Syphilis among Roma Community: a Single-Center Experience in Bulgaria (Socio-Demographic Data Collection, 2008-2022)

Introduction: With a population of roughly 11 million, the Roma (Gypsies) are the largest ethnic minority in Europe, particularly in the countries of Central and Eastern Europe. A number of serious socioeconomic issues, such as poor health, low levels of education, unemployment, discrimination, criminal activity, high-risk sexual behavior, and a high rate of illnesses, including STDs, are present in their society. Aim: This study set out to investigate the frequency and demographics of syphilis within the Pleven region’s Roma population. Materials and methods: The methodology pertains to the study of data obtained from the Pleven registrations of the University Clinic of Dermatology and Venereology. The patients were chosen between the years 2008 and 2022. Results: The findings demonstrated that over the course of the study’s 15 years, 323 people fell ill, with 35% of those individuals being Roma. Simultaneously, the proportion of Roma people living in the Pleven region fluctuated between 4.09% in 2011 and 3.09% in 2021. There were 113 Roma patients with syphilis, with 55% being female and 45% being male. The age group most commonly affected was 20–29 years old (44%), followed by singles (32%), and cohabiting individuals (49%), 49% had primary and basic education, 54% were unemployed, and 82% were heterosexual. Among Roma women, 11.5% were prostitutes, 14% were pregnant, and 15% gave birth. Cases of congenital syphilis were 4.4%. Statistically significant differences in all observed characteristics in Roma and patients from other ethnic groups are consistent with the data in other Central and Eastern European countries. Conclusion: In conclusion, our findings confirm the high risk of contracting syphilis.


INTRODUCTION
Multiple lesions on the skin and mucous membranes are the clinical signs of syphilis (also known as Lues), a complicated infectious disease that experiences periods of exacerbation and remission.[3] Treponema pallidum causes it.All ages are susceptible to infection, which primarily occurs through sexual contact.In cases of congenital syphilis, the bacteria are passed from a sick mother to the developing fetus through the placenta. [4,5]yphilis and other sexually transmitted diseases have been more common worldwide throughout the past ten years, according to a global trend.It is advised to increase the screening of risk groups, such as HIV-positive individuals, sex workers, men who have sex with men (MSM), injection drug users, unemployed individuals, marginalized populations, and members of ethnic minorities, in order to reduce the frequency of these diseases.[8] The Roma minority is the biggest and most vulnerable ethnic group in Europe.Approximately 70% of the 9-11 million Roma population in Europe reside in the former Soviet Union's republics as well as in Central and Eastern Europe.Roma poverty is greatest in Bulgaria, Hungary, and Romania, where a sizable portion of the Roma people resides.A number of well-known facts regarding the lives of Roma people include their high birth rate, active migration, awful living conditions, inadequate nutrition, lack of education, and high-risk sexual behavior. [9,10]The high occurrence of sexually transmitted infections (STIs) among Roma is a result of their risky sexual behaviors, which includes early sexual onset, promiscuity, disregard for personal protective equipment, drug and alcohol abuse, prostitution, bisexual behavior, paid oral sex, and particularly anal intercourse. [10,11]esearchers from Bulgaria investigated the rates of sexual risk for HIV/STDs among young men in the Republic of Bulgaria and its capital, Sofia, at the beginning of the twenty-first century.They discovered that the majority of men of Roma descent use drugs, have multiple partners, hardly ever use condoms, and frequently have sex with other men.14] We conducted a retrospective analysis of the clinical-epidemiological and socio-demographic data on syphilis among the Roma population in the Pleven region from 2008 to 2022 as a result of these data.The Pleven Clinic for Skin and Venereal Diseases database was used to extract the study population, which also includes public data from our previous study on the incidence of syphilis from 2009 to 2018.Because a separate examination of the indicators of ill Roma was not conducted, the article found trends in the prevalence and epidemiological characteristics of the disease in the general population. [15]ntil now, we have not found a similar epidemiological and clinical analysis of syphilis among the Roma community in the country in Bulgarian scientific periodicals.

AIM
The study aims to determine the prevalence of syphilis among the Roma ethnic group in the Pleven region and to describe the socio-demographic characteristics of the affected Roma.The study was conducted between 2008 and 2022.

