Prevalence and behavioral risk factors for STIs / HIV among attendees of the Ministry of Health hospitals in Saudi Arabia

Introduction: Sexually transmitted infections (STI) are a major public health, social, and economic problem leading to morbidity, mortality, and stigma. This study was conducted to determine the prevalence of STIs, investigate behavioral risk factors and the relationship between the STIs/HIV and demographic factors. Methodology: A cross-sectional survey was conducted between 2013 and 2014 among attendees of the Ministry of Health hospitals. Results: The total number of participants was 3,994 (2,441 males and 1,553 females), with a mean age of 31.95 ± 9.45 years (range 12 to 77 years). The prevalence of STIs and HIV was 6.2% and 0.05% respectively. The mean age for infected people with STIs was 29.42 ± 7.51, vs. 32.12 ± 9.55 for non infected (p < 0.05). There was no diffference between infected and non infected people regarding gender, occupation and marital status. The prevalence of STIs was more commonly reported among non-Saudi (10.9%). Drug use (OR = 4.74; 95%; CI: 3.47– 6.48), intravenous drug use (OR = 4.51; 95% CI: 1.45–13.12), illegal sex (OR = 10.7; 95% CI: 7.62–13.32), sex for money (OR = 6.36; 95% CI: 4.52–8.93), sex for pleasure (OR=9.76; 95% CI: 7.29–13.07) were significantly associated with STIs. Conclusion: The prevalence of STIs including HIV in Saudi Arabia is low compared to other countries in the region and globally.


Introduction
Sexually transmitted infections (STIs) are a major public health problem and are one of the most common causes of illness and death in the world [1].The World Health Organization (WHO) estimated a total of 499 million new cases of curable STIs in adults per annum, mainly in South and South East Asia and sub-Saharan Africa [2].The most common STIs are gonorrhea, chlamydia, syphilis, trichomoniasis, chancroid, genital herpes, genital warts, human immunodeficiency virus (HIV) and hepatitis B virus [1].Most STIs are easy to diagnose and treat; however, viral conditions, such as herpes and HIV, are costly and incurable [2].Most of the published data on the prevalence and incidence of STIs come from developed countries [3].In the Saudi society, discussing STIs is considered a taboo based on ethical and social factors [4].Information about STIs in Islamic countries, where non-marital sex and homosexuality are prohibited by religion, is notably limited [5].The current study was carried out to determine the prevalence of STIs and HIV, investigate behavioral risk factors and determine the relationship between the occurrence STIs/HIV and demographic factors.

Study design and setting
The current study was based on a cross sectional hospital-based survey, conducted among attendees of the Ministry of Health (MOH) hospitals, Kingdom of Saudi Arabia (KSA) between 2013 and 2014.The study was carried out in five geographical areas; Central, Eastern, Western, Northern and Southern parts of KSA.

Study Sample
Multistage random technique was applied for site selection as follows: -Southern: included four regions (Baha, Asir, Jazan and Najran) and one province (Bisha).

Second stage
In each geographical area, one region or province was selected by simple random sampling technique for the study: -Riyadh region was selected from the Central Area.-Eastern region (Al-Dammam) was selected from the Eastern Area -Jeddah province was selected from the Western Area.-Northern frontier region (Arar) was selected from the Northern Area.-Asir region was selected from the Southern Area.

Third stage
In each of the selected regions or province 20% of the MOH hospitals were randomly selected and included in the study.The total number of hospitals included in the study was 18.

Data collection
The questionnaire used in the study was prepared and delivered according to WHO guidelines [6] and included demographic and behavioral risk factors associated with STIs and HIV.Training workshop for 2 days was conducted targeting STIs and HIV coordinators from the selected regions for the study aiming to determine the study needs, to evaluate the internal consistency of the questionnaire, to discuss how to distribute and collect the questionnaire from the selected hospitals, as well as how to answer any question related to the study.Field survey was carried out after obtaining approval for conducting the study from the Directorates of Health Affairs and from all hospitals that were chosen for the study.Data were collected through the following clinics: dermatological, obstetrical and gynecological, urological, and infectious diseases.All patients attending the above clinics for any purposes during the period of data collection (between May 1, 2013 to the end of April 2014) were requested to be included in the study.A total of 3,994 patients accepted and signed a written consent before participation in the study.Privacy and confidentiality were ensured during data collection process.Data were collected by health care providers through an interview questionnaire from all participants.All suspected cases of STIs or those having high risk behavior were submitted to rapid test to confirm or disprove diagnosis.The rapid tests were performed using blood samples, vaginal or urethral swabs and ulcer swabs.Every suspected case of STIs was tested for: HIV, Syphilis, Gonorrhea, Chlamydia, Herpes Simplex Virus (HSV) type 2 and Human Papilloma virus.

