL, Bessel M, Hohenberger GF, Benzaken A, Wendland E. Self-reported syphilis and associated factors among Brazilian young adults: findings from a nationwide survey. Braz J Infect Dis. 2019;23(4):274-7. https://doi.org/10.1016/j.bjid.2019.06.009
  » https://doi.org/10.1016/j.bjid.2019.06.009
• ³⁸ Carvalho RXC, Araújo TME. Knowledge, attitudes, and practices of university adolescents regarding syphilis: cross-sectional study in the Northeast of Brazil. Rev Saude Publica. 2020;54:120. https://doi.org/10.11606/s1518-8787.2020054002381
  » https://doi.org/10.11606/s1518-8787.2020054002381
• ³⁹ Neves RG, Wendt A, Flores TR, Costa CS, Costa FS, Tovo-Rodrigues L, et al. Simultaneity of risk behaviors for sexually transmitted infections in Brazilian adolescents, 2012. Epidemiol Serv Saude. 2017;26(3):443-54. https://doi.org/10.5123/S1679-49742017000300003
  » https://doi.org/10.5123/S1679-49742017000300003
• ⁴⁰ Jahanfar S, Pashaei Z. Sexual attitudes and associated factors of risky sexual behaviors among university students. Brain Behav. 2022;12(8):e2698. https://doi.org/10.1002/brb3.2698
  » https://doi.org/10.1002/brb3.2698
• ⁴¹ Spindola T, Santana RSC, Antunes RF, Machado YY, Moraes PCD. Prevention of sexually transmitted infections in the sexual scripts of young people: differences according to gender. Cien Saude Colet. 2021;26(7):2683-92. https://doi.org/10.1590/1413-81232021267.08282021
  » https://doi.org/10.1590/1413-81232021267.08282021
• ⁴² Silva VR, Moura JF Junior. Girls from the system: an intersectional analysis of the profile of adolescent girls deprived of their freedom in Ceará. Margens [Internet]. 2021 [cited 2024 Mar 14];15(24):61-84. Available from: Available from: https://periodicos.ufpa.br/index.php/revistamargens/article/view/10099/756
  » https://periodicos.ufpa.br/index.php/revistamargens/article/view/10099/756
• ⁴³ Noor MN, Holt M, Qureshi A, de Wit J, Bryant J. Sexual risk-taking among homeless young people in Pakistan. Health Soc Care Community. 2021;29(5):1550-8. https://doi.org/10.1111/hsc.13220
  » https://doi.org/10.1111/hsc.13220
• ⁴⁴ Mokgatle MM, Madiba S, Cele L. A comparative analysis of risky sexual behaviors, self-reported sexually transmitted infections, knowledge of symptoms and partner notification practices among male and female university students in Pretoria, South Africa. Int J Environ Res Public Health. 2021;18(11):5660. https://doi.org/10.3390/ijerph18115660
  » https://doi.org/10.3390/ijerph18115660
• ⁴⁵ Head SK, Eaton D, Lloyd PC, McLaughlin A, Davies-Cole J. Exchange sex among high school students-Washington, DC, 2017. J Adolesc Health. 2021;68(2):350-6. https://doi.org/10.1016/j.jadohealth.2020.06.006
  » https://doi.org/10.1016/j.jadohealth.2020.06.006
• ⁴⁶ She B, Liu Y, Lin S, Lu F, Liu Y, Sun J, et al. Clustering analysis of sexual behavioral patterns and risk of sexually transmitted infections in Chinese men who have sex with men. J Infect Public Health . 2025;18(8):102786. https://doi.org/10.1016/j.jiph.2025.102786
  » https://doi.org/10.1016/j.jiph.2025.102786
• ⁴⁷ Allen H, Kirwan P, Brown AE, Mohammed H, Hughes G, Marks M, et al. Does being on HIV antiretroviral therapy increase the risk of syphilis? An analysis of a large national cohort of MSM living with HIV in England 2009-2016. Sex Transm Infect . 2021;97(3):221-5. https://doi.org/10.1136/sextrans-2020-054603
  » https://doi.org/10.1136/sextrans-2020-054603
• ⁴⁸ Evers YJ, Op den Camp KPL, Lenaers M, Dukers-Muijrers NH, Hoebe CJ. Alcohol and drug use during sex and its association with sexually transmitted infections: a retrospective cohort study among young people aged under 25 years visiting Dutch STI clinics. Sex Transm Infect . 2023;99(2):97-103. https://doi.org/10.1136/sextrans-2021-055355
  » https://doi.org/10.1136/sextrans-2021-055355
• ⁴⁹ Laar AS, Harris ML, Khan MN, Loxton D. Views and experiences of young people on using mHealth platforms for sexual and reproductive health services in rural low-and middle-income countries: a qualitative systematic review. PLOS Digit Health. 2024;3(12):e0000362. https://doi.org/10.1371/journal.pdig.0000362
  » https://doi.org/10.1371/journal.pdig.0000362
• ⁵⁰ Rhodes SD, Mann-Jackson L, Alonzo J, Song EY, Garcia M, Robles Arvizu JA, et al. Increasing STI and HIV preventive behaviors and addressing community-prioritized social determinants of health among young GBQMSM and transgender women of color: piloting a bilingual multilevel intervention. Sex Transm Dis. 2025;52(4):248-54. https://doi.org/10.1097/OLQ.0000000000002106
  » https://doi.org/10.1097/OLQ.0000000000002106

*

Paper extracted from master’s thesis “Modelo preditivo de desfecho de testagem rápida para sífilis em jovens, segundo fatores sociodemográficos, econômicos e comportamentais”, presented to Universidade Federal da Paraíba, João Pessoa, PB, Brazil. This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) - Finance Code 001, Brazil and supported by Fundação de Amparo à Pesquisa da Paraíba (FAPESQ), Grants # PPSUS-TO 12/2021 and #TO 830/2026, Brazil.

Corresponding author:

William Caracas Moreira [e-mail] https://orcid.org/0000-0003-2138-3445

Conflict of interest:

the authors have declared that there is no conflict of interest.

Associate Editor:

Aline Aparecida Monroe

Publication Dates

• Publication in this collection
  19 Oct 2026
• Date of issue
  2026

History

• Received
  16 May 2024
• Accepted
  04 Feb 2026