A case-control study of beliefs and behaviors associated with sexually transmitted disease occurrence in Estonia

What puts them at risk? A cross-sectional case-control survey of demographic profile and sexual behavior of patients with sexually transmitted infections at a tertiary care center in North India

BACKGROUND

Sexually transmitted infections (STIs) are a major public health problem in developing nations. Identification of risk factors can help in formulating effective strategies against them. The present study was conducted in a tertiary care hospital in North India over 1 year to identify the risk factors associated with STIs.

MATERIALS AND METHODS

A questionnaire-based cross-sectional case-control survey was conducted where participants answered questions on demographic details, sexual behavior, and awareness of STIs. Cases were patients with STIs whereas controls were randomly selected from healthy individuals accompanying patients with nonvenereal complaints attending our hospital.

RESULTS

There were 106 cases and 64 controls. STI patients had sexual debut 2 years before controls. A higher proportion of STI cases had lower education, multiple sexual partners, lived separately from their partner, had nonregular partners, had protected sex in the last month, had sex under influence of alcohol/illicit drugs, sex in unstructured settings, and engaged in transactional sex, in comparison to controls (P < 0.05). More cases were aware of the symptoms/preventive measures of STIs (P < 0.001). On multivariate analysis, multiple sexual partners, sex under influence of alcohol/illicit drugs with nonregular partner, protected sex in the last month, and knowledge of preventive measures were found to be statistically associated with STIs (P < 0.05).

CONCLUSIONS

Our study identifies risk-behavior patterns in patients with STIs, which should be modified to reduce the burden of these diseases. Increasing the knowledge about STIs in these patients can translate into more common condom usage that lends support for strengthening sexual health programs at grass-root levels.

LIMITATIONS

The small size of the study population could have led to decreased power of the study to detect differences between cases and controls. The external validity of our results needs to be tested in different population groups involving larger sample sizes.

Reported contraceptive use, risk behaviours and STIs among military conscripts in Estonian defence forces

Limited research exists on sexually transmitted infection (STI) and risk behaviour among military personnel. Published research on condom use and types of contraceptives used yield mixed results, yet, the perception that military members are at higher risk for STIs remains. The objectives of this cross-sectional study were to measure factors such as condom use, contraceptive methods, and risky behaviours (i.e. drug use and sex with commercial sex workers) and investigate differences between ethnic groups, where culture could influence behaviour. Data were collected from a recruited population of 584 male, military conscripts in northeastern Europe. Using multinomial logistic regression models, statistically significant findings include an interaction between the use of contraceptive methods of Russians with casual partners and ethnicity, with higher odds of effective methods used among Estonians with regular partners (OR = 8.13) or casual partners (OR = 11.58) and Russians with regular partners (OR = 4.98). Effective contraceptive methods used less frequently with casual partners by ethnic Russians is important in providing education and risk reduction services to young, male conscripts. These findings may be used as a baseline to inform health education and STI prevention programmes tailored to military members in Eastern Europe in the absence of other published studies.

A surveillance report of HIV status and high risk behaviors among rapid testing participants in Tallinn, Estonia

Estonia has the second highest adult HIV prevalence in Europe of 1.3%. The primary transmission is among injecting drug users (IDU), who account for 56-90% of HIV infections (Report on the Global AIDS Epidemic: UNAIDS/WHO, July 2008 and Platt et al. AIDS 20(16):2120-2123, 2006). Of those persons newly diagnosed, 50.4% reported injecting drugs in the last 12 months, 16.3% of these reported IDU as the sole risk factor and 31.2% reported IDU among other risk factors. In this sample (n = 790) 170 persons reported a high risk behavior and 51 persons received a positive result through rapid testing. The largest proportion (35.29%) was among persons reporting high risk heterosexual intercourse and second (33.33%) among persons sharing injecting equipment. Covariates in a logistic regression model indicate that male sex (OR = 2.57, 95% CI 1.00-6.59), non-Estonian ethnicity (OR = 2.68, 95% CI 1.46-4.93), higher education (OR = 0.56, 95% CI 0.40-0.80), and high risk heterosexual intercourse (OR = 2.68, 95% CI 1.19-6.02) are statistically significant in predicting a positive HIV status.

