International Journal of Infectious Diseases (2007) 11, 115—122
http://intl.elsevierhealth.com/journals/ijid
Sexually transmitted Chlamydia trachomatis,
Neisseria gonorrhoeae, and HIV-1 infections in
two at-risk populations in Barcelona:
female street prostitutes and STI clinic attendees
M. Vall-Mayans a,*, M. Villa b, M. Saravanya a, E. Loureiro a, M. Meroño c,
E. Arellano a, B. Sanz a, P. Saladié a, A. Andreu b, M.G. Codina b
a
Sexually Transmitted Infections Unit, Primary Health Center Drassanes, Catalan Health Institute, E-08001 Barcelona, Spain
Microbiology and Parasitology Service, Hospital Vall d’Hebron, Catalan Health Institute, Barcelona, Spain
c
Àmbit Dona, Àmbit Prevenció, Barcelona, Spain
b
Received 17 May 2005; received in revised form 28 October 2005; accepted 15 November 2005
Corresponding Editor: Salim S. Abdool Karim, Durban, South Africa
KEYWORDS
Chlamydia trachomatis;
Neisseria gonorrhoeae;
HIV-1;
Prostitution;
STI clinic
Summary
Objective: To determine the prevalence of Chlamydia trachomatis (CT), Neisseria gonorrhoeae
(NG), and HIV-1 infections in female street prostitutes and STI clinic attendees in Barcelona.
Design: This was a prospective study carried out in two four-month periods over two years. Urine
specimens were tested for CTand NG using a PCR pooling algorithm. Among street prostitutes HIV1 testing in urine was also carried out.
Results: The prevalences of CT, NG, and HIV-1 in female street prostitutes (n = 301) were 4.7%,
3.7%, and 1.0%, respectively. Women from Eastern Europe had the highest prevalence of CT
( p = 0.01). Prevalences of CT, NG, and HIV-1 among all clinic attendees (n = 536) were 4.3%, 4.5%,
and 4.4%, respectively. Prevalence of HIV-1 infection among homosexual men was higher
compared with heterosexual men and women ( p < 0.001).
Conclusions: : Overall CT prevalence is currently lower than in other European countries,
although it could increase as a result of immigration. Rates of HIV-1 and of NG are higher among
homosexual than among heterosexual men.
# 2006 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights
reserved.
Introduction
* Corresponding author. Tel.: +34 93 441 4612; fax: +34 93 441 4612.
E-mail address: mvall.pbcn@ics.scs.es (M. Vall-Mayans).
Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG)
are two of the most common sexually transmissible infective
agents. It is well recognized throughout the world that both
1201-9712/$32.00 # 2006 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijid.2005.11.005
116
M. Vall-Mayans et al.
Methods
detailing the study to participants. After giving their
informed consent, sex workers were invited to answer a
structured questionnaire that was completed by a female
health professional hired for the project. They were also
invited to submit a urine specimen while at the Àmbit Dona
for NG, CT, and HIV-1 testing. Those participating in the study
were invited to attend the STI unit of the Catalan Health
Institute, Barcelona for further STI check ups. In addition,
participants with a positive result for NG or CTwere provided
free oral treatment on site according to recommended guidelines.9 The HIV-1 test results from this population were used
only for epidemiological purposes.
A few male street prostitutes who had also requested the
services of the outreach organization while the study was
ongoing were also asked to participate. As male street
prostitutes were not the target study population and selection bias could not be ruled out, only urine STI prevalence
results are given for this specific population.
