S. Akhtar  ( Department of Community Health Sciences, The Aga Khan Unviersity, Karachi. )
S.P. Luby  ( Department of Community Health Sciences, The Aga Khan Unviersity, Karachi. )
M.H. Rahbar  ( Department of Community Health Sciences, The Aga Khan Unviersity, Karachi. )

Obective: To identify sexual risk behaviours associated with lifetime risk of urethritis in prison inmates.
Design: A cross-sectional study using a pre-designed questionnaire. Setting Fourteen prisons throughout the Sindh Province, Pakistan.
Subjects: Three thousand three hundred ninety-five prison inmates incarcerated during July, 1994.
Main outcome measure: Lifetime risk of urethritis occurrence (whether or not the subject was ever affected with urethritis up to his present age)
Results: Lifetime risk of urethritis occurrence in the study population was 20.8% (706/3395). The final multivariate logistic regression model indicated that risk behaviours associated with lifetime risk of urethritis in this population were ‘sexual intercourse with a female’ (adjusted OR = 2.18; 95% Cl 1.60, 2.95), ‘multiple female sexual partners’ (adjusted OR = 1.67; 95% CI 1.28, 2.18) and ‘sexual intercourse with man’ (adjusted OR = 2.75; 95% CI 2.29, 3.31).
Conclusion: The prevalence of urethritis in this population was very high. High prevalence of various risky sexual behaviours among inmates indicates, their unawareness as to what precautions they might take to avoid risk of acquiring STDs including HIV. The study subjects meet the characteristics of a core group of STDs transmitters and provides short window of opportunity for STD/HIV control programs to intervene, while they are in detention to reduce the risk not only for this group but also for general population (JPMA 49:268, 1999).

Sexually transmitted diseases (STDs) are among the most commonly recorded medical problems in prison population^1,2 that may serve as reservoir for STDs in the general population³. Furthermore, a recent evidence suggested that STDs may facilitate the transmission of human immunodeficiency virus (HIV)^3-7. The increased risk for acquiring STDs and HIV infection in prison inmates results from their risky sexual behaviours. Several risk behaviours for transmission of STDs include male-to-male sexual intercourse⁸, that occurs in prison², illicit drug use^7,9-11, contact with commercial sex workers¹², inconsistent or no condom use and multiple sex partners¹³.
Among the STDs, urethritis (gonococcal and non­gonococcal) is the most frequently reported STD in men attending STD clinics¹⁴. Information on the prevalence of STDs and high risk behaviors of any target population is a pre-requisite for health care planning and interventions. Several studies conducted elsewhere have reported the prevalence and associated risk factors for urethritis^15,16. However, no definitive research had been reported from within Pakistan’s prison system, despite the fact that prisons have high background rate of STDs, because of prevailing high-risk behaviours among inmates. Only one study has reported 21% prevalence of urethritis, but there is paucity of documented data describing risk behaviours associated with urethritis. The objective of the present investigation, therefore, was to characterize the relationship of drug use and risky sexual behaviors with urethritis in prison inmates population of Sindh.

Study Subjects and Data Collection
The study setting and sampling technique used to select the study population has been described elsewhere. Briefly, 3395 male prison inmates were included in the present analysis. They were selected using one-in-three systematic random sampling technique from among 10600, Inc., Chicago, IL, USA).

The prison inmates in the study sample (n = 3395) were evenly distributed in four quartiles of age, duration of imprisonment and two main ethnic groups i.e., Urdu and Sindhi speaking. Fifty precent of the inmates had no formal school education and were nearly in equal proportions of ever married and never married groups (Table 1).

The distribution (%) of various risk behaviours reported by inmates is also given in Table 1. The reported lifetime risk of urethritis in the study population was 20.8% (706/3395). Results of bivariate analyses (Table 2),

showed that urethritis-affected inmates tended to be 23-33 years old (P = 0.016), Sindhi speaking (P = 0.005) and were incarcerated for more than 9 months (P <0.005). None of the two injecting drug use variables (i.e., Do you inject drugs intravenously? Do you share needles?) were related with the lifetime risk of urethritis. All other risk behaviours including promiscuous heterosexual contacts, male-to-male sexual contact, knwoledge of risk behaviours of sexual p rtners and use of condom were significantly (P<0.001) related to lifetime risk of urethritis in inmates in bivariate analysis.
Multivariable logistic regression model
The final model (Table 3)

indicates that risk behaviours associated with the lifetime risk of\\\' urethritis occurrence in this population were ‘sexual intercourse with a female’ (adjusted OR = 1.67; 95% Cl 1.60, 2.95), ‘multiple female sexual partners’ (adjusted OR 1.67; 95% CI 1.28, 2.18) and ‘sexual intercourse with a man’ (adjusted OR = 2.75; 95% CI 2.29, 3.31). The Hosmer-Lemeshow goodness-of-fit test demonstrated an adequate model fit (Hosmer-Lemeshow x2 = 2.87, df= 5, P value 0.726).