Associations of high-risk behaviour and HIV status with HIV knowledge among persons in Tallinn, Estonia

AIM

The aim of this study was to determine the associations between the level of HIV knowledge, HIV-related risk behaviours, and HIV status among persons receiving voluntary counselling and testing services in Tallinn, Estonia.

DESIGN

A cross-sectional study design was used.

METHODS

A total of 772 subjects completed a 47-item questionnaire gathering information on demographics, HIV-related risk behaviours, and HIV-related knowledge. Participant's HIV status was determined by an anonymous rapid test. Only incident HIV cases were included in regression analyses. An analysis of covariance (ANCOVA) modelling evaluated associations between HIV knowledge and high-risk behaviours while multivariable logistic regression assessed association between HIV status and HIV knowledge.

RESULTS

The final ANCOVA model indicates that HIV risk behaviours are significantly associated with HIV knowledge (p = 0.01). Compared to participants with no identified high-risk behaviour, the adjusted mean score of HIV knowledge was higher among persons sharing injection equipment (p = 0.05), and persons engaging in unprotected heterosexual intercourse (p = 0.03); there was no statistical difference observed among men engaging in unprotected sex with other men. Women had higher mean scores than men (p = 0.01) and persons of ''other'' ethnicities had a higher mean knowledge score than ethnic Estonians (p = 0.01) and Russians (p < 0.01). Logistic regression indicated that mean knowledge was higher among participants who tested HIV positive (OR = 1.42; 95% CI = 1.12-1.87).

CONCLUSIONS

In this sample, higher knowledge scores were not associated with lower infection rates. These results indicate the importance of targeting all high-risk groups in HIV prevention and education programmes.

Demographic and behavioral characteristics of non-sex worker females attending sexually transmitted disease clinics in Japan: a nationwide case-control study

Background

Although number of sexually transmitted infections (STIs) reported in STI surveillance increased rapidly for women in Japan during the 1990s, the sexual behavior of women potentially at risk of STI infection remains unknown.

Methods

In order to determine the demographic and behavioral characteristics of non-sex worker (SW) females attending STI clinics, female attendees (n = 145), excluding SW, from nine clinics across Japan and female controls from the general population (n = 956), both aged 18-50 years, were compared using two data sets of nationwide sexual behavior surveys conducted in 1999.

Results

Although the occupation-type and education level were unrelated to STI clinic attendance in multivariate analysis, non-SW females attending STI clinics were younger (adjusted odds ratios [AOR] = 0.94, 95%CI: 0.89, 0.99), and more likely to be unmarried (AOR = 4.11, 95% CI: 1.73, 9.77) than the controls from the general population. In the previous year, STI clinic attendees were more likely to have had multiple partnerships (AOR = 3.09, 95% CI: 1.42, 6.71) and unprotected vaginal sex with regular partners (AOR = 3.59, 95% CI: 1.49, 8.64), and tended to have had their first sexual intercourse at a younger age (AOR = 1.77, 95%CI: 0.89, 3.54) and more unprotected vaginal and/or oral sex with casual partners (AOR = 2.08, 95%CI: 0.75, 5.71). Identical sexual behavior patterns were observed between the female attendees with a current diagnosis of STI (n = 72) and those before diagnosis (n = 73) and between those with a past history of STI (n = 66) and those without (n = 79).