(b) The participants at the STI unit of the Catalan Health
Institute, Barcelona included mainly self-referred asymptomatic subjects requesting HIV testing and, to a lesser extent,
STI symptomatic patients (15%) and non-street prostitutes
(25%). All were given a leaflet in a relevant language about
the study before consultation, and after being informed
about the project by a nurse or physician and giving their
informed consent, they were asked to submit a urine specimen for NG and CT testing. This study population was not
asked to answer a questionnaire since information was
retrieved from clinical records by the health professional
hired for the project under the supervision of the principal
investigator of the study who belonged to the clinic. Each
subject was asked to participate in the study once at his/her
visit to the clinic. As usual, treatment, additional testing,
and contact tracing were offered in the clinic following
recommended guidelines.9 HIV status from the STI unit
attendees was obtained on the same day as HIV testing
was requested or consented to. Details concerning seroprevalence of HIV from the STI unit of the Catalan Health
Institute, Barcelona have been published eleswhere.7
This study was approved by the ethical and scientific
committees of the Primary Health Care Division of the Catalan Health Institute (Fundació Jordi Gol i Gurina per a la
Recerca a l’Atenció Primària).
Study sites and populations
Specimen collection, transport, and processing
Between February and June 2002 and again in 2003, firstcatch urine specimens were collected from consecutively
enrolled study participants in the two selected populations:
(a) female street prostitutes and (b) STI clinic attendees.
With a 95% confidence interval and a power of 80%, a sample
size of 200 female street prostitutes was required to estimate
a prevalence of NG or CTaround 5% with a precision of 3%, and
a sample size of 800 STI clinic attendees to estimate a
prevalence of NG or CT around 2% with a precision of 1%.
(a) Female street prostitutes in the Ciutat Vella old district of Barcelona, a popular location for prostitution, were
approached after contacting a well-respected Catalan outreach organization, Àmbit Prevenció, with a specific service
for female prostitutes, Àmbit Dona (i.e., women’s site).
Outreach workers informed the women about the project
and handed out a leaflet (produced in different languages)
First-void urine specimens were collected in a sterile container and were shipped to the laboratory at 4 8C. They
were stored at 2—8 8C for up to seven days or at 20 8C until
they were processed. Pools of four specimens were
prepared each by mixing 400 mL of urine.10 Specimen processing was undertaken following the manufacturer’s
instructions for the urine-based CT/NG PCR (Cobas Amplicor,
Roche Diagnostics, Branchburg, NJ, USA). Specimens
yielding CT or NG signals above the test cutoff were interpreted as positive regardless of the internal control result. If
these signals were negative and the internal control
was above the cutoff value, the sample was considered
negative. Specimens with signals below the cutoffs for CT,
NG, and internal control, were interpreted as inhibitory.
Positive pools or pools with inhibitory activity were retested
individually.
of them cause sexually transmitted diseases and affect the
reproductive tract with grave sequelae.1 The prevalence of
infection attributable to each of these organisms varies
geographically and according to the population studied:
broadly speaking CT is more prevalent than NG in industrialized countries and the reverse in developing countries, and
both of them are more prevalent among people at high risk of
sexually transmitted infections (STIs).
Many studies have documented high rates of CT in parts of
Europe2 and North America3 affecting young people, both
heterosexual and homosexual men, and especially women.
The burden of CT and NG in Catalonia and Spain is largely
unknown due to the scarcity of data. Taking into consideration the fact that the few studies undertaken have been
limited to symptomatic patients in some STI centers or other
populations at lower risk, using generally insensitive testing
methods, the prevalence of CT in Catalonia and Spain still
appears to be lower than that in other parts of Europe.4
Similar to other cities in industrialized countries, since the
late 1990s there has been a progressive increase in the
number of NG cases diagnosed in Barcelona, affecting homosexual men in particular.5
HIV infection is the STI with the highest impact worldwide
and it has consistently been shown to be associated with
other STIs.6 The overall HIV epidemic in Spain is concentrated, with relatively low prevalence among all heterosexuals, including female prostitutes, but with much higher
prevalence among subpopulations of homo/bisexual men
and immigrants.7,8
Globalization has had an impact on sex-related issues such
as prostitution and international travel to specific sites to
engage in sexual activities (homosexual and heterosexual). In
the past few years the number of migrant prostitutes in
Barcelona has increased considerably, and some information
suggests that this city has become a popular destination for
men to meet and practice risky homosexual sex. We undertook this study to determine the prevalence of CT, NG, and
HIV-1 in two populations at risk for STIs in Barcelona, namely
female street prostitutes and male and female STI clinic
attendees.
