Assessment of Magnitude of Sexually Transmitted Infections , Sexual and Reproductive Health Status among Prisoners Aged Between 18-49 Years in Tabor Prison , Hawassa , Ethiopia

Lack of access to SRH is a major public health concern, especially in developing countries. The objective of the study is to assess the magnitude of STIs and SRH status among prisoners aged between 18-49 years in Tabor prison, Hawassa, Ethiopia. A descriptive cross sectional study was conducted. Systemic random sampling technique was used and the sample size was 292. The living status of the respondents before detention ( 2 =12.8, p<0.05), maternal and paternal education ( 2 =20.6, p<0.05), and sexual health information ( 2 =11.9, p<0.05), having intercourse with multiple sexual partners (p<0.05), and STIs before imprisonment (p<0.05) had shown significant association at p<0.05 and p<0.01. The magnitude of STIs was found as 5.1% among the respondents and 30 (14.5%) respondents were HIV positive.


INTRODUCTION
Sexual and reproductive health (SRH) is important to all human beings, and for the social and economic development of communities and nations.SRH is a state of complete physical, mental and social wellbeing not merely the absence of disease or infirmity in all matters related to reproductive system and to its function.SRH therefore implies people are able to have satisfying and safe sexual life and they have a capability to reproduce and the freedom to decide when and how often to do so (WHO/UNODC/ UNAIDS, 2004).Lack of access to SRH is a major public health concern, especially in developing countries.For instance, death and disability caused by SRH accounted for 18 percent of the total disease burden globally in 2001, though there is considerable regional variation (Glasier et al., 2006).Sexually transmitted infections (STIs) are the significant infections of the young mainly because their sexual relations are often unintentional, sometimes as a result of pressure or force, and typically happen before they have the experience and skills to defend themselves (Glasier et al., 2006).
Every year, 30 million people spend time in prisons or other closed settings and more than 10.2 million are incarcerated at any given time.Prisoners live in a high-risk environment for HIV transmission with drug use and needle sharing, tattooing with homemade and unsterile equipment, unsafe sex and rape.Overcrowding as well as stress, malnutrition, drugs, and violence weaken the immune system, making people living with HIV more susceptible to getting ill.Yet, prisoner wellbeing is often neglected and overlooked (Walmsley, 2013).
Prison is a factor leading to deterioration of health and well-being of prisoners, and becoming breeding grounds for communicable diseases and facilitates unhealthy behavior.Additionally it forms high risk settings because of unprotected sexual relations, prostitution, rapes, and high turnover of populations (Hayton, 2007).Globally, an estimated 9 million people are in prisons per year.Prisoners were the vulnerable group of population often to the sexual and other demands.This population is constantly changing so they are not permanently sealed off from the community (WHO, 2007).A prison is an environment with special difficulty in the promotion of health.Prisoners may tend to have poor physical, mental and social health than the general population because their life style is more likely to put them at risk of several diseases (WHO/UNODC/UNAIDS, 2007a&b).Prisoners are at high risk for the transmission of STIs in the closed environment of prison.Women prisoners are especially vulnerable to sexual abuse including rape by both male prison staffs and male prisoners (WHO/UNODC/UNAIDS, 2007a&b).There are countries where women prisoners were held in small facilities adjacent to or within the prison of men.STIs are a major public health problem in prison and their escalating prevalence rate was largely as a result of unprotected sex and, to some extent sharing of contaminated needles.Prison population statistics showed that a large proportion of male prisoners aged 21-39 years were pleasure seekers, since they were more likely to have injection of drugs, have multiple sexual partner and sex with the same sex (Stewart, 2007).
Several studies have shown that sexual activity including rape and other forms of sexual violence occurs in prisons and result in transmission of HIV and other STIs (Barry & Katie, 2009).A study done in Nepal revealed that 71% of prisoners were intravenous drug users and 75% of them always shared needles, 38% had casual partners and 30% had frequent visits to sex workers, none of the inmates ever used condoms, and only 14% perceived that they might have HIV (Herman, 2001).Another study done in India revealed that 76.6% of the male inmates gave history of penetrative sex, among these 54.2% gave a history of having multiple sexual partners and the majority had unprotected sex, even with commercial sex workers while 72.5% of them were not aware of HIV (Anjali, 2014).A study conducted in Nigeria showed that 14.9% of inmates reported having sexual intercourse in the prison and among these 43.8% claimed to have used condoms regularly; it is thus seen that prisoners engage in sexual activities right inside prisons during incarceration, although one would think this should not be possible because a prisoner's freedom is expected to be limited (Olugbenga et al., 2013).
In Ethiopia, traditional practices and poor living situations often lead young people to engage in sex at an early age.As most of the young adults who enter into a sexual relationship for the first time do not use condom, the unprotected sex exposes the young to STIs.Early sexual debut, the practice of having multiple sexual partners, and limited use of condoms were the major risk factors for the spread of STIs among this population (Zhuzhi et al., 2008).

