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Revista Española de Sanidad Penitenciaria

versión On-line ISSN 2013-6463versión impresa ISSN 1575-0620

Rev. esp. sanid. penit. vol.21 no.3 Barcelona  2019  Epub 24-Feb-2020

 

Original Articles

Prevalence and predictive factors of Chlamydia trachomatis genital infection in inmates 25 to 65 years old in four Catalan prisons

Prevalencia y factores predictivos de infección por Chlamydia trachomatis genital en presos de 25 a 65 años en cuatro prisiones de Cataluña

D Carnicer-Pont1  5  6  , V González2  6  7  8  , E López-Corbeto3  6  8  , E Turu4  , Grupo de trabajo de salud penitenciaria

1Catalan Institute of Oncology. L'Hospitalet de Llobregat (Barcelona). Cancer Control and Prevention Group.

5Biomedical Research Institute of Bellvitge-IDIBELL. L'Hospitalet de Llobregat (Barcelona)

6CIBER Epidemiology and Public Health (CIBERESP).

2Microbiology Service. University Hospital of Universitari Germans Trias i Pujol. Badalona (Barcelona). Badalona (Barcelona).

7Centre of epidemiological studies on sexually transmitted infections and AIDS of Catalonia (CEEISCAT). Department of Health. Generalitat of Catalonia. Badalona (Barcelona).

8Research Institute Germans Trias i Pujol (IGTP). Badalona (Barcelona).

3Centre of epidemiological studies on sexually transmitted infections and AIDS of Catalonia (CEEISCAT). Department of Health. Generalitat of Catalonia. Badalona (Barcelona). Research Institute Germans Trias i Pujol (IGTP). Badalona (Barcelona). CIBER Epidemiology and Public Health (CIBERESP).

4Programme of Health in Correctional Centres – Catalan Institute of Health. Barcelona (Spain)

ABSTRACT

Objectives

Determine the prevalence of Chlamydia trachomatis (CT) infection, the risk factors for infection in inmates aged 25 to 65 years old in four Catalan prisons.

Materials and methods

This is a cross sectional study conducted in four Catalan prisons chosen at convenience with a random stratified sample of the penitentiary population 25 to 65 years old taken within these centres. A urine specimen was analysed using the Anyplex CT/NG Seegene technique. An ad hoc questionnaire was used to determine sociodemographic and behavioural risk factors for infection within the previous year. The prevalence estimates of CT were calculated. Crude and adjusted odds ratios (ORs) and 95% Confidence Intervals (CIs) were used to estimate associations between infection and risk factor.

Results

Out of 1,469 participants, 15 men tested positive for CT (prevalence: 1.02%). We explored age, country of birth, education, occupation, sexual orientation, age initiation sexual activity, number and type of sexual partners (sporadic vs. stable) in a year, concurrency of sexual partners, preservative use in previous sexual relationship, etc. The only factor independently associated with infection was being heterosexual man having sexual relationships with different sporadic partners. Among those who had had an STI (Sexually Transmitted Infection) in life 27% did not notify to all their partners and the main reason was not being able to retrieve them.

Conclusions

CT prevalence in inmates 25 to 65 years old is very low in four prisons of Catalonia. No systematic screening of infection is justified although prisoners having different sporadic sexual partners may need more sexual infection prevention advice.

Keywords: prevalence; Chlamydia trachomatis; prisons; screening

RESUMEN

Objetivos

Determinar la prevalencia de Chlamydia trachomatis (CT) en la población penitenciaria con edad comprendida entre los 25 y 65 años y los factores de riesgo en cuatro prisiones de Cataluña.

Materiales y métodos

Estudio transversal realizado, en cuatro centros escogidos a conveniencia, con una muestra aleatoria estratificada de presos por grupo de edad y sexo dentro de cada uno de los centros. Se recogió una muestra de orina para determinar el ADN de CT mediante la técnica Anyplex CT/NG Seegene: se utilizó una encuesta ad hoc para recoger las variables sociodemográficas, de comportamiento y de factores de riesgo de infección en el año anterior. Para estimar la asociación entre infección y factor de riesgo, se calcularon: las razones de posibilidades u odds ratios (OR) crudas y ajustadas y los intervalos de confianza del 95% (IC).