Sexually transmitted C. trachomatis, N. gonorrhoeae, and HIV-1 in Barcelona
HIV-1 detection in street prostitutes was performed in
urine due to the difficulties in performing venous punctures in the field. The use of urine for HIV-1 diagnosis
purposes is not usually seen to be convenient because
antibody concentrations are lower in urine compared with
those in serum11 and because of the oscillations of antibodies in urine over time.12 However, its use does appear
to be appropriate for epidemiological purposes in some
populations.13 In this study, IgG anti-HIV-1 antibodies were
detected with the Calypte HIV-1 urine enzyme immunoassay (EIA) test (Calypte Biomedical Corp., Alameda, CA,
USA) in individual samples according to manufacturer’s
instructions. Samples that were initially reactive were
retested in duplicate. Repeatedly positive samples were
confirmed by Western blot. We could not use the Western
blot initially licensed for use in urine specimens due to
problems with the supplier. Hence, we used another test
(Bioblot HIV-1 plus, Genelabs Diagnostic, Geneva, Switzerland) with minor variations;14 the dilutions were 3/4 for
each urine (1500 mL of urine and 500 mL of blotting buffer)
and the samples were incubated for 16—20 hours. Results
were considered positive when reactivity to two bands
including gp41, gp120, or gp160 were observed and negative when bands were not observed. Otherwise they were
classified as indeterminate.
Study variables and additional laboratory tests
Details of sex, sexual orientation, age, origin (defined as
country of birth), education, social risk factors (being or
having a partner who is an intravenous drug user, being a
user of other drugs, having an HIV positive partner, or being a
user of prostitution), and previous history of STIs were
collected from all participants. Details concerning type
of partner, sexual practices, and use of condoms during
the last 12 months were also collected from all participants
and recorded in each site as explained before. However,
information about specific sexual practices and their
corresponding use of condoms by type of partner is
seldom recorded in detail in the clinical histories of the
STI unit at the Catalan Health Institute in Barcelona.
Information on the presence of symptoms of urethritis
and cervicitis was retrieved from the clinical records of
subjects attending the STI clinic. Additional information
related to the practice of prostitution and the reproductive
health of street prostitutes was collected in the structured
questionnaire and this will be presented elsewhere.
Participants at the STI clinic had a serological HIV test
(EIA and Western blot) and they were also offered tests
for hepatitis B (antiHBc) and syphilis (rapid plasma reagin
test (RPR) and Treponema pallidum hemagglutination test
(TPHA)).5 The same tests were also performed for the street
prostitutes who agreed to come to the STI clinic for further
checkups.
Data analysis
Microsoft Access 97 was used for data collection and management. Results are presented separately for the two selected
populations (female street prostitutes and STI clinic attendees). Statistical analyses were performed with SPSS 10.0 for
117
Windows (SPSS, Inc., Chicago, USA) and Epi Info version 6
(CDC, Atlanta, GA, USA). Prevalences of the STIs investigated
(NG, CT, and HIV-1) were calculated with their corresponding
95% confidence intervals (95% CI) using the exact method.
The association between categorical variables and the STI
was assessed using the Chi-square test or Fisher’s exact test,
as appropriate. The chosen level of significance was 5% and
the p values described are two-tailed. In order to increase
the numerators for the purpose of analyzing the risk of STIs in
relation to condom use in different sexual practices by type
of partner among female street prostitutes, a combined
variable (combined test result) that included the results of
the three STIs investigated was created. A positive combined
test result was defined as any positive result from NG, CT, or
HIV-1 testing.
Results
Female street prostitutes
A total of 301 female street prostitutes participated in the
study. Their main characteristics are shown in Table 1.
With a median age of 27, around half of them were
younger than 25 years old. Only 5% were autochthonous;
the majority came from Latin America (31%), sub-Saharan
Africa (25%), and Eastern Europe (24%) with the main countries of origin being Ecuador, Nigeria, and Romania. With
regard to sexual behavior, 61% of them had a steady partner,
and 28 women and 22 women, respectively, practiced anal
sex with their partners and clients.