MATERIALS AND METHODS
We conducted a retrospective study to determine the prevalence of different types of syphilis among the Roma community in the Pleven region.Statistical data for representatives of other ethnic groups in the region was analyzed in a comparative analysis.The data were extracted from the patient's registration cards, which are required to be completed in accordance with Republic of Bulgaria regulations for annual reports on the operations of the Center on Sexually Transmitted Infections in the University Clinic and the Regional Health Inspectorates (RHI) in Pleven.The sociodemographic data was acquired using a documentary technique.Extensive and intensive indicators were used to study epidemiological and demographic characteristics: number of patients, incidence per 100,000, sex and age distribution of reported cases, location of residence, educational, family, and social status, and sexual orientation.
The study, which takes place between 2008 and 2022, includes 113 patients of Roma descent who were diagnosed with different forms of syphilis and treated at the skin-venereal clinic in town of Pleven.Eleven patients were identified as the infection's source, and five patients were contacts of an infected person.The patients were chosen following an outpatient clinical examination at the patient's request by a dermatovenerologist (for 30 Roma), during blood donation, preventive examinations, or laboratory tests in a hospital (60 people).Their mean age was 28.50±1.80years; there were 51 men (45.13%) and 62 females (54.87%).The diagnosis of syphilis was based on the patient's history and physical examination and confirmed with the following diagnostic serologic methods: nonspecific screening Rapid Plasma Reagin test (RPR) and after mandatory confirmation with specific Treponema pallidum hemagglutination assay (TPHA) and enzyme-linked immunosorbent assay (ELISA) Treponema pallidumspecific IgM /IgG.All dispensary persons were also examined for carrying HIV (HIV carrier ELISA HIV1/2 Ag-Ab and HIV1/2 Rapid test).
The IBM® SPSS ® Statistics 26.0 program was used to analyze the data statistically.Descriptive statistics and comparative analysis (χ 2 test and Fisher's exact test with the corresponding 95% confidence interval) were applied to the frequency distribution of the compared groups.The results are described through tables and numerical values (continuous variables are given as means and standard deviations (±SD), and category variables in percentages).The assessment of statistical significance in the studied groups was carried out using the value of p, and p<0.05 was chosen as the level of significance at which the null hypothesis was rejected.
This study used secondary data, and no ethical approval was needed.The health information of the person with a diagnosis of syphilis was stored under a code excluding the possibility of identifying the specific person and in compliance with the requirements of the Personal Data Protection Law (Art.64 of Ordinance No. 3/26.05.2016). [16]

RESULTS
An average of 35% of all syphilis cases that were documented between 2008 and 2022 were among the Roma.Data from the two most recent population censuses in Bulgaria (2011 and 2021) show that the percentage of Roma in the Pleven region's overall population ranges between 4.09% and 3.09%.Additionally, the data show that the infection rate among Roma is higher than that of the region's general population -13 times higher in 2011 and 10 times higher in 2021.
The frequency of syphilis among the Roma and other ethnic groups of the population of the Pleven region is presented over five years in Table 1.A significant difference was found in the frequency distribution of patients from the two subpopulations over the three 5-year periods (χ 2 (2)=11.68,p=0.003,N=323).Among Roma with syphilis, men are 45.13%, and women are 54.87%.They ranged in age from 0 to 63 years (mean age 28±11.8 vs. 35.30±14.4 in the other patients).The most affected age is 20-29 years (44.2%).32.7% are unmarried, and 48.8% are cohabiting without marriage.48.7% have primary and basic education, 54% are unemployed, 82.3% are heterosexual.Roma men who declared themselves homosexual represent 9.7% of all patients and 21.5% of men.Among Roma women, 11.5% were prostitutes, 14% were pregnant, and 15% were in labor.Early syphilis (8 with primary, 24 with secondary and 61 with early latent) is 82.3%, and cases of congenital syphilis are 5 (4.4%).There are significant differences in almost all observed characteristics between sick Roma and sick representatives of other ethnic groups (Table 2).
The results show that Roma are younger, less educated, more often cohabiting without marriage and unemployed.In the study population, among the Roma, there are more female prostitutes (11.5% vs. 2.4%) and a smaller percentage of homosexuals (9.7% vs. 18.6%).