Resultados

La prevalencia de CT fue del 1,02%, afectando a 15 hombres heterosexuales entre 1.469 participantes. Se exploró la edad, el país de nacimiento, la educación, la ocupación, la orientación sexual, la edad de inicio de relaciones sexuales, el número y el tipo de parejas sexuales (esporádicas frente a estables) en el año anterior, la concurrencia de parejas, el uso del preservativo en la última relación sexual, etc. El único factor asociado independientemente a la infección por CT fue tener relaciones sexuales con parejas esporádicas dentro o fuera de la prisión. Entre los que manifestaron haber tenido una infección de transmisión sexual (ITS) en el curso de su vida, el 27% no lo notificaron a todas sus parejas, y la principal razón fue la imposibilidad de recuperar el contacto con ellas.

Conclusión

La prevalencia de CT en la población penitenciaria de 25 a 65 años es muy baja en las cuatro prisiones de Cataluña. El cribado sistemático de CT en esta población no está indicado. Los presos que tienen relaciones esporádicas con distintas parejas pueden necesitar un mayor soporte de prevención de infecciones de transmisión sexual.

Palabras clave: prevalencia; Chlamydia trachomatis; prisiones; diagnóstico

INTRODUCTION

Genital infection of Chlamydia trachomatis (CT) is increasing among the Catalan population, most frequently among youngsters1. The last available prevalence of the population under 25 years of age was around 8.5%2. This is a highly transmissible infection, mainly asymptomatic, but with the potential to produce serious complications, most importantly pelvic inflammatory disease in women and infertility in both men and women. Early detection and treatment are crucial to guarantee prevention and control3. However, there is no good-quality evidence to suggest that widespread testing strategies have had an impact on the transmission of chlamydia in the population4 while other studies suggest that partner notification is more cost-effective than screening for CT control5.

Since 2007, the Catalan government has regularly conducted cross sectional studies of CT screening among youngsters under 25, either in correctional facilities6-7 or in primary health centres but the situation among persons over 25 is poorly known, particularly in key populations such as individuals in correctional facilities. It is suspected that adult inmates have a higher risk of CT infection because of potentially hazardous sexual behaviour (clients of sex workers)8. The only study in our country that specifically considers such issues is one from 2011 among inmates of 18 to 35 years old9. The only available information on prisoners older than 25 to 35 years is from 2008, which shows a CT prevalence of 4%9. However, the increasing trend of infection, from 5.7% in 2008 to 7.5% in 2014 among under 25 years old suggests the need to explore the situation among persons over that age.

It is unclear whether CT screening of inmates over 25 years old should be recommended in Catalan prisons. There are no European Guidelines regarding CT screening in prisons and the Centres for Disease Control (CDC) of Atlanta10 recommend screening on entering prison for all women and men younger than 35 and 30, respectively. On the other hand, some Spanish Scientific Societies recommend screening for STIs in people entering correctional centres11. The objective of this study is to determine the prevalence of CT, the risk factors for infection in inmates aged 25 to 65 years old in four Catalan prisons so as to provide more information for the debate on systematic screening among this population.

MATERIAL AND METHOD

There are two prison administrations in Spain: the Central Government and the Catalan administration. The Catalan administration manages nine prisons containing mainly two types of inmate: preventive (those on short time stays, mostly recently incarcerated and still not sentenced) and convicted inmates (those with a longer average stay). The socio-demographic and behavioural characteristics of these inmates are expected to be different and may have an effect on CT infection. This is a cross sectional study with a representative sample of the prison population of 25 to 65 years of age in Catalonia. In 2017, there were 5214 new prisoners in Catalonia and the total prison population was 14,868 people12. There were 2053 preventive inmates (13.8%) and 12,815 convicted prisoners (86.2%). The sex distribution of this population was 13657 men (93%) and 1028 women (7%). The average stay in prison was 267 and 1232 days among preventive and convicted prisoners, respectively. Weekend leave permits were given to 2204 inmates. Most of the inmates, except the ones with security restrictions, have one or two conjugal visits a month. This study is conducted in two prisons for convicted inmates and two for preventive inmates as this makes the study more representative and also because of the availability of health professionals within prison system.