Frequencies of condom use by sexual practice and type of
partner are shown in Table 2; the frequency of condom use
with clients was found to be high and the contrary was found
with steady partners.
Prevalences of NG, CT, and HIV-1 in urine samples were
respectively as follows: 3.7% (95% CI: 1.8—6.4), 4.7% (95% CI:
2.6—7.7), and 1.0% (95% CI: 0.2—2.9) (Table 1). There were
no statistical differences in the prevalences of the above STIs
by age or origin (data not shown), with the exception of the
prevalence of CT being the highest among women from
Eastern Europe (12.7%) ( p = 0.01). Condom use was not a
risk factor associated with having a positive combined test
result, with the exception of a marginal increased risk
( p = 0.07) for prostitutes not always using condoms during
vaginal sexual practices with clients (Table 2). Data from the
23 women who decided to attend the STI unit for further
checkups showed prevalences of hepatitis B virus (HBV) of
34.8% and syphilis of 4.5%. Prevalences of NG, CT, and HIV-1
from 28 male street prostitutes were respectively: 0%, 0%,
and 28.6%.
Concerning the performance of HIV-1 testing in urine in
female and male street prostitutes, overall there were 30
(9%) EIA reactive tests that required confirmation by Western
blot. Following this, 11 results (three from women and eight
from men) were considered positive and three (all women)
indeterminate. Five of the patients with HIV-1 positive tests,
three men and two women (and one with an indeterminate
result too) knew they were HIV positive according to interview. None of the women who also attended the STI clinic
were found to be HIV-1 positive either by urine or blood
testing.
118
Table 1
M. Vall-Mayans et al.
Main characteristics and STI prevalences of study participants by recruitment site
Variable
Female street prostitutes (n = 301)
STI clinic attendeesa (n = 536)
n
%
n
%
301
—
100
—
202
334
38
62
—
—
—
—
193
133
59
41
136
163
45
55
138
397
26
74
15
94
76
71
31
0
12
5
31
25
24
10
—
4
185
163
30
25
11
33
38
38
34
6
5
2
7
8
Education
None or primary studies
Secondary
University
148
140
13
49
47
4
50
331
153
9
62
29
Social risk factors b
Yes
No
5
296
2
98
186
350
35
65
Previous STI
Yes
No
9
292
3
97
74
171
30
70
Type of partnerc
Steady
Occasional or client
184
301
61
100
227
200
42
37
Sex
Female
Male
Sexual orientation (men)
Heterosexual
Homo/bisexual
Age
25
>25
Origin
Autochthonous
Latin America
Sub-Saharan Africa
Eastern Europe
North Africa
Western Europe
Other
HBV (AntiHBc)
Positive
Negative
8
15
34.8
65.2
30
172
14.9
85.1
Syphilis (RPR and TPHA)
Positive
Negative
1
21
4.5
95.5
22
283
7.2
92.8
Neisseria gonorrhoeae
Positive
Negative
11
290
3.7
96.3
24
508
4.5
95.5
Chlamydia trachomatis
Positive
Negative
14
287
4.7
95.3
23
509
4.3
95.7
HIV-1
Positive
Negative
3
295
1.0
99.0
13
280
4.4
95.6
Note: Totals for some categories do not add up to the number of participants as a result of missing information in some variables.
a
Includes 24 male and 110 female non-street prostitutes.
b
Social risk factors considered: being or having a partner who is an intravenous drug user, being a user of other drugs, having an HIV positive
partner, or being a user of prostitution.
c
Non-exclusive categories.