Conclusion

These results indicate that not only multiple partnerships or unprotected sex with casual partners, but also unprotected vaginal sex within a regular partnership is prevalent among non-SW female STI clinic attendees. The identical sexual behavior patterns observed between female attendees with a current STI diagnosis and those without, and between those attendees with a past history of STI diagnosis and those without, indicate that the result are unlikely confounded with the cases of non-STI infection. This sexual behavior pattern may be predictive of STI infection among young Japanese women and could have contributed to the STI epidemic in women in Japan during the 1990s.

The trends and risk factors for hepatitis B occurrence in Estonia

Hepatitis B virus (HBV) infection is prevalent worldwide and is a significant cause of morbidity and mortality. This article describes the trend in HBV occurrence in Estonia from 1990 to 2005 in Estonia, with the aim of highlighting key determinants in transmission dynamics, risk groups, and possible implications for prevention and control. A marked increase in reported numbers of new HBV cases occurred in mid 1990s (reaching 39 per 100,000 population) and decline thereafter. We present data on HBV prevalence from different population groups (persons with verified sexually transmitted infection, prisoners, medical personnel, blood donors and injection drug users). Special vaccination programmes introduced in Estonia have been successful in the prevention of HBV, however, we suggest that the main risk groups such as injection drug users (IDUs), men having sex with men (MSM) and HIV infected persons should be actively encompassed into HBV vaccination programme.

HIV epidemic in Estonia in the third decade of the AIDS era

This article describes current trends of HIV/AIDS and related conditions in Estonia, with the aim of highlighting key determinants in transmission dynamics and risk groups, problems and barriers of combating HIV/AIDS, and possible implications for prevention and control. Throughout the transition period Estonia has experienced major changes in political, economic, and social structure which all have contributed to increased violence, high-risk sexual behaviour, and substance abuse. Incidences of hepatitis B, C and sexually transmitted infections (STIs) increased in the early 1990s. HIV outbreaks were first detected among injecting drug users (IDUs) in 2000 and are still concentrated among this population group. High rates of sexual risk behaviour and inadequate knowledge regarding prevention of disease transmission in Estonia emphasizes the threat of a sex-related and STI facilitated driven HIV epidemic. To prevent further spread of HIV it is necessary to implement harm reduction interventions among IDUs. However, without effective management of socioeconomic and administrative barriers to health care and other services, an explicit policy on drugs will not reach marginalized groups and will not be able to prevent a further spread of these interrelated epidemics.

The prevalence of chlamydial infection in Estonia: a population-based survey

The aim of this study was to estimate the prevalence of Chlamydia trachomatis infection among Estonian men and women by a cross-sectional study based on the screening of a probability sample of the residents of Tartu using participant-collected, mail-delivered testing for C. trachomatis complemented with the self-administered questionnaire. Full participation as defined by returning both the questionnaire and specimen was 34% (n = 479; 95% confidence interval [CI] 32-37%). Study participation was 40% (n = 560; 95% CI 37-43%) for subjects returning either or both the study questionnaire and specimen. After weighing the population distribution, the prevalence estimate for the age group of 18-35 years was 5.4% (95% CI 3.0-7.5%), 6.9% (95% CI 3.6-10.3%) among women and 2.7% (95% CI 0.3-5.0%) among men. The number of sexual partners in the past 12 months was the strongest predictor of infection.

Barriers to effective STI screening in a post-Soviet society: results from a qualitative study

OBJECTIVE

This qualitative study assesses knowledge about sexually transmitted infections (STI), identifies perceived barriers to STI testing, and recommends strategies to optimise participation in a home based STI testing programme.

METHODS

Five focus groups composed of 29 total participants were recruited using convenience sampling methods based on age (18-40 years), gender (male and female), and residency (Tartu region, Estonia).

RESULTS

The focus groups revealed significant knowledge deficits and a widespread attitude of denial. However, participants acknowledged that STIs are a serious problem and recommended strategies for increasing participation in an STI testing and treatment programme. Successful STI prevention programmes must address a number of challenges, including disease stigmatisation and privacy protection.