Process

A urine specimen was analysed using the Anyplex CT/NG Seegene technique. An “ad hoc” questionnaire was used to determine socio-demographic, behavioural and risk practices for infection over the previous year. The questionnaire was administered by health professionals to all participants after obtaining their informed consent.

Sample size

We took a convenience sample of four out of nine prisons and a random sample of 1498 out of 3325 prisoners from the four centres. There were two prisons with preventive inmates and two with convicted inmates. This was sufficient to estimate CT prevalence with a 95% confidence interval and a precision of +/- 0.75, provided that previous prevalence was not greater than 4%. The participating centres received a random number table stratified by sex and age group (25 to 35 and 36 to 65) for participation. The exclusion criteria was having done the test in the previous month.

Questionnaire

The questionnaire explored socio-demographic data (sex, age, country of birth, date of arrival to the country, date of entry in prison, educational level) and behaviour over the previous year (sexual orientation: heterosexual, homosexual, bisexual, transexual or unknown; number of partners; age of first sexual relation; type of partners: sporadic, stable, unknown; concurrency of sexual partners in a year; new partner in three months; preservative use in previous sexual contact; practicing sex in clubs; use of chats; being a sex worker; being client of a sex worker; having had an STI in a year; Hepatitis C, B and HIV serostatus). Questions were piloted with 15 prisoners for understanding and internal validity.

Ethical considerations

Approval of the study was obtained from the Ethics Committee of the “Institute of Research in Primary Health” IDIAP Jordi Gol. An information sheet and the informed consent were given to candidates. After signing the informed consent, the participating inmates were asked to collect urine for testing in a sampling devise and also answer the above mentioned questionnaire. Both the questionnaire and urine sample were linked by an alpha-numeric identification code that enabled the data be managed without personal identification. To comply with the Spanish Organic Law on Personal Data Protection (LOPD) informed consents were kept under protection in each Penitentiary centre. This document, which also included the alpha-numeric number, allowed health professionals to identify the results, record them in the computerized medical record and, when necessary, treat the inmates according to the results of the tests.

Specimen collection and analysis

First void urine specimens were collected from 1498 individuals using the Multicollect Specimen Collection kit (Abbott Molecular Inc, Abbott Park, IL, USA) as recommended by the manufacturer. The pooling was carried out by combining 400 microlitres of each specimen to yield a total volume of 1600 microlitres. Five hundred microlitres of each pool were used to perform DNA extraction of Chlamydia trachomatis by MICROLAB Nimbus IVD system (Seegene, Seoul, Korea) according to the manufacturer’s instructions. The semi-quantitative results were obtained based on cyclic-CMTA (catcher melting temperature analysis) ) 13-14. The reaction was performed in a CFX96 real time thermocycler (bio-Rad, Hercules, CA, USA) according to the manufacturer’s instructions. Each pooled set of specimens was tested, and Chlamydia trachomatis positive pooled samples were individually tested to identify the positive specimen(s).

Data collection and analysis

After receiving the laboratory results, the information from test results and questionnaires was entered into a database at the Catalan Institute of Oncology (ICO). Data analysis was done using Stata V.14, (Stata statistical software: release14. College Station, Texas, USA: StatCorp, 2014), accounting for stratification and weighting of the sample. The prevalence estimates of CT were calculated as the number of positive participants divided by the number of participants whose urine specimens were tested. Ninetyfive percent confidence intervals (CIs) were generated from proportions of binomial distributions. Crude and adjusted Odds Ratios (ORs) were used to estimate associations between infection and risk factor and 95% CIs were calculated. Gender stratification was not possible because no woman tested positive for infection.

RESULTS

1498 inmates were evaluated during the period of study. After excluding 29 (1.9%) of inmates who were found to be younger than 25 or older than 65, there were 1374 men and 95 women eligible for participation. The average age was 40 years (range: 25-65 years). There were 12 (0.8%) and 21 (1.5%) out of 1374 men who mentioned having had sex with men (MSM) or who were bisexual, respectively. Half of the participants were foreigners. Most of them came from Western Europe (54%) followed by Latin America (16%), North Africa (10%) and Central Europe and Central Asia (6%). Most of them (91%) had gone to school and had received a primary (39%), secondary (43%) or university (9%) education.

