Pathophysiological and Clinical Aspects of Certain Urogenital Infections in Women of the North Caucasus Region within the Penitentiary System

The dissertation is devoted to the study of the pathophysiological and clinical aspects of sexually transmitted infections (STIs) in women of the North Caucasus region held within the penitentiary system. The research covers the epidemiological situation, mechanisms of STI transmission, specifics of the clinical course, and the influence of concomitant diseases — HIV infection, hepatitis B and C, tuberculosis, and syphilis — on the course of urogenital mixed infections. Special attention is given to the role of psychoemotional stress, characteristic of conditions of deprivation of liberty, in the formation of clinicopathophysiological manifestations of STIs.

The work presents the results of a comparative analysis of STI morbidity among women in pre-trial detention centers and corrective institutions of the North Caucasus region with the population of the same region. Blood biochemical indicators characterizing the functional state of the liver in convicted women with STIs and concomitant infections are examined. An algorithm for treatment has been developed, proposing the optimal combination of antibiotic therapy and an immunocorrector, along with recommendations for primary and secondary prevention of STIs adapted to penitentiary conditions.

The rapid development of civilization constantly changes the content of many social phenomena and gives rise to new problems.

In this regard, sexually transmitted diseases remain highly relevant, carrying significant social importance for all segments of society. Changes in sexual behavior, urbanization, social and demographic, and medical factors have contributed to a sharp increase in the number of patients suffering from sexually transmitted infections [Yu.K. Skripkin et al., 1975; V.I. Kisina, 2000; A.A. Kubanova, O.K. Loseva, 2000; O.S. Mudrenko, M.V. Yatsukha, 2000; A.K. Churin, A.A. Galkin, 2001; G.A. Dmitriev, 2003; L.D. Kuntsevich, N.N. Komov, 2003; CDC, 1991].

The general patterns and specific features of the spread of sexually transmitted infections allow them to be regarded as one of the structural components of infectious pathology in humans. The emergence of certain social groups — drug users, prostitutes, homosexuals — for whom frequent partner change has become the norm of life, has led to a transformation of the classical epidemiology of infectious diseases [A.A. Kubanova et al., 2000; V.I. Kulagin et al., 2001; V.P. Adaskevich, 2004; M.A. Zakharova, 2004; V.V. Chebotarev et al., 2005; S. Aral, 1996].

New treatment regimens for patients with sexually transmitted diseases, including broad-spectrum antibiotics, have made it possible to shift to outpatient treatment of these infections. However, subsequently, many patients developed resistance to the applied antibiotic therapy, which necessitated prolonging the duration of treatment, adjusting the dosage of the primary agent, and incorporating immunomodulating therapy [V.F. Eremin, L.G. Baranov, 2002; G.A. Dmitriev, 2003; M.M. Vasiliev et al., 2005; R. Ingolls et al., 1995; A. Wald et al., 1995].

A significant impact on the deterioration of the epidemiological situation in the population regarding major socially significant diseases and sexually transmitted infections, according to contemporary views, is exerted by the presence of a substantial reservoir of infections in penitentiary institutions. The level of STI morbidity in places of deprivation of liberty is a mirror image of the epidemiological processes occurring in society, which is associated not only with the specifics of the sexual behavior of inmates but often also with the lack of positive motivation among convicts to continue treatment after release [N.M. Ovchinnikov, V.V. Delektorovsky, 1986; V.L. Sazhin, 2001; I.L. Shivko, 2002; L.D. Kuntsevich et al., 2003, 2005].

The penitentiary system is characterized by a number of specific factors: the presence of unfamiliar and unusual living conditions with restrictions and compulsions, disruption of regular heterosexual sexual life, and, as a consequence, the spread of homosexual contacts.

At the present time, in domestic literature, a small number of works have begun to appear devoted to the study of morbidity among the special contingent of the penitentiary system [L.P. Efimova, 1995; V.A. Syresin et al., 2000; I.L. Shivko, 2002; V.V. Sivak, 2003, 2004]. However, the conducted research does not sufficiently illuminate the features of the pathophysiology and clinical course of STIs in women in penitentiary conditions, as well as primary and secondary prevention taking into account the social characteristics of the special contingent.

The goal of our research is the study of the features of the pathogenesis of STIs in women held in penitentiary conditions, who are in a state of chronic psychoemotional stress; and the improvement of the efficacy of treatment for sexually transmitted infections, including against the background of a number of concomitant diseases.

To achieve the stated goal, the following tasks were set: 1. To study the epidemiological situation regarding STIs and concomitant HIV infection, hepatitis B and C, tuberculosis, and syphilis among women of the North Caucasus region sentenced to imprisonment, and its dynamics over the period 2000–2005.

2. To determine the features of the clinical picture of STIs in convicted women, including against the background of concomitant diseases.

3. To evaluate the biochemical and cytochemical indicators of the functional state of the liver (enzymatic activity, bilirubin concentration, disturbances of lipid and protein metabolism) in women of the North Caucasus region serving criminal sentences, suffering from STIs and hepatitis B, C, HIV infection, syphilis, and tuberculosis.

4. To study the influence of psychoemotional stress on the clinicopathophysiological manifestations of STIs in women, including against the background of concomitant diseases.

5. To improve the algorithms for the treatment of women with urogenital mixed infections, as well as in combination with hepatitis, HIV infection, tuberculosis, adapted to the conditions of places of deprivation of liberty.

6. To develop a strategy for primary and secondary prevention of STIs in women in penitentiary conditions.

Scientific novelty.

For the first time, a pathophysiological analysis of the features of the course and spread of sexually transmitted diseases and their combinations with other infections in women sentenced to imprisonment has been conducted.