CONCLUSION

The fear of enforced disease control methods coupled with the current stigmatisation of STIs creates a serious challenge for Estonian STI prevention and treatment efforts. This qualitative study provides a good contextual reference for STI control programmes in eastern Europe.

Sex work in Tallinn, Estonia: the sociospatial penetration of sex work into society

BACKGROUND

It is important to describe and understand the underlying patterns and dynamics that govern sex work in societies undergoing rapid political and social changes, its heterogeneity across populations, and its evolution through time in order to inform future research, sound policy formation, and programme delivery.

OBJECTIVES

To describe the socioeconomic and cultural determinants, organisational structure, distinct categories, and spatial patterning of sex work in Tallinn, Estonia, and identify recent temporal changes in sex work patterns.

METHODS

In-depth interviews with key informants; naturalistic observations of sex work and drug use venues, geo-mapping of sex work sites, review of media, public policy, and commissioned reports, and analyses of existing data.

RESULTS

Sex work takes place in a hierarchy of locations in Tallinn ranging from elite brothels and "love flats" to truck stops. These sites vary in terms of their public health importance and social organisation. There are full time, part time, and intermittent male and female sex workers. Among others, the taxi driver, madam and the bartender are central roles in the organisation of sex work in Tallinn. Cell phone and internet technology enable sex work to be highly dispersed and spatially mobile.

CONCLUSION

Future research and programmatic service delivery or outreach efforts should respond to the changing profile of sex work in Tallinn and its implications for STD/HIV epidemiology.

Syphilis as a social disease: experience from the post-communist transition period in Estonia

Increased incidence of sexually transmitted diseases (STD) and radical social changes have taken place at the same time in Estonia. Our aim was to study the trends in syphilis incidence, selected sociodemographic factors and health status indicators during the economic transition. Associations were estimated by the ordinary least square regression method for change in and actual values of syphilis and tuberculosis incidence rate (IR), percentage of non-ethnic Estonians and urban population, homicides rate, unemployment rate and, birth rate. The analysis was performed by counties at three different time periods. Syphilis IR significantly correlated with the proportion of non-ethnic Estonians, urban population, tuberculosis IR and birth rate. Change of syphilis IR correlated significantly with concurrent changes in unemployment rate and tuberculosis IR. Our findings support the theory that syphilis is a social disease, thus emphasizing the importance of social factors in the occurrence of STDs.

Prevention myths and HIV risk reduction by active drug users

Drug injectors and crack users (526) in South Florida responded to a survey questionnaire that was designed to examine belief in the effectiveness of various strategies, other than condom use, employed to reduce personal risk of contracting HIV during sexual acts. Each strategy was believed to be effective by at least one quarter of the study participants. Factor analysis was used to group these strategies. Subsequent multivariate analysis indicated that the participants who believed in the effectiveness of HIV prevention strategies other than condom use were also less likely to report using condoms. These findings highlight the need for prevention interventions to elicit prevention myths and the full range of risk reduction strategies practiced.

The cost effectiveness of hepatitis immunization for US college students

Hepatitis B immunization is recommended for all American children, and hepatitis A immunization is recommended for children who live in areas with elevated disease rates. Because hepatitis A and B occur most commonly in young adults, the authors examined the cost effectiveness of college-based vaccination. They developed epidemiologic models to consider infection risks and disease progression and then compared the cost of vaccination with economic, longevity, and quality of life benefits. Immunization of 100,000 students would prevent 1,403 acute cases of hepatitis A, 929 cases of hepatitis B, and 144 cases of chronic hepatitis B. Hepatitis B vaccination would cost the health system $7,600 per quality-adjusted life year (QALY) gained but would reduce societal costs by 6%. Hepatitis A/B vaccination would cost the health system dollar 8,500 per QALY but would reduce societal costs by 12%. Until childhood and adolescent vaccination can produce immune cohorts of young adults, college-based hepatitis immunization can reduce disease transmission in a cost-effective manner.