Characteristics of inmates by sex

No significant differences were found between men and women in terms of socio demographic characteristics (age, born in foreign country, educational level). As regards risky practices, there were more men than women with a heterosexual orientation (95.8% vs 84.2%, p<0.001), who had their first sexual relationship when they were 5 to 15 years old (61.7% vs 45.2%, p<0.05), who had different sporadic partners (19.3% vs 8.4%, p<0.01), had more than two partners in the previous year (14.2% vs 7.4%, p=0.05), practiced sex in clubs (46.5% vs 28.4%, p<0.05), used chats to find sexual partners (17.6% vs 3.2%, p<0.0001), consumed drugs before or while having sex (76.4% vs 53.7%, p<0.0001), were clients of sex workers (56.6% vs 5.3%, p<0.0001) and had a positive hepatitis B serostatus (29.3% vs 6.3%, p<0.0001), (Table 1).

Table 1 Characteristics of inmates by sex 

Participants N=1.469 Women N=95 Men N=1.374 P value
N, means %, range N, means %, range
Age (means, range)     39,5 37,7-41,4 40 39,6-40,5  
Country of birth Spain 734 46 51,6 688 49,9 0,755
  Abroad 734 49 51,6 686 49,9  
  No studies 129 4 4,2 125 9,1 0,462
Primary level 574 42 44,2 532 38,7  
Educational level Secondary level 630 41 43,2 589 42,9  
University level 129 8 8,4 121 8,8  
  Unknown 7 - - 7 0,5  
  Heterosexual 1.396 80 84,2 1.316 95,8 <0,001
Homosexual 16 4 4,2 12 0,9  
Sexual orientation Bisexual 30 9 1,0 21 1,5  
Transsexual 1 1 1,0 0 0  
  Unknown 26 1 1,0 25 1,6  
  5 to 10 36 1 1,0 35 2,5 0,026
11 to 15 855 42 44,2 813 59,2  
Age 1st sexual 16 to 20 511 46 48,4 465 33,8  
relation 21 to 25 42 5 5,3 34 2,5  
Older than 25 3 0 0 3 0,2  
  Unknown 25 - - - -  
Sporadic non stable 273 8 8,4 265 19,3 <0,01
Type of partners Stable 796 64 67,4 732 53,3  
  Unknown 400 23 24,2 377 27,4  
Concurrency sex in Yes 207 7 7,4 200 14,6 0,134
a year No 1.111 74 77,4 1.037 75,5  
  Unknown 151 14 14,7 137 9,9  
  0 336 17 17,9 319 23,2 0,05
Number of sexual 1-2 813 65 68,4 748 54,4  
partners in a year More than 2 208 7 7,4 201 14,2  
  Unknown 112 6 6,3 406 7,7  
  Yes 116 10 10,5 105 7,6 0,525
New partner in 3 months No 1.202 73 76,8 1.130 82,2  
  Unknown 151 12 13,7 139 22,2  
Preservative Yes 398 17 17,9 381 27,7 0,123
(condom) use in No 1.014 75 78,9 939 68,3  
previous sexual contact Unknown 57 3 3,2 54 4,0  
  Yes 666 27 28.4 639 46.5 <0.05
Sex in clubs No 778 67 70.5 711 51.7  
  Unknown 25 1 1 24 1.7  
Using chats to find Yes 245 3 3.2 242 17.6 0.001
partners No 1.197 91 95.8 1.106 80.5
  Unknown 27 1 1.05 26 1.9  
Drug consumption Yes 1.101 51 53.7 1.050 76.4 <0.001
and sex No 352 43 45.3 309 22.5  
  Unknown 16 1 1.05 15 1.1  
  Yes 116 7 7.4 109 7.9 0.446
Sex worker No 1.330 85 89.5 1.245 90.6  
  Unknown 23 3 3.2 20 1.46  
Client of sex Yes 574 5 5.3 569 56.6 <0.001
workers No 856 18 82.1 778 1.9  
  Unknown 39 12 12.6 27 5.1  
  Yes 78 8 8.4 70 5.1 0.081
STI in a year No 1.305 80 84.2 1.225 89.2  
  Unknown 86 7 7.4 79 5.7  
  Yes 192 11 11.6 181 13.2 0.612
Hep C serostatus No 1.134 76 80 1.058 77  
  Unknown 143 8 84 135 9.8  
  Yes 408 6 6.3 402 29.3 <0.001
Hep B serostatus No 894 80 84.2 814 59.2  
  Unknown 167 9 9.5 158 11.5  
  Yes 116 6 6.3 110 8.0 0.385
HIV serostatus No 1.216 83 87.4 1.133 82.5
  Unknown 137 6 6.3 131 9.5  