Prevalence of sexual risk behaviours
Male prison inmates place themselves at risk of acquisition of STDs, including gonococcal/non-gonococcal urethritis by engaging in unsafe sexual practices²³. The proportion of inmates who had more than one lifetime sexual partners and had sex with commercial sex workers ranged from 26-60%. Also, the inmates who admitted to various aspects of male-to-male sexual contact during their lifetime up to present age ranged from 20-26%, which is consistent with reports on prison inmates from other parts of the world. However, inmates who had had sex during present incarceration was only 3.3%, a proportion that differed from the earlier findings^24,25, that up to 17-30% inmates indulge in homosexuality during imprisonment. Prevalence of drug related behaviours such as injecting male prisoners incarcerated in judicial custody as indicted criminals in 14 prisons of Sindh during July, 1994. The subjects interviewed comprised mainly two self-identified ethnic groups. The subgroups were identified based on their mother-tongue i.e., Sindhi, Urdu. However, a small proportion also comprised other ethnic groups. Inmates were eligible to participate in the study, if they spoke Urdu, being a national language. Because of the varying literacy levels of the prison inmates, a structured risk behaviour interview was administered to each study subject in confidence by trained research interviewer in a private area within the prison. The interview focused on seeking information on demographic, sexual and drug use behaviours during the subject’s lifetime up to his present age. The questions on sexual behavior solicited information on number and type of sex partners, homosexuality both before and after incarceration, condom use and illicit drug use. Inmates were asked, if they had painful purulent urethral discharge in the past (lifetime risk of urethritis occurrence i.e. if the respondent ever had this condition up to his present age). The question concerning the past history of urethritis was phrased to deliver a concise description of the common signs and symptoms associated with gonococcal and non-gonococcal urethritis^17-19. Specifically, the question asked was: have you ever had a painful, purulent urethral discharge a few days after sexual intercourse?
Ethics and Confidentiality
Informed verbal consent of each study subject was sought and to ensure frank and complete answers, they were assured about complete confidentiality of all interview questionnaire responses. This study was approved by the Institutional Committee for Human Subjects Protection.
Data Analysis
For all analysis, the dependent variable, lifetime risk of urethritis occurrence had two categories: ever affected and never affected. We categorized the continuous variables such as age and duration of imprisonment into quartiles to reduce the influence of outliers. Frequencies (%) of demographic variables and sexual behaviours were computed²⁰. The relationship between the dependent variable and the independent variables was examined by using two-way and multi-way contingency comparisons; the x2 test was used to compare proportions²¹. The crude measure of association between a single putative risk factor and inmates urethritis status was expressed as the odds ratio (OR) and the corresponding 95% confidence intervals (Cl) was derived by means of first-order Taylor series approximations method²⁰.
A multivariable logistic regression model was used to estimate the effect of each variable on the lifetime risk of urethritis adjusting for the effects of other variables in the model. For multivariate analysis, a full model was specified with all independent variables significantly (P<0.00l) related with outcome variable in univariate analysis.
Backward stepwise multiple logistic regression analysis was carried out to arrive at the final multivariable model relating the variables simultaneously to the lifetime risk of urethirits occurrence²². In addition to significant (P<0.001) main effects, identified through univariable analysis, some interaction terms were considered for possible inclusion in the final model. Selection of the final model was based on parsimony, biological interpretability and statistical significance. The parameters of the logistic regression model were estimated by the maximum-likelihood method. The adjusted odds ratios (ORs) and their 95% confidence interval (CIs) were computed using the estimates of parameters of final logistic regression model and were the main focus for substantive interpretation of the model. In all the analyses 5% significance level (a = 0.5) was used unless stated otherwise. All the analyses were carried out at using SPSS/PC windows version 7.5 (SPSS drugs and sharing needles was 1.4% and 3.6% respectively and comparatively far below than what was reported from prisons of some other countries^26-28, where 18% to 35% injecting drug users were found among prison inmates. The proportion of inmates who never used condom during sexual intercourse was 92.8%. This high proportion of non-users of condom in our sample is certainly a cause of concern and most likely reflects cultural aspects, since explicit information about condom use on electronic and print media is nearly unavailable.
