Epidemiology of STDs and improvement of syphilis management in a prison of women in Bolivia.

Transcription

1 Epidemiology of STDs and improvement of syphilis management in a prison of women in Bolivia. Laurent GÉTAZ, MD MPH Division of Penitentiary Medicine & Division of Tropical and Humanitarian Medicine Geneva University Hospitals Collaboration CH Bolivia INSTITUTIONS SALUD REGIMEN PENITENCIARIO MINISTERIO DE GOBIERNO, Cochabamba UNIVERSIDAD MAYOR DE SAN SIMON, Cochabamba HOSPITAL VIEDMA, Cochabamba HOSPITAL UNIVERSITARIO DE GINEBRA, Suiza

2 «MENU» Why a project related to STI among women in a Bolivian prison? Prison setting in Bolivia The project in the prison of San Sebastian

3 Cochabamba department: 6 prisons San Sebastian (~700) San Sebastian (250 70) San Antonio (~350 ) El Abra (5km du centre de Cbba), (secu maxi, ~300) San Pedro (Sacaba, 13km de Cbba), (~220, 30 ) San Pablo (Quillacollo, 15km de Cbba) (~270 &, séparés) Prison population: ~2500 prisoners

4 some prisons are mixed, men and women live together San Pedro, Sacaba, & ensemble

5 Many children live with one of their parents in prison. Some of them go to school

6 Overcrowding Ex: San Sebastian : official capacity of 250 places=> 700 (0.8 m 2 /pers)

7 Women's cell, and at night several women sleep on the floor...

8 to increase the area for dormitories, inmates build half floors with planks of wood San Sebastian

9 Many prisoners are abandoned by their families and by society... Some prisoners may work in prison and sell their products, but without guaranteed income San Antonio

10 To eat... you have to pay... Today, roasted chicken 6BS => 1 CHF San Sebastian

11 Health system in prison Only 3 doctors in 2011 for inmates, no nurses Restricted access to medicines: estimated at less than 10% of necessities High proportion of prisoners are from a low socioeconomic level => no money to buy drugs Lack of access to complementary exams, surgery => difficult for the same reason Lack of epidemiological data => lack of arguments to justify public health programs

12 Determinants of increased STI risks in prison in Cochabamba Promiscuity mixed gender in prison ease of access to visit prisoners and also access to sex workers opportunity to work as a sex worker in prison difficult access to condoms Justification for conducting an epidemiological study in this prison setting

13 Gynecological examination equipment available,... but doubt about the effectiveness of the sterilizer. => Additional risk factor for STI's transmission? San Sebastian

14 No clinical laboratory in prison Lack of infrastructure Lack of staff Lack of economic resources Collaboration with private lab with fees paid by inmates... Idea: use of rapid tests in these conditions could facilitate access to diagnosis?

15 Project Syphilis, HIV, hepatitis B and herpes 2 in a female prison in Bolivia

16 Introduction Syphilis is a chronic STI, involving serious consequences and potentially lethal, its treatment is effective, cheap and simple. Herpes simplex virus type 2 (HSV2)causes multiple painful genital ulcers, sometimes with fever and meningitis relapses in several infected people increases 3 times the risk of transmission of other STIs, including HIV. in several countries, prevalence of STIs is often higher among inmates than in the general population. Kelly A, CSG 2010.

17 Introduction Few investigations related to infectious diseases among inmates in Bolivia Concerning treatment and management of HIV and other STIs, there is no prison health policy in Bolivia.* The prison population is a closed population, but not isolated from the society. Detention is a temporary phase but risk factors of infectious diseases are linked to their life before, during and after detention. * Diagnóstico Rápido sobre el VIH y SIDA en el sistema penitenciario de Bolivia. Informe final. Enero 2011.

18 Syphilis in Cochabamba Cochabamba / pregnant women=> prevalence 4.3% Southwick % of pregnant women never collect the serological results for syphilis when a screening is done during pregnancy => treatment not prescribed! Risk factors demonstrated in bolivia: Low socio economical level Low education level Villazón Vargas 2009 Villazón Vargas 2009

19 Objective To determine the prevalence of and factors related to syphilis, HIV, HBV and HSV2 among women incarcerated in a prison of the city of Cochabamba, Bolivia. To investigate knowledge of transmission and protection modes of STI To evaluate the usefulness of the rapid test Determine to diagnose syphilis

20 Material and Methods We conducted a cross sectional study between September and October The study was approved by the ethic committee of the San Simon university. All participants gave written consent. Data including sociodemographic characteristics and sexual practices were collected using a structured questionnaire. Serologic tests were performed to detect syphilis, HIV, HSV2 and HBV. Factors associated with infections were evaluated by univariate analysis.

21 Material and Methods Syphilis: Non treponemic test: RPR Treponemic tests: FTA (Bioscientifica y Biomerieux) TPPA Rapid test: syphilis Determine Alere Hepatitis B: antihbc, AgHbs HSV2: ELISA specific antibodies HIV Rapid test (Determine); ELISA y WB in case of positivity

22 Item RESULTS Socio demographic data % (n) Participation rate 99.5% (219/220) Age (mean) Education level Illiterate Primary Secundary Higher education 36 years old 6.4% (14/219) 37.0% (81/219) 42.0 % (92/219) 14.6% (32/219)

23 RESULTS Socio demographic data Item Number of children Abortion or miscarriage Yes No % (n) 13.2% (29/219) 38.8% (85/219) 33.8% (74/219) 9.1% (20/219) 9.6% (21/219) 49.3% (108/219) 50.7% (111/219) 50% of women have 3 or more children! 219 inmates => 500 children ~70 children are in prison with their mother