Note. STI: sexually transmitted infection.

Characteristics of inmates by type of prison

The characteristics of inmates vary notably according to their correctional process. There were more foreigners in preventive centres than in centres with convicted inmates as well as inmates who had had their first sexual relation at a young age. There were more men in centres for convicted inmates, as well as more inmates who had different sporadic partners, concurrent sexual partners, practiced sex in clubs, used chats to find new sexual partners, consumed drugs while having sex, were sex workers or clients of same, had been diagnosed with an STI in the previous year and with positive hepatitis C, B and HIV serostatus. CT prevalence, although not significant, was higher in centres with convicted inmates (13 CT infections out of 1078 tested, 1.2% prevalence) than in centres with preventive ones (2 CT infections out of 391 tested, 0.5% prevalence) (Table 2).

Table 2 Characteristics of inmates by type of correctional centre 

Centres of Convicted inmates Centres of Preventive inmates
N answers N, means %, range N answers N, means %, range P value
CT prevalence 1.078 13 1.2 391 2 0.5 0.242
Sex (man) 1.078 1.023 94.9 391 351 89.8 0.000
Age (means, range) 1.078 43 26-65 391 39 25-65 -
Born abroad 1.074 497 48.1 395 238 60.2 0.000
Illiterate (no education) 1.077 93 8.6 385 36 9.3 0.077
Heterosexual orientation 1.065 1.028 96.5 382 368 96.3 0.822
Age group 1st sex (5 to 15 years) 1.053 379 35.9 388 174 44.8 0.000
Different sporadic partners 794 220 27.7 275 53 19.3 0.006
Concurrency sex in a year 981 173 14.6 339 34 10.0 0.000
Number of partners in a year (mean) 993 2 - 364 1 - -
New partner in 3 months 985 95 9.6 337 20 5.9 0.113
Preservative use in previous sex 1.078 307 28.5 391 91 23.3 0.177
Practicing sex in clubs 1.063 518 48.7 381 143 37.5 0.000
Using chats to find partners 1.061 197 18.6 383 44 11.5 0.002
Drug consumption and sex 1.066 98 9.2 391 16 4.2 0.007
Sex worker 1.069 841 78.7 384 252 65.6 0.000
Client of sex workers 1.059 492 46.5 375 77 20.5 0.000
STI in a year 942 72 7.0 369 4 1.1 0.000
Hep C serostatus 1.064 171 16.1 376 21 5.6 0.000
Hep B serostatus 1.057 371 35.1 373 37 9.9 0.000
HIV serostatus 1.063 111 10.4 372 8 2.1 0.000

Note. CT: Chlamydia trachomatis; STI: sexually transmitted infection.

Chlamydia trachomatis prevalence

15 men and no woman were positive for CT infection. The prevalence was 1.02%. Bivariate analysis is presented in Table 3, where the only variables associated with infection were having sporadic non stable partners and having more than 2 partners. After multivariate analysis (Table 4) adjusting for the variables independently associated with infection (having sex with different sporadic non stable partners and having more than two partners in a year) the only factor remaining weakly associated with infection is having sex with different sporadic non stable partners (OR: 1.8, 95% CI:0.9-3.4).