Predictors of lifetime risk of urethritis
Prisons inmates are considered at high-risk for STDs including gonococcal/non-gonococcal urethritis. The lifetime risk of occurrence of urethirits among inmates in our study sample was 20.8%. The variables subjected to analysis were those, which we thought would adequately capture sexual behaviours potentially associated with lifetime risk of urethritis occurrence. The inmates who reported having had sex with a female or with more than one female were significantly more likely to report of having been affected with urethritis in their lifetime.
A high number of lifetime sexual partners is considered to be a major indicator of high risk sexual behaviour and is probably the most studied²⁹, marker in measuring risk of acquiring STDs including urethritis. The present study confirmed the findings of previous studies^13,16. These studies have reported that men having multiple sex partners and/or sex with commercial sex workers were more likely to have all types of urethritis. The consistency of our findings with our expectation and prior studies provides some assurance that our database and analysis are valid.
The inmates who reported to have had male-to-male sexual intercourse were nearly three times more likely to report of being affected with urethritis in their lifetime. The findings of high lifetime risk of urethritis among inmates having male-to-male sexual intercourse coincide with the results of previous studies^30-32. These studies reported that despite overall trends towards safer sex practices in bisexual men, they remain at high risk for STDs acquisition. For example Neisseria gonorrhea was isolated in 11% homosexual men compared with 6% exclusively heterosexual men who attended the STD clinics during the same time period. In another study⁸, homosexual men were found at increased risk of urethritis and urinary tract infections due to coliform bacteria, presumably acquired during anal intercourse. We believe that homosexual men in the study group need to be counseled that this sexual practice carries a risk of acquiring STDs for the receptive partner and urethritis by the insertive partner.
Our study had several limitations that must be considered in the interpretation of the findings. One limitation is our reliance on self-report for history of sexual behaviours. Self-report of past sexual behaviours, drug use and the characteristics of sex partners may be subject to recall bias and results and misclassification. In particular, drug use may be under-reported because of the issues related to social desirability or fear of negative repercussions, if this behaviour was reported. The extent of this or other information bias cannot be quantified and was beyond the scope of this study. Our study subjects were a highly selected group and not representative of general population. This study was cross-sectional, therefore, cause-and-effect relationship is difficult to ascertain for the observed associations.
Some of our findings were neither unexpected or new. However, multivariate logistic model did provide insight into risk behaviour profile of prison inmates, which affects the lifetime risk of urethritis, the syndromic assessment of a disease which is a consequence of many specific and non-specific infections. A population specific STD education/prevention program for the inmates in detention could have formidable impact on STDs control. Subsequently such a control program may help in subsiding the HIV/AIDS epidemic which is still at an early stage in this country, since improved sexually transmitted disease control program reduces HIV infection rates³³. Also, our study subjects meet the characteristics of a core group of STDs transmitters described in literature³⁴ and provides short window of opportunity for STDs control programs to intervene through behaviour change, while they are in detention.