119
Sexually transmitted C. trachomatis, N. gonorrhoeae, and HIV-1 in Barcelona
Table 2
Combined STI test results by sexual practice, use of condom, and type of partner among 301 female street prostitutes
Sexual practice
Steady partner
Vaginal
Anal
Oral
Client
Vaginal
Anal
Oral
a
b
Use of condom (%) a
Combined test result b
Total n (%)
p Value
Positive n (%)
Negative n (%)
Yes (8)
No
3 (20)
13 (8)
12 (80)
156 (92)
15 (100)
169 (100)
0.13
Yes (11)
No
1 (33)
2 (8)
2 (67)
23 (92)
3 (100)
25 (100)
0.30
Yes (3)
No
0 (0)
10 (9)
4 (100)
101 (91)
4 (100)
111 (100)
1
Yes (96)
No
23 (8)
3 (25)
266 (92)
9 (75)
289 (100)
12 (100)
0.07
Yes (86)
No
1 (5)
1 (33)
18 (95)
2 (67)
19 (100)
3 (100)
0.26
Yes (91)
No
11 (6)
3 (16)
179 (94)
16 (84)
190 (100)
19 (100)
0.12
Percentage of participants that used condoms always.
Combined test result from Neisseria gonorrhoeae, Chlamydia trachomatis, or HIV-1 testing.
STI clinic attendees
During each year of the study period, approximately 13 000
visits (60% men) took place at the STI clinic. Subjects who
were invited to participate were mainly those who requested
an HIV test between February and June (around four months).
The response rate was 84%. Of these subjects, 536 (202
women and 334 men, 59% of them heterosexual) agreed to
be screened for NG and CT by providing a urine sample in the
context of this study. The main characteristics of these
participants are shown in Table 1.
With a median age of 32, 74% of them were over 25 years
old. The majority were autochthonous (38%) and from Latin
America (34%); foreigners represented 55 different countries. The prevalence of HBV was 14.9% and that of syphilis
7.2%. Concerning sexual behavior, 42% and 37% of the subjects had steady and occasional/client partners, respectively. Information available for only 96 (33%) men and
women non-street prostitute heterosexuals attending the
STI clinic showed that 22% of them with occasional partners
never used condoms. Information on the frequency of condom use among STI clinic homo/bisexual men non-prostitutes
attending the STI clinic was available for around 30 (28%)
only, and depended on sexual practice; high levels of condom
use in anal sex, especially with occasional partners (77%), and
low levels of use in oral sex (32%) were reported.
In the STI clinic setting, results for NG and CT were not
available for one woman, two heterosexual men, and one
homosexual man, and those for HIV were not available for 62
women, 107 heterosexual men, and 68 homo/bisexual men.
Overall, prevalences of NG and CT in urine and of HIV-1 in
blood samples were respectively as follows: 4.5% (95% CI:
2.9—6.6), 4.3% (95% CI: 2.8—6.4), and 4.4% (95% CI: 2.4—7.5)
(Table 1).
The specific rates of NG, CT, and HIV-1 by sex and sexual
orientation in men that include non-street prostitutes
attending the STI clinic are shown in Table 3. The prevalences
of the three STIs were not statistically different after stratifying by practice of prostitution either in women ( p values
for CT, NG, and HIV-1 were 1.0, 0.7, and 0.6, respectively) or
in homosexual men ( p values for CT, NG, and HIV-1 were 1.0,
0.6, and 1.0, respectively). Prevalences of NG and CT were
not statistically different between the three groups in Table 3
(data not shown). In addition, there were no statistical
differences in those prevalences by age or origin in any
of the three groups, with the exception of NG among
Table 3 Prevalence of Neisseria gonorrhoeae, Chlamydia trachomatis, and HIV-1 in women and in men by sexual orientation
attending the STI clinic (includes 24 male and 110 female non-street prostitutes)
Women n = 201
Heterosexual men n = 191
Homosexual men n = 132
a
b
Neisseria gonorrhoeae
Chlamydia trachomatis
HIV-1 a
nb
%
(95% CI)
nb
%
(95% CI)
n
%
(95% CI)
9 (1)
6 (5)
9 (8)
4.5
3.1
6.8
(2.1—8.3)
(1.2—6.7)
(3.2—12.5)
9 (1)
8 (2)
6 (4)
4.5
4.2
4.5
(2.1—8.3)
(1.8—8.1)
(1.7—9.6)
3
1
9
2.2
1.2
13.8
(0.4—6.1)
(0.3—6.3)
(6.5—24.7)
62 women, 107 heterosexual men, and 68 homo/bisexual men from Table 1 with missing information on HIV.
