Offering HCV treatment to prisoners is an important opportunity: key principles based on policy and practice assessment in Europe.

BACKGROUND: Prisoners have a high prevalence of hepatitis C virus (HCV) infection but may find it difficult to access healthcare services. This may be related to risk behaviour including history of injecting drugs and marginalisation related to problem drug use/ opioid use disorder (OUD). Direct-acting antiviral products with superior efficacy and safety compared to interferon-based regimens offer HCV cure. Many citizens in Europe have been treated, although few received therapy in prisons. METHODS: Analysis of prisoner HCV treatment need and policy determinants of clinical practice was completed for 5 EU countries. Evidence was collected from national statistical sources and peer-reviewed publications to describe prison populations and HCV prevalence, to map national prison/ HCV health policy or guidance. A consensus of important principles for prisoner HCV care was developed. RESULTS: Data from published sources describing prisoner HCV prevalence is limited. Prisoner population requiring HCV treatment is not known; estimated numbers based on analysis of evidence: England and Wales, 9000, France, 8000, Spain, 6000, Italy, 6000, Germany, 6000. Treatment access: national law defines right to equivalent care in all countries implying access to HCV therapy in prison similar to community; useful prisoner HCV guidance facilitating treatment decisions present in: 4 of 5 national/ regional HCV policy documents, 4 of 5 national prison healthcare policies. Four of five had practical prison HCV clinical guidelines. Despite existence of policy, implementation of guidance, and so HCV treatment, is suboptimal in many locations. CONCLUSIONS: Prison is an important location to detect, address and treat HCV infection in people who may be underserved for healthcare and find it difficult to navigate community treatment pathways. This is often related to problems with OUD and resulting social inequity. HCV management in prisons must be improved. Policy and clinical practice guidance must be set to promote treatment, and practical steps to make treatment easy should be followed including education to promote engagement, set-up of optimal screening and work up processes with modern tools to reduce time needed/ achieve efficiency; programs to make it easier to get specialists' input include remote working and nurse-led services.

[Multi-centre study of the prevalence of infection from HIV and associated factors in Spanish prisons]. / Estudio multicéntrico de Prevalencia de Infección por el VIH y factores asociados en las prisiones de España.

OBJECTIVE: To determine the prevalence and associated factors of HIV infection amongst inmates in Spain. MATERIAL AND METHODS: Observational and transversal study (June 2008). For 62,000 inmates an "n" of 364 was determined (5% variability, error correction α 5% and 10% missing). 18 prisons were randomly selected and 21 inmates/prison. Frequency measurement: prevalence. Magnitude of the association: odds ratio of prevalence (ORP) with 95%. Statistical significance p<0.05. RESULTS: 371 prisoners were studied (91.6% male, 66.9% ≤ 40 years, 60.6% Spanish, 23.5% IDU and 71.2% incarcerated <5 years). HIV prevalence was 10.8% (CI: 7.5 to 14). 85% were co-infected with HCV, 12.5% with HBV and HCV and 63.2% with M. tuberculosis. This represents a proportion to the prison population of 9.2%, 1.3% and 6.7% respectively. HIV infection was associated with: a) > 40 years (p <0.01), b) imprisoned> 5 years (p <0.001), c) non-Arab (p <0.01), d) Spanish nationality (p <0.001), e) IDUs (p <0.001), f) co-infected with HCV (p <0.001), and g) co-infected with HBV (p <0.001]. Multivariate analysis confirmed the association: a) ≥ 40 years [OR = 2.66 (CI : 1.16-6.07), b) IDU [OR = 28.08 (IC-9.61-81.99), c) infected with HCV [OR = 6.96 (CI :1.90-25.39)], and d) infected with HBV [OR = 13.52 (CI = 1.76-103.82). CONCLUSION: The prevalence of HIV infection among prisoners in Spain is 10.8%. Those that are infected are usually IDUs and over 40 years. 85% are co-infected with HCV and 12.5% with HBV and HCV.