1. Kim M, Cloud GA, Wallace LS, et al. Sexual behaviour and sexually transmitted diseases among male adolescents in detention. Sex Transm. Dis., 1994:21 :127-32.
2. Moran JS, Peterman T. Sexually transmitted diseases in prisons and jails. Prison J., 1989;69:1-6.
3. Pepin J, Plummer FA, Brunham RC, et al. Editorial reviews: The interaction of HIV infection and other sexually transmitted diseases: An opportunity for intervention. AIDS, 1989:3:3-6.
4. Wasscrheit J. Epidemiological Synergy: Interrelationships between human immundeficiency virus infection and other sexually transmitted diseases. Sex Transm. Dis., 1992;19:61-77.
5. Plummer FA, Tyndall MW, Ndiua-Achola JO, et al. Sexual transmission of HIVs and the role of sexually transmitted diseases. In: Essex M, Mboup S. Kanki PJ, et al. eds. AIE)S in Africa, New York, Raven Press, 1993, pp. 195- 209.
6. Simonsen JN, Cameron DW. Gakinya MN, et al. Human Immunodeficiency virus infection among men with sexually transmitted diseases. N. Eng. J. Med., 1988:319:274-78.
7. Laga M, Manoka A, Kivervu M, et al. Non-ulcerative SIDs as risk factors for HIV-1 transmission in Women: Results from a cohort study. AIDS, 1993;7:95-102.
8. Barnes RC, Daifuku R, Roddy RE, et al. Urinary tact infection in sexually active homosexual men. Lancet, 1986:1:171-73.
9. Fullilove RE, Fullilove MT, Bowser BP, et al. Risk of sexually transmitted disease among black adolescent crack users in Oakland and San Francisco, CA. JAMA, 1990;260:2009.
10. Marx R, Aral SO, Rolfs RI, et al. Crack, sex and STD. Sex Transrn. Dis., 1991,18:92- 101.
11. Rolfs RI, Goldberg M, Sharror RG. Risk factors for syphilis: cocaine use and prostitution. Am. J. Public Health, I 990;80:853-57.
12. Da-Costa Li, Plummer FA, Boumer I, et at. Prostitutes are a major source of sexually transmitted diseases in Nairobi, Kenya. Sex Transm. Dis., 1985:12:64-67.
13. Schwartz MA, Lafferty WE, Hughes JP, et at. Risk factors for uretliritis in heterosexual men: The role of fellatio and other sexual practices. Sex Transm. Dis., 1997;24:449-55.
14. Wellington M, Ndowa F, Gumcd DD, et at. Risk factors t’or sexually transmitted disease in Harare: A case-control study. Sex Transm. Dis., 1997,24:528-32.
15. Anderson JE, McCormick L, Fichtner R. Factors associated with self-reported STDs: Data from a national survey. Sex Transm. Dis., 1994;21:303-8.
16. McCutchan JA. Epidemiology of venereal urethritis: Comparison of gonorrhoea and nongonococcal urethritis. Rev. Infect. Dis., 1984:6:669-88.
17. Bowie WR. Urethritis in men. In: Holmes KK, Mardh PA, eds. International perspective on neglected sexually transmitted diseases: impact on venerelogy, infertility and maternal and infant health. Washington DC, Hemisphere Publishing Co., 1983, pp. 141-57.
18. Osoba AO. Epidemiology of urethritis in Ibadan. Br. J. Vener. Dis., l972;48: 116-20.
19. Arya OP, Nsanzumuhire H. Taber SR. Clinical, cultural and demographic aspects of gonorrhea in a rural community in Uganda. Bull. WHO., 1973:49:587-95.
20. Rothman Ki. Modern Epidemiology. Boston, Little Brown and Company, 1986.
21. Rosner B. Fundamentals fBiostatistics. Boston, Duxbuiy Press, 1986.
22. Hosmer DW, Lcrncshow S. Applied Regression Analysis. New York, John Willey, 1989.
23. Cohen D, Scribner R, Clark J, et at. The potential role custody facilities in controlling sexually transmitted diseases. Ani. J. Public Health, 1992;82:552­ 56.
24. Horsburg CR, Jarvis JQ, Mcarthur T, et at. Seroconversion to human immunodeficiency virus in prison inmates. Am. J. Public Health, 1990:80:209-10.
25. Prison Reform Trust. lily, AIDS and Prisons, London, Prison Reform Trust, 1988.
26. Dye S, lsaacs C. Intravenous drug misuse among prison inmates: implications for spread of HIV, Br. Med. J., 1991:302:1506.
27. Gore SM, Bird AG, Burns SM, et al. Drug injection and H~V prevalence of Glenochil prison. Br. Med. J., 1995:310:293-96.
28. Kennedy DH, Nair G, Elliott L, et al. Drug misuse and sharing of needles in Scottish prisons. Br. Med. J., 1992:302:1507.
29. art G. Risk profiles and epidemiologic interrelationships of sexually transmitted diseases. Sex Transm. Dis., 1993 ;20: 126-36.
30. Doll LS, Judson FN, Ostraw DG, et al. Sexual behavior before AIDS: The hepatitis B studies of homosexual and bisexual men. AIDS, 1990:4: 1067-73.
31. Steiner S, Lemke AL, Roffman RA. Risk behavior for UIV trnsmission among gay men surveyed in seattle bars. Public Health Rep., 1994:109:563­66,
32. Handsfield HH, Schebke JR. Trends in sexually transmitted diseases in homosexuality active men in King County, Washington 1980-1990. Sex Transm. Dis., 1990:17:211-15.
33. Grosskurth H, Mosha F, Todd J, et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomized controlled trial. Lancet, 1995:346:530-36.
34. Padian NS, Shiboski SC, Hitchcock PJ. Risk factors for acquisition of sexually transmitted diseases and development of complications. In: Wasserheit IN, Aral SO, Holmes KK, eds. Reasons and Issues in Human Behaviour and Sexually Transmitted Diseases in the AIDS Era. Washington. DC, American Society for Microbiology, 1991, pp. 83-96.