DISCUSSION
The World Health Organization published data on the frequency of sexually transmitted infections in 2023, revealing that more than 1 million people worldwide become ill every day as a result of STIs, with 7.1 million people contracting syphilis. [8]Although lues can be effectively cured, latent forms are a sign of untreated infection and are defined as early latent syphilis (acquired within 1 year) and late latent syphilis (acquired after 1 year). [5,19,20]If not treated in time, congenital syphilis leads to stillbirth or early neonatal death. [21]Also, through the clinical presentation of genital and or anorectal lesions, syphilis may increase the risk of HIV transmission and acquisition, particularly among men who have sex with men (MSM). [22]][25] Our results for the Roma population in the Pleven region are consistent with the data for the countries from Eastern Europe and the Balkans -4.09%. [17,18]The incidence of syphilis in the Pleven region has increased from two to four times the national average, with the infection 13 times more common among Roma than the general population in 2011, and ten times more common in 2021.
Historically, conservative patriarchal norms characterized the Roma community and influenced the sexual behavior of individuals.Traditionally, Roma men have more power and control in relationships, have sexual freedom before and during marriage and often engage in sexual practices with multiple partners.Romani women are expected to preserve their virginity and be monogamous after marriage, so the risk of STIs in Romani communities is largely determined by the behavior of men, who are more likely to suffer from sexually transmitted diseases. [26]mong Roma women, problems arise, such as early onset of sexual life, teenage pregnancy, low levels of contraceptive use, high frequency of abortions, and prostitution. [9,27]In confirmation of the above data, the most affected age group among Romani women is 15-25 years (20.4% against 10.6% for men), and the frequency of Romani women with syphilis is higher (54.87% against 45.13%), of which 14.2% are pregnant, and 15% are women in labor.
In general, our results show that in the Pleven region, Roma with Lues is younger, less educated, and more often unemployed compared to patients of other ethnicities, which corresponds to the published data of Kabakchieva et al. [13] for the city of Sofia, as well as Knezevic [28] for Belgrade.In the conditions of poverty and unemployment, it is not surprising that 11.5% of Roma women and only 2.4% of the other cases declared that they were sex workers.According to Bjekić et al. [23] , Roma with syphilis were significantly more likely to engage in prostitution (35.3% vs. 3.4%), a fact that supports our results.Among our syphilis patients, 9.8% of Roma men identified themselves as men who have sex with men versus 18.6% in other ethnicities, with some studies showing a significantly lower percentage of Roma men admitting their homosexual orientation. [14,26]Contrary to numerous publications about a high incidence of syphilis-HIV co-infection among men who have sex with men [22,29] , we did not find co-infection among our studied Roma population with syphilis.
There are several limitations in this study.The anamnesis and clinical examination results, along with the data from the syphilis patients' required registration, form the basis of this study.Despite the fact that a doctor is present throughout the registration procedure, the Roma patient's personal behavior history data may be erroneous or even deliberately misleading.
During the population census, some Roma did not self-identify as such, which is why only declared Roma could be scientifically studied, a fact we have taken into account.
The results reflect the experience of one clinic, and the data on syphilis-affected Roma from the Pleven region may be different from the data for other regions in the country.We are not aware of such specific studies investigating syphilis prevalence trends among the Bulgarian Roma in the last ten years, but our results are supported by data published in world scientific periodicals.

CONCLUSION
The results of our study show that the number of diagnosed and treated cases of syphilis among the Roma ethnic group at the Pleven Dermatology Clinic increased after 2018.Roma with Lues are younger, less educated, and more often unemployed, most in their 20s to 29 years, and the frequency of infection is 10-13 times higher compared to other ethnic groups living in the region.These facts correspond to data published in scientific literature over the past 15 years by other authors from Central and Eastern Europe and the Balkans, where about 70% of the Roma population of the continent lives.In general, Roma communities' social, economic, family, and health difficulties pose a substantial public health challenge in various countries attempting to integrate Roma people.Limiting sexual risk through recommendations to minimize the number of sexual encounters, safe sex, and frequent testing for sexually-transmitted diseases are only some of the activities for preventing and controlling not only syphilis but also other STIs in the Roma community.

Table 1 .
Frequency of syphilis among Roma population and other ethnic groups in the Pleven region for the three five-year periods from 2008 to 2022