Table 3 Bivariate analysis of risk factors for Chlamydia trachomatis 

Socio demographic and behavioural variables Participants N=1.469 CT infection N (%) P value
Type of prison Preventive inmates 395 2 (0.5) 0.234
Convicted inmates 1.974 13 (1.2)
Sex Men 1.374 15 (100) 0.306
Women 95 0
Unknown 0 0
Age group 25 to 35 497 7 (1.4) 0.541
36 to 45 569 6 (1.1)
46 to 55 300 2 (0.7)
56 to 65 101 0
Unknown 2 0
Country of birth Spain 734 4 (0.5) 0.070
Abroad 735 11 (1.5)
Unknown 1 0
Educational level No studies 129 2 (1.5) 0.893
Primary level 575 6 (1.0)
Secondary level 629 5 (0.8)
University level 129 2 (1.5)
Unknown 7 0
Sexual orientation Heterosexual 1.397 15 (1.1) 0.978
Homosexual 15 0
Bisexual 30 0
Transsexual 1 0
Unknown 26 0
Age group 1st sexual relation 5 to 10 33 0 0.751
11 to 15 855 10 (1.2)
16 to 20 511 4 (0.8)
21 to 25 42 1 (2.4)
Unknown 28 0
Type of partners Sporadic non stable 273 8 (2.9) 0.002
Stable 796 6 (0.7)
Unknown 400 1 (0.2)
Concurrency sex in a year Yes 207 4 (1.9) 0.195
No 1.111 11 (1.0)
Unknown 151 0
Number of sexual partners in a year 0 336 1 (0.3) 0.018
1 or 2 813 8 (1.0)
More than 2 208 6 (2.9)
Unknown 112 0
New partner in 3 months Yes 116 2 (1.7) 0.338
No 1.202 13 (1.1)
Unknown 151 0
Yes 394 2 (13.3) 0.530
No 1.022 13 (86.7)
Unknown 39 0
Practice of sex in clubs Yes 666 10 (1.5) 0.237
No 778 5 (0.6)
Unknown 25 0
Using chats to find partners Yes 245 4 (1.6) 0.520
No 1.197 11 (0.9)
Unknown 27 0
Drug consumption and sex Yes 1.101 12 (1.1) 0.854
No 352 3 (0.8)
Unknown 16 0
Sex worker Yes 116 2 (1.7) 0.660
No 1.330 13 (0.8)
Unknown 23 0
Client of sex workers Yes 574 4 (0.7) 0.452
No 856 11 (1.3)
Unknown 39 0
STI in a year Yes 78 2 (2.5) 0.255
No 1.305 13 (1.0)
Unknown 86 0
Hep C serostatus Yes 192 1 (0.5) 0.707
No 1.134 12 (1.1)
Unknown 143 2 (1.4)
Hep B serostatus Yes 408 3 (0.7) 0.792
No 894 10 (1.1)
Unknown 167 2 (1.2)
HIV serostatus Yes 116 1 (0.9) 0.859
No 1.216 12 (1.0)
Unknown 137 2 (1.5)

Note. CT: Chlamydia trachomatis; STI: sexually transmitted infection

Table 4 Chlamydia trachomatis: risk factors for infection among inmates 

Variable N answers N condition CT infection CT prevalence (%) Crude Odds ratio 95% (CI) Adjusted Odds ratio 95% (CI)
CT prevalence (overall) 1.469 1.469 15 (%) 1.0 NA
Convicted inmates 1.469 1.074 13 1.2 2.4 (0.7-7.0)
Sex (man) 1.469 1.374 15 1.09 *
Age (25 to 34 years) 1.467 497 7 1.4 0.9 (0.9-1.0)
Born abroad 1.469 735 11 1.5 2.8 (0.9-8.8)
No studies or high school 1.462 129 2 1.5 1.2 (0.7-2.0)
Heterosexual orientation 1.469 1.397 15 1.07 *
Age group 1st sex (11 to 15 years) 1.441 855 10 1.1 0.8 (0.3-2.3)
Different sporadic partners 1.069 273 8 2.9 2 (1.2-3.4) 1.8 (0.9-3.4)
Concurrency sex in a year 1.320 207 4 1.9 2.0 (0.6-6.2)
More than two partners in a year 1.357 208 6 2.9 3.8 (1.3-10.7) 1.5 (0.4-5.6)
New partner in 3 months 1.318 116 2 1.7 1.2 (0.7-1.9)
Preservative use in previous sex 1.430 394 2 0.5 0.7 (0.4-1.2)
Practicing sex in clubs 1.444 666 10 1.5 1.5 (0.9-2.6)
Using chats to find partners 1.442 245 4 1.6 1.3 (0.7-2.4)
Drug consumption and sex 1.453 1.101 12 1.1 1.1 (0.6-2.1)
Sex worker 1.446 116 2 1.7 1.8 (0.4-8.0)
Client of sex workers 1.430 574 4 0.7 0.5 (0.2-1.7)
STI in a year 1.383 78 2 2.6 2.6 (0.6-12.0)
Hep C serostatus 1.326 192 1 0.5 0.8 (0.4-1.6)
Hep B serostatus 1.302 408 3 0.7 0.9 (0.6-1.3)
HIV serostatus 1.332 116 1 0.9 0.9 (0.5-1.9)