METHODOLOGY
A descriptive cross sectional study was conducted in Tabor sub-city, Hawassa, southern part of Ethiopia.Systemic random sampling technique was used and the sample size was determined by using single proportion formula with the following assumptions: prevalence of STIs=0.26,degree of precision=5%, level of confidence=95% (z=1.96), and the final sample size was 292.The response rate was 99%.A self-administered structured questionnaire was administered to the subjects.The questionnaire enquires the socio-demographic data, prison conditions, use of substances, sexual and reproductive health behaviors, self-reported symptoms of STIs, general health status of the respondents and factors associated with STI symptoms.The questionnaire was tested for its reliability, consistency, and validity.

Ethical Clearance
Ethical clearance was obtained from Institutional Review Board, Hawassa University.Formal permissions were obtained from the concerned authorities of the prison.No materials were used during the study.Source of funding is not applicable.

Socio-demographic Variables of Respondents
The characteristics of the sample by gender showed that male prisoners were 233 (80%), females were 58 (20% were providing both support and food.

Sexual and Reproductive Health Behaviors of Prisoners
Among of 25-30 years, and 3 (1.4%)had it after the age of 30 years.Median age at first sex was 17±2.5 years.99 (46.5%) of the respondents had multiple sexual partners, 67 (31.5%) of male prisoners gave a history of sex with commercial sex workers, and 20 (9.3%) had history of STIs.Among 214 sexually active respondents, 210 (98.1%) inmates identified themselves as heterosexual before detention.Among 13 respondents who had consensual sex in prison, 10 (76.9%) considered themselves as heterosexual and 3 (23.1%)as homosexuals.Among 214 sexually active respondents, more than half of the respondents (55.1%) didn't use condom consistently before imprisonment.8 (73%) of the 11 respondents had the symptoms of STIs once during their stay in the prison and 9 (81.9%) of the 11 respondents reported STI symptoms and received treatment.

Self-reported Symptoms of STIs among Respondents
Among 292 respondents, 20 (6.8%) reported STI symptoms before incarceration, and 11 (3.8%) reported the symptoms in prison.All of those 11 respondents who reported the STI symptoms in prison had history of burning sensation during urination and sore penis except one female respondent (9%) who had sore vagina; 10 of those 11 respondents (91%) reported abnormal genital discharge; 5 (45.4%) had pain during or after sexual intercourse; and 8 (72%) reported more than one symptom.The one female respondent had experienced white vaginal discharge, bleeding or blood spotting from the vagina, thick, cloudy or strong vaginal odor discharge from vagina, vaginal itching or irritation, and abnormal menstrual bleeding.

General sexual and reproductive health of respondents
Among the 291 respondents, 14 (4.6%) answered it is possible to have sex in prison by legal ways.76 (26.1%) respondents had sexual and reproductive health checkups in prison; of those, 50% had checkups more than two times, 22.4% had twice, and 27.6% once per year.
In this study, 51.5% respondents said prison had no effect on SRH, 25.5% respondents said it had both positive and negative effects, 14.4% said prison has negative effect and only 8.6% said prison had positive effect on sexual and reproductive health.206 (70.8%) respondents had HIV test.135 (65.5%) were tested before three months of this study and 30 (14.5%) were found HIV positive.

Factors Associated with STI Symptoms of Respondents
In Chi-square association, living status of the respondents before detention, maternal and paternal education, sexual health information, having intercourse with multiple sexual partners, and STIs before imprisonment had shown significant association at p<0.05 and p<0.01 (Table 1).

CONCLUSION
Prisoners in Tabor, Hawassa, were having access to use alcohol and khat in the prison.Such substances are likely to cause unhealthy and risky behaviors related to the general, sexual and reproductive health of the inmates and will lead to several diseases including STIs.5.1% of the 214 sexually active inmates were found with STI symptoms in the prison.Therefore, one of the measures by which prison authorities can control the STIs in prison is by preventing the accessibility of the abusive materials to the prisoners.Also, it would be ideal to conduct medical tests for HIV and other STIs and STDs both at the time of entry into prison and release from the prison.If such screening of the inmates is conducted early, the infected inmates and the healthy inmates can be provided with the facilities in the prison appropriately, and thus further spread of the STIs can be controlled.

Table 1 .
Association of factors with symptoms of STIs among respondents in Tabor prison, Hawassa, 2014 (N=292).