Data analysis
Quantitative data were expressed as Mean ± SD, while qualitative data were expressed as frequency and percent.Data were entered, organized, tabulated and analyzed using SPSS version 21.Student t test was used to measure the difference between means of two quantitative groups, while Chi square (χ 2 ) was used to assess the relationship between two qualitative variables, with the significant level set at 0.05.Crude odds ratio (OR) and their 95% confidence intervals (CI) were calculated to test the significance of associated factors.

Discussion
STIs represent a major health problem worldwide causing significant morbidity and mortality both in men and women in developing and developed countries [7].In the current study the prevalence of sexually transmitted infections was 6.2% which is lower than that reported in few studies [8,9], and higher than that reported by other investigators [10,11] indicating differences in methodology, study population and time of the study.
Striking variations in HSV-2 prevalence were noted in different geographic regions.HSV-2 prevalence is in general higher in Africa and the Americas, lower in western and southern Europe, and the lowest in Asia.Age-specific HSV-2 prevalence is usually higher in women than men and in populations with higher risk sexual behavior [12].In the current study the prevalence of HSV was (0.5%) and is different than those in other studies [13][14][15].These studies mainly measure seroprevalence in different groups and in different countries.The same findings hold true for the prevalence of syphilis compared to other studies [16][17][18].
Estimates by the World Health Organization (WHO) and the Joint United Nations Program on HIV/AIDS (UNAIDS) show that HIV-prevalence is low in the Middle East and North Africa regions (0.2%-0.4%) [19] and the current study revealed even much lower prevalence of 0.05%.
Several factors may explain the discrepancy in the prevalence STIs and HIV among the previous studies such as differences in the population surveyed, demographics, social, cultural, and diagnostic procedures.Impact of adhering to Islamic values on the prevalence of STIs was demonstrated by several studies.According to the United Nations and the WHO, the prevalence of HIV infection in Islamic countries is strikingly low compared to other countries.A survey of published journal articles containing data on HIV prevalence and religious affiliation showed that six out of seven such studies indicated a negative relationship between HIV prevalence and being Muslim [20].
The prevalence of STIs was higher in Arar and Riyadh.One possible explanation of the higher prevalence of STIs in Arar and Riyadh is the fact that Arar is located in an area bordering some of the Arabic countries which has been experiencing internal conflicts and instabilities.People from these countries frequently cross the borders to Arar and interact with local residents and may increase the vulnerability of the local residents to many risks including STIs.Also the presence of large numbers of migrant workers in these regions may play a role in the transmission of STIs as previously reported [21].
The level of education is a factor with a significant effect on STIs [11].In the current study, STIs were more prevalent among less or non educated people, in agreement with other studies [11].Similarly, a history of selling sex for money or drugs or pleasure was significantly associated with HBV, HCV, HSV, and syphilis [22][23][24].
Unprotected sex with an infected partner is by far the most important risk factor for STIs/HIV transmission worldwide.Consistent and correct use of male latex condoms can reduce the risk of STIs transmission.Thus, the prevalence of STIs was commonly reported among non condom users [26] .One of the factors for no-use of condoms is the cost [27], a trustable partner, using an alternate contraceptive method, and dislike for condoms [28,29].
Adequate knowledge is crucial to clearing misconceptions about STIs including the acquired immune deficiency syndrome (AIDS) [30].The study showed that, the most common source of information about STIs were TV/Radio, internet, friends, brochures, books and magazine/newspapers, in agreement with other studies [4,11].

Conclusions
The prevalence of STIs including HIV in Saudi Arabia is low as compared with other countries.
Factors significantly associated with STIs were presence of migrants, inadequate knowledge about STIs, and low educational level.Drug abuse and practice of illegal sex (for money or pleasure) were behavioural risk factors which were significantly associated with STIs.STIs was low among condom users.The most common reasons for not using a condom were: dislike a condom, sexual partner refuse using it, not available, it never came to their mind, and expensive.While the reasons for using a condom were; protection from STIs including HIV, and to prevent unwanted pregnancy.
Further in-depth studies need to be conducted to explore the prevalence and behavioural risk factors associated with STIs among migrant workers.Intensification of health education campaigns to raise public awareness regarding types, modes of transmission, negative health impact and ways of prevention of STIs should be warranted.Establishment of a hotline to deal with public inquiries and questions about STIs.There is a need for STIs screening program for drug abusers and others at increased risk.Since the pattern of utilization of the Ministry of Health facilities between Saudi and non-Saudi is not well known, there is a possibility that the data might not be generalized to the whole population.

Table 1 .
Distribution of studied sample according to general characteristics *Statistically significant difference.

Table 2 .
Distribution of studied sample according to some behavioral risk factors and blood transfusion (* multiple responses could be answered for each question) * Significantly associated factors.

Table 3 .
Distribution of studied sample according to the source of STIs information (* of the total 2012 responses).

Table 4 .
Distribution of STIs cases according to STIs manifestation and using a condom during STIs manifestations (* multiple responses could be answered for each question)