Note. CI: confidence interval; CT: Chlamydia trachomatis; NA: not applicable; STI: sexually transmitted infection. *All infected were men and of heterosexual orientation.

Other Sexually Transmitted Infections (STI) and partner notification

Out of 1469 participants, 78 (5.4%) inmates mentioned having an STI in the 12 months prior to the date of the interview. Three were diagnosed with syphilis, two had gonorrhoea and the remaining 73 did not mention any STI. Information about knowledge, attitudes and practices related to partner notification during their lives is shown in Table 5.

Table 5 Knowledge, attitudes and practices related to notifying partner at some point in inmates’ life 

N answers %
1. Gave answer about notifying partner at some point in their life 224 100
Notified all partners 163 73
Notified only some partners 18 8
Notified no partners 43 19
2. Did not notify partners at some point in their life 61 100
Gave reasons for not notifying partners 43 70
Unable to locate partner 19 44
Ashamed of the situation 11 26
Believed that there was no obligation to tell partner 8 19
The doctor did not tell him/her to notify partner 5 12

No question about STI-related partner notification within the previous 12 months was asked but there were 224 answers to the question if they notified partners at some time in their lives. Most of them, 163 (73%), mentioned notifying all their sexual partners, 18 (8%) mentioned notifying only some of their partners and 43 (19%) did not notify any of their partners. 43 out of 61 (70%) mentioned the reasons for not notifying some or all their partners about the STI. The main reasons were not being able to make contact (19 out of 43, or 44%) followed by feeling ashamed (11 or 26%), believed there was no obligation to notify (8 or 19%), and because the doctor did not tell them to do so (5 or 12%). Partner notification was not associated with any of the potential differential variables such as age, sex, sexual orientation, educational level or country of birth.

DISCUSSION

This analysis of CT prevalence amongst inmates over 25 is one of the few studies available in Catalonia. Until now, there was no robust data to aid in deciding on the advisability of CT screening in inmates over 25. Our findings show that CT prevalence is very low in this population. Prevalence was higher in men than in women, unlike CT prevalence studies in the general population and similarly to other results from prison studies, although not significantly so15-18. In Catalonia, because of this low prevalence in correctional facilities, systematic screening of CT in inmates older than 25 years is not justified. In addition, it is noteworthy that preventive inmates (most recently admitted to prison) and convicted inmates (incarcerated for much longer periods) despite not showing significant differences in infection (0.5% vs. 1.2%), their prevalence is still very low compared to the CT prevalence of inmates under 25 (7.5% in the year 2014). The prevalence of CT is low, but it is consistent with the history of previous STIs, which were mentioned only by 10%. It is also noteworthy that all cases occurred in heterosexual men, probably because in these correctional centres heterosexual orientation was more frequent in men (97.3%) than in women (85.1%). Additionally, women showed a lower risky sexual behaviour (fewer different sporadic partners than men, lower mean number of sexual partners, less practice of sex in clubs, use of chats to find new partners or drug consumption while having sex), explaining the lower CT prevalence.

In a population study conducted in the city of Barcelona, the increase of STIs was observed in men who have sex with men (MSM), men who have sex with women (MSW) and women who have sex with men (WSM), with the exception of women infected with HIV, in which a reduction was observed19. They have also found an increase in risky sexual behaviour: basically an increase in the number of partners and subgroups prone to higher-risk sexual practices (Chemsex) mainly associated with MSM.