For the first time, a comparative analysis of STI morbidity indicators among women in pre-trial detention centers and corrective labor colonies in the North Caucasus region with the population of the same region, as well as concomitant diseases — tuberculosis, HIV infection, hepatitis, and syphilis — has been carried out.

For the first time, the results of comparative studies of blood biochemical indicators characterizing the functional state of the liver (enzymatic activity, total bilirubin concentration, direct bilirubin fraction, lipid and protein metabolism indicators) in women of the North Caucasus region held in places of isolation, suffering from STIs and in combination with tuberculosis, hepatitis B and C, and HIV infection, have been presented.

For the first time, a treatment algorithm has been developed that includes the optimal combination of antibiotic therapy and an immunocorrector, affecting not only the causative agent of the diseases but also the overall condition of the human body (Zi-factor and Reaferon-ES).

Practical significance.

The pathophysiological features of the course of STIs in women of the North Caucasus region in corrective institutions have been established. Infection occurs in freedom and within the first year of imprisonment (129 — 86.6%). A single examination of women made it possible to identify STIs (in 44 — 87%) among those newly admitted to corrective labor colony IK-3, and (in 78 — 55.5%) among those serving long-term sentences in penitentiary conditions.

It has been shown that in women recently admitted to places of confinement, urogenital trichomoniasis (in 100%), mycoplasmosis (in 13.2%), and chlamydia (in 10.6%) predominate. In inmates serving long-term sentences (5 years and more), chronicity of trichomoniasis and chlamydia, as well as asymptomatic course of bacterial vaginosis, have been identified.

The influence of concomitant diseases — HIV infection, tuberculosis, hepatitis B and C — on the course of STIs and blood biochemical indicators (total bilirubin and its fractions, LDH, ALP, AST, ALT) has been established.

An algorithm for managing women with STIs in penitentiary conditions has been developed. A syndromic approach has been justified for the treatment of women in places of deprivation of liberty suffering from STIs and concomitant diseases, as well as under conditions of chronic psychoemotional stress, which exerts a negative influence on the clinicopathophysiological manifestations of STIs, complicating their treatment and prevention.

Recommendations for primary and secondary prevention of STIs in women, adapted to penitentiary conditions, have been developed. New approaches to the interaction of medical units of the Federal Penitentiary Service (GUFSIN) and public health regarding the diagnosis, treatment, and observation of women with STIs have been presented.

Implementation.

The results of the research have been implemented in the practice of the IK-3 institution (settlement Dvubratsky, Ust-Labinsky district), the Central District Hospital of the city of Ust-Labinsk (gynecological department, maternity hospital).

Furthermore, the materials of the dissertation are used in lectures at the postgraduate education faculties of the Stavropol State Medical Academy, Rostov State Medical University, Kuban State Medical University, and its Adygei branch in the city of Maykop.

Positions of the dissertation to be defended.

1. STI morbidity among women admitted to places of deprivation of liberty in the Krasnodar region is significantly higher than the morbidity indicators of the population of the same region. The majority of inmates become infected in freedom and within the first year of their stay in correctional institutions.

2. The clinical manifestations of STIs and the spectrum of concomitant pathology are closely related to the socio-demographic characteristics of women of the North Caucasus region in the penitentiary system.

3. Changes in blood biochemical indicators characterizing the functional state of the liver (enzymatic activity, increased total bilirubin concentration due to the direct fraction, disturbances of lipid and protein metabolism) in convicted women are associated with concomitant pathology: hepatitis B and C, tuberculosis, HIV infection, and other diseases. This leads to a prolongation of the incubation period of STIs, affects the nature of clinical manifestations, and the efficacy of the applied therapy.

4. Psychoemotional stress in convicted women exerts a negative influence on the clinicopathophysiological manifestations of STIs, complicating their treatment and prevention.

5. High morbidity of women with STIs and other socially significant diseases in the limited conditions of the medical services of the Federal Penitentiary Service justifies a syndromic approach to the treatment of urogenital mixed infections.

6. The treatment algorithm for STIs in women in corrective institutions should take into account the form and stage of STIs and the influence of concomitant infectious pathology (hepatitis, tuberculosis, HIV infection) on the overall condition of the body and blood biochemical indicators.

7. Women in places of deprivation of liberty constitute a group of elevated behavioral risk. Among them, primary prevention of STIs adapted to penitentiary conditions is necessary.

Presentation of the work.

The materials of the dissertation were reported and discussed at the VI Russian Congress of Infectious Disease Physicians, St. Petersburg, 2003; the Scientific-Practical Conference dedicated to the 60th anniversary of the Department of Skin and Venereal Diseases of the city of Krasnoyarsk, "Current Issues of Venereology and Dermatology," 2003; the Russian Scientific-Practical Conference "Genetic Diagnostics of Infectious Diseases," 2005; the X International Congress on Rehabilitation in Medicine and Medical Rehabilitation, Athens, Greece, 2005; the V Scientific-Practical Conference "Socially Significant Diseases in Dermatology. Diagnosis, Therapy, Prevention," Moscow, 2005, Scientific Research Center of the Sechenov Medical Academy; the Second Southern Russian Scientific-Practical Conference with international participation, "Current Issues of Infectious Pathology of Southern Russia," Maykop, 2006.

Publications.

On the topic of the dissertation, 17 scientific works have been published, including 6 in journals approved by the VAK of the Russian Federation.

Volume of the work.

The dissertation is presented in 136 pages of computer text and consists of an introduction, a review of the literature (Chapter 1), materials and methods of investigation (Chapter 2), 4 chapters of original observations, conclusions, findings, and practical recommendations. It is illustrated with 19 tables and 13 figures. The reference list includes 145 works by domestic and 50 works by foreign authors.