24 RESULTS Sexual practices Item Number of sexual partners throughout life >5 Don t want to answer Survivor of rape Yes No Don t want to answer Sex work Yes No Don t want to answer % (n) (0/219) (180/219) (17/219) (19/219) 15% (33/219) 80% (175/219) 5% (11/219) 6.8% (15/219) 90.4% (194/219) 4.6% (10/219)

25 RESULTS Sexual practices Item Condom use during sexual intercourse in prison Never Sometimes Always Don t want to answer % (n) 79.7% (55/69) 13% (9/69) 5.8% (4/69) 1.5% (1/69) Reasons of no use (never/ sometimes) not necessary, I trust my partner* I don t have condoms My partners refuse Other reasons** 59.3% (38*/64) 15.6% (10/64) 18.8% (12/64) 10.9% (7**/64) *10/38 have multiple partners! **Other reasons: Afraid to ask partners I don t like it I do not know how to use I have an intra uterine device

26 RESULTS Knowledge / information Item Do you think you have enough information about STIs? Yes No % (n) 28.8% (63/219) 71.2% (156/219

27 RESULTS Prevalence Analysis % (n) Syphilis, RPR+ & TPPA+ 12.8% (28/219) (IC95% ). VIH positive 1.4% (3*/219) (IC95% ) (IC95% ) For 2 positive patients, diagnostic known before the study HSV2, Ab positive 62.6% (137/219) (IC95% ) Hepatitis B, anti HBc pos 11.9% (26/219) (IC95% ) Hepatitis B, Ag Hbs pos 0.5% (1/219) (IC95% ) resolved or chronic hepatitis B Chronic hepatitis B

28 RESULTS Factors associated with STIs Sif+ HSV2+ HBV+ Level of education Illiterate primary secundary higher level 20/95 (21%) 8/92 (8.7%) 0/32 (0%) /95 (70.5%) 56/92 (60.9%) 14/32 (43.7%) /95 (17.9%) 8/92 (8.7%) 1/32 (3.1%) Age <36 years old 36 years old 13/118 (11%) 15/101 (14.8%) /118(61.8%) 64/101 (63.4%) /118 (5.9%) 19/101 (18.8%) Number of children /178 (11.8%) 7/41 (17%) /178(63%) 25/41 (61%) /178 (9.5%) 10/40 (25%) A low level of education was significantly associated with syphilis, HBV and HSV2. Being over 36 years old and having more than 4 children were only associated with HBV

29 RESULTS Factors associated with STIs Syf+ HSV2+ HBV+ Nb of sexual partners /180 (10.6%) 2/17 (11.8%) /180 (60.5%) 12/17 (70.6%) /180 (11.7%) 2/17 (10.5%) 0.88 Ø answer 7/22 (31.8%) 16/22 (72.3%) 3/22 (13.6%) History of rape Yes No 5/33 (15.2%) 21/154 (13.6%) /33 (63.6%) 110/175 (62.9%) /33 (15.1%) 20/175 (11.4%) 0.55 Ø answer 2/11 (18.2%) 6/11 (54.5%) 1/11 (9.1%) Sex work Yes No 2/15 (13.3%) 25/194 (12.9%) /15 (73.3%) 122/194 (62.9%) /15 (6.7%) 24/194 (12.4%) 0.51 Ø answer 1/10 (10%) 4/10 (40%) 1/10 (10%) Number of sexual partners, history of rape or sex work were not associated with STIs.

30 RESULTS Knowledge Modes of transmission of HIV: Incorrect knowledge : 28% 53% (kissing, using toilets, cooking utensils, shaking hands) Modes of transmission of HBV Incorrect knowledge : 77% 91% (unprotected sexual intercourse, toothbrush, shaver, tattoos, pregnancy, food, shaking hands, coughing)

31 Rapid test Determine for syphilis: PPV (positive predictive value), NPV (negative predictive value) TPPA + y RPR+: Yes TPPA+ y RPR+: No Total Determine pos Determine neg PPV: 28/39 => 72% NPV: 0/180 => 100% However, there is no "gold standard" => PPV 72% must be interpreted Perhaps there are cases with false negative TPPA, and / or false negative RPR! 39 rapid test Determine+ 28: RPR+ y TPPA+ 7 : RPR+ y/o FTA+ y/o TPPA+ 4 : RPR /FTA /TPPA

32 niño 1: 3 meses

33 niño 1: 3 meses

34 niño 1: 3 meses

35 niño 2: 9 meses

36 Niño 2: 9mois Jail FT

37 Discussion The prevalence of syphilis and HSV 2 is particularly high in this vulnerable female population. Determine rapid test to diagnose syphilis => excellent tool in prison setting, high sensitivity, good specificity, low cost Prevention, education and treatment are necessary to mitigate these infections and limit its spread.

38 RECOMMENDATIONS Prevention campaigns / education Provision of condoms Program of screening and treatment of syphilis and other STIs

39 CONCLUSION GOOD PRISON HEALTH is GOOD PUBLIC HEALTH Syphilis in San Sebastian prison illustrates this sentence Syphilis prevalence in prison is higher than in the general population To treat women in prison not only prevents serious complications in infected people, but also in their children. In addition, it also protects the general population

40 Thank you for your attention

41 RESULTS treponemic tests FTA (with immunofluorescence microscope): Type lamps : halogen => sensitivity (3/37) compared to illumination using mercury lamp "Age" of the lamp : > 200 hours => sensitivity (some false negatives, especially if the laboratory technicien has little experience) Bioscientifica Biomérieux: sensitivity of 35% with bioscientifica! TPPA (agglutination test without microscope): Excellent sensitivity Easy to use