In our setting, risky sexual behaviour (different sporadic sex partners, concurrency of sexual partners, sex in clubs, drug consumption) is found more frequently among convicted than preventive inmates. This may be explained by the fact that convicted inmates may be more prone to living dangerously when they are under have a leave permit to be outside prison, or even within prison, while having their conjugal visits. However, the use of condoms in previous relationship is not a differential factor between types of inmates.

Further qualitative observation should enable the reasons explaining such differences to be identified.

This study presents some limitations: Firstly, the low prevalence obtained may have limited the identification of other possible predictors of infection and may explain the borderline significance of the risk factors associated with infection. Secondly, the study characterizes a specific population: prison inmates in Catalonia. Prisoners from other regions or countries may have similar or different STI risk behaviours. Finally, the questionnaire was mainly administered by health professionals who may have influenced the sense of some answers. We should not discount the “look good effect” on some occasions.

On the other hand, the study provides real data on the prevalence of CT infection in prisoners over 25 for the first time, which allows the Health Administration to make decisions with greater guarantees. In addition, this type of work allows the most affected groups to be identified, which should help to redesign preventive programs in order to find the most efficient way to reach these groups in the population. In our study, CT infection was more frequent among inmates with multiple diverse sporadic partners. No other socio demographic or behavioural characteristic was found to be associated. Therefore, the use of condoms should be particularly reinforced amongst these inmates. Being in prison should become an opportunity for inmates to get full training on STI prevention. In primary health care centres, partner notification has proven to be more cost-effective than opportunistic screening to stop transmission of CT and other curable STI, we therefore think that the same situation may apply to prisons. Although most of the inmates who have had an STI mentioned notifying all their partners, there were still a considerable number (27%) who did not. Similarly to the findings of other studies conducted in Catalonia among MSM19 or among users of primary health care centres20, not being able to locate their partners, feeling ashamed or believing that there was no obligation to notify were the main reasons for not notifying their partners. This may be explained by low motivation, low health education and a lack of appropriate tools for notification.

Health professionals have a crucial role in enforcing partner notification and in convincing persons recently diagnosed with an STI about the need to do so. Unfortunately, most of these health professionals are overworked, lack awareness of the importance of partner notification in stopping transmission of STIs or do not have appropriate tools that show how to notify partners. In this era of new technologies, the use of internet or new phone applications could facilitate partner notification promoted by health professionals. This should be part of the caring process in prisons.

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Recibido: 17 de Octubre de 2018; Aprobado: 19 de Febrero de 2019

Correspondence: Dolors Carnicer-Pont Instituto Catalán de Oncología. Instituto Catalán de Oncología. Grupo de Control y Prevención del Cáncer. Instituto de Investigación Biomédica de Bellvitge. L'Hospitalet de Llobregat. Barcelona. CIBER Epidemiología y Salud Pública (CIBERESP). E-mail: dcarnicer@iconcologia.net

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The Prison Health Working Group is composed of: Solé N (Equipo de Atención Primaria Penitenciaria (EAPP) Barcelona I. Barcelona), Puig L (Equipo de Atención Primaria Penitenciaria (EAPP) Barcelona I. Barcelona), Tarrés Y (Equipo de Atención Primaria Penitenciaria (EAPP) Barcelona I. Barcelona), Quiroga T (EAPP Barcelona II. Barcelona), Guixè Q (EAPP Barcelona II. Barcelona), Macias C (EAPP Sant Esteve Sesrovires I. Barcelona), Domènech N (EAPP Sant Esteve Sesrovires I. Barcelona), Yela E (EAPP Sant Esteve Sesrovires I. Barcelona), Gramunt J (EAPP Sant Esteve Sesrovires I. Barcelona), Ruíz AM (EAPP Sant Esteve Sesrovires II. Barcelona), Mangues J (EAPP Sant Esteve Sesrovires II. Barcelona), Prats M (EAPP Sant Esteve Sesrovires II. Barcelona), Balsells R (EAPP Sant Esteve Sesrovires II. Barcelona).

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