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).
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).
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).
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
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.
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.