Number of patients with symptoms of urethritis/cervicitis in brackets.
120
heterosexual men where men from North Africa had the
highest prevalence (29%, two cases out of seven subjects)
( p < 0.001). Table 3 also shows the number of patients with
symptoms of urethritis or cervicitis with positive tests. All
women with a positive test for NG or CT were asymptomatic,
with the exception of one. On the contrary, the majority of
men with positive tests were symptomatic, with the exception of heterosexual men with a positive CT test where only
two out of eight had symptoms. The prevalence of HIV-1
infection was higher among homosexual men when compared
to that of heterosexual men and women ( p < 0.001)
(Table 3).
Discussion
This study provides new information about STIs of public health
importance in two different at-risk populations in Barcelona —
female street prostitutes and STI clinic attendees. Prior to this
study the available information on STI prevalence in these
populations has been limited. It is the largest study to be
carried out in Catalonia and in Spain, and the first one to use a
pooling algorithm for laboratory testing, to screen at-risk
populations for NG and CT using amplification-based technology in urine specimens. It is also the first one to provide HIV-1
prevalence data from street-recruited prostitutes using urine
samples.
Like other countries in Southern Europe,15,16 Spain is also
experiencing the phenomenon of migrant prostitution. In
Barcelona, a high proportion of street prostitutes are very
young and with low rates of previous STIs, probably reflecting
a recent commencement of prostitution. As the outreach
organization provided condoms to prostitutes, it is also
probable that it played a role in their high frequency of
condom use with clients. Hence, it is important to recognize
the pivotal role that such non-governmental organizations
(NGOs) play in preventing the spread and the acquisition
of STIs.
In this study we document moderate prevalences of STIs
among street-recruited female prostitutes, lower than
those described in a similar study carried out in Italy.15
The most important finding from this part of the study is
the significantly higher rate of CT infection in women from
Eastern Europe, reflecting the difficulties in targeting interventions among this group.15,16 This population of female
prostitutes seems to be very mobile, traveling as tourists,
seldom using condoms, and the NGO Àmbit Dona reported a
high frequency of voluntary abortions among them during
the study period.
In Europe, HIV infection rates are low in female sex
workers who do not use intravenous drugs, even among
foreign-born women.8,17 However, HIV rates are much higher
in male prostitutes,18 as also indicated in this study, bearing
in mind the limitations mentioned. Interventions facilitating
the diagnosis and treatment of STIs,6 like the one provided in
this study, and those to prevent the spread of STIs among
street-recruited foreign prostitutes extended to men, clearly
need to be implemented and maintained.
Our findings regarding STI clinic users give support to
the relatively low prevalence of CT in our setting. Overall,
it seems that the prevalence of CT varies across Europe,
generally being higher in Northern Europe compared to
M. Vall-Mayans et al.
Southern Europe.4 In our study, the prevalence rates of
CT found in the different at-risk populations studied are in
the range of those found in similar populations tested in
Spain using less sensitive methods,19—21 and are much
lower than those found in similar study settings from other
European countries, where they are even experiencing
increasing rates.22 These differences provide interesting
hypotheses concerning sexual behavior, bacterial ecology,
and others to be tested. For example, it has been suggested that the higher frequency of sexual activity,
the higher engagement in risk-taking behavior, and the
lower use of barrier contraceptives may contribute to
the higher prevalence of CT infection in German compared
to Spanish students.23 Nevertheless, we cannot be complacent about the moderate rates of CT among STI clinic
attendees in Barcelona, as a study carried out among
women attending this STI clinic 10 years earlier using
nucleic acid amplification methods found a prevalence
of CT of only 1.06%.24
International movement of people will probably lead to an
increase in the prevalence of CT in this population and the
situation needs to be monitored very carefully. This, combined with the fact that CT infection is very often asymptomatic, raises the issue of whether screening for CT should be
expanded to different STI clinic attendees in our setting.25 As
expected, NG rates were higher in homosexual men than in
heterosexuals,5,22 and the vast majority of these infections
were asymptomatic in women while the contrary happened
in men, both heterosexual and homosexual. The progressive
increase in NG in homosexual men in Europe has been related
to a reversion to risky sexual behaviors.22 The pattern of HIV
infection in men and women was similar to the one previously
described,7 although in this study selection bias that overestimated the prevalence of HIV in homosexual men could
not be entirely ruled out.