Estudio Multicéntrico de Prevalencia de Infección por el VIH y factores asociados en las prisiones de España / Multi-centre study of the prevalence of infection from HIV and associated factors in spanish prisons

Objetivo: Determinar la prevalencia y factores asociados de infección por VIH en presos de España. Material y método: Estudio observacional y transversal (junio 2008). Se determinó para 62.000 internos una "n" de 364 (variabilidad 5%, error α 5% y corrección 10% por posibles pérdidas). Se seleccionaron aleatoriamente 18 prisiones y 21 internos/ prisión. Medida de frecuencia: prevalencia. Magnitud de la asociación: odds ratio de prevalencia (ORp) con IC del 95%. Nivel de significación estadística p< 0,05. Resultados: Se estudiaron 371 presos (91,6% varones, 66,9% ≤ 40 años, 60,6% español, 23,5% UDI y 71,2% encarcelado< 5 años). La prevalencia de VIH fue del 10,8% (IC: 7,5-14). El 85% estaba coinfectado con VHC, el 12,5% con VHB y VHC y el 63,2% con el M. tuberculosis, que representa una proporción para la población penitenciaria del 9,2%, 1,3% y 6,7%, respectivamente. Se asoció ser VIH+ a tener >40 años (p<0,01); estar preso >5 años (p<0,001); no ser árabe (p<0.01); ser español (p<0,001); ser UDI (p<0,001); estar coinfectado con VHC (p<0,001) y estar coinfectado con VHB (p<0,001]. El análisis multivariante confirmó la asociación con: a) tener ≥40 años [OR= 2,66 (IC:1,16-6,07), b) ser UDI [OR=28,08 (IC:9,61-81,99); c) estar infectado por el VHC [OR=6,96 (IC:1,90-25,39)]; y d) estar infectado por el VHB [OR= 13,52 (IC=1,76-103,82)]. Conclusión: La prevalencia de infección por VIH en presos de España es del 10,8%. Los infectados suelen ser UDI y mayores de 40 años. El 85% está coinfectado con el VHC y el 12,5% con el VHB y VHC(AU)

Objective: To determine the prevalence and associated factors of HIV infection amongst inmates in Spain. Material and Methods: Observational and transversal study (June 2008). For 62,000 inmates an "n" of 364 was determined (5% variability, error correction α 5% and 10% missing). 18 prisons were randomly selected and 21 inmates/prison. Frequency measurement: prevalence. Magnitude of the association: odds ratio of prevalence (ORP) with 95%. Statistical significance p<0.05. Results: 371 prisoners were studied (91.6% male, 66.9% ≤ 40 years, 60.6% Spanish, 23.5% IDU and 71.2% incarcerated <5 years). HIV prevalence was 10.8% (CI: 7.5 to 14). 85% were co-infected with HCV, 12.5% with HBV and HCV and 63.2% with M. tuberculosis. This represents a proportion to the prison population of 9.2%, 1.3% and 6.7% respectively. HIV infection was associated with: a) > 40 years (p <0.01), b) imprisoned> 5 years (p <0.001), c) non-Arab (p <0.01), d) Spanish nationality (p <0.001), e) IDUs (p <0.001), f) co-infected with HCV (p <0.001), and g) co-infected with HBV (p <0.001]. Multivariate analysis confirmed the association: a) ≥ 40 years [OR = 2.66 (CI : 1.16-6.07), b) IDU [OR = 28.08 (IC-9.61-81.99), c) infected with HCV [OR = 6.96 (CI :1.90-25.39)], and d) infected with HBV [OR = 13.52 (CI = 1.76-103.82). Conclusion: The prevalence of HIV infection among prisoners in Spain is 10.8%. Those that are infected are usually IDUs and over 40 years. 85% are co-infected with HCV and 12.5% with HBV and HCV(AU)

[Reasons for not initating HCV treatment in prison: a subanalysis of the EPIBAND study]. / Causas de no inicios al tratamiento de la hepatitis C en el medio penitenciario: subanálisis del estudio EPIBAND.

OBJECTIVE: This sub-analysis was designed within the framework of the EPIBAND study to establish the reasons why prison patients do not initiate HCV treatment. METHODS: Epidemiological, prospective, multicentre study conducted in 26 centres. We present the results from those patients included in the EPIBAND study who did not initiate HCV treatment for different reasons. RESULTS: A total of 195 patients were evaluated (average age 39 ± 6.6 years, 86.7% male and 96.9% Spanish nationality). The reasons why this population did not initiate HCV treatment were secondary ones relating to the patient (41%), medical reasons (30.8%), and the prison environment (3.6%). 47.5% of patients reported lack of awareness and motivation, and 18.8% did not initiate treatment as a result of adverse events. Immunological status (35%). as well as psychiatric and neurological disorders (28.3%) were the main medical reasons for contraindication. Aspects associated to prison environment such as impending release or change of prison (64.4%) were among the various reasons that influenced treatment initiation. CONCLUSIONS: Lack of motivation and awareness in patients as well as adverse events were the main reasons for not initiating therapy. These factors are subjective, modifiable aspects that depend on patient education and adequate medical care.

Hepatitis C and B prevalence in Spanish prisons.

Purpose The Prevalhep study