There are some possible limitations to this study. Female
migrant street prostitutes are a very mobile population who
work under restrictions of legal and personal issues. Hence,
prevalences found at one time may not be representative of
the prevalences found subsequently. However, the results of
this study still provide information on the recent burden of
STIs in this specific population in Barcelona. So far, the risk
factors analyzed do not allow the identification of further
potential strategies to reduce the burden of these infections.
In any case, given the problems surrounding commercial sex,
the best affordable intervention in this study population is
the continuation of the services provided by the outreach
NGO.
Concerning the clinical setting, the anticipated sample
size was not achieved, in part because of a lack of willingness to participate in some attendees and in part because
of the complexities of running a research project such as
this one during busy clinics. Nevertheless, the final sample
size is still satisfactory in part because the prevalences
found doubled the anticipated ones. The sample size that
was increased at the expense of STI attendees, who were
not tested for HIV, also increased the number of subjects
with missing information on this variable. However, the
heterogeneity of the populations studied in the clinical
setting seems not to have influenced the estimation of
the STI prevalences, with the exception of an overestimate
of HIV in homosexual men.
Sexually transmitted C. trachomatis, N. gonorrhoeae, and HIV-1 in Barcelona
The mean age of participants, especially that of STI clinic
attendees, might have contributed to an underestimate of
the prevalence of CTand the low level of positive cases would
not allow us to find differences by age. In any case, it is still
plausible that our rates of CT are lower than those found
elsewhere when comparing them with those in similar populations attending STI clinics.2 Further studies among younger
populations might contribute to the understanding of the
epidemiology of CT in our setting.
The limited information concerning sexual behavior
among clinic attendees should be taken circumspectly
although generally speaking it fits in with current patterns
of sexual behavior.22 Yet it may be useful information since
this kind of data from Catalonia and Spain are nonexistent.
With consideration to the HIV-1 testing in urine, both the
performance of the test and the accuracy of the pooling
algorithm have been satisfactorily validated.10,13
In conclusion, this study has provided new and important
information about the current epidemiological pattern and
prevalence of STIs in at-risk populations in Barcelona. Among
street prostitutes and STI clinic attendees, CT prevalence is
currently lower than in other European countries. It is possible that the prevalence of CT could increase as a result of
immigration. The prevalence of CT among young people and
low-risk heterosexuals needs to be investigated. The rates of
NG and HIV-1 infections are higher among homosexual than
among heterosexual men. The prevalence of all three STIs in
all at-risk groups needs to be monitored in a rapidly changing
situation. Finally, apart from the clinical benefits of case
identification, an outreach screening program such as the one
directed at street prostitutes, can serve as a significant
vehicle for health promotion, and, as has been the case
here, the fostering of collaboration between governmental
and key community nongovernmental services.
Acknowledgements
This work was supported by FIPSE (Foundation formed by the
Spanish Ministry of Health and Consumer Affairs, Abbott
Laboratories, Boehringer Ingelheim, Bristol Myers Squibb,
GlaxoSmithKline, Merck Sharp and Dohme, and Roche),
exp. 24238/01.
We thank the staff and volunteers of Àmbit Dona who
facilitated the field study. Thanks are also due to the anonymous English expert who reviewed and edited the first
version of this manuscript.
Conflict of interest: No conflict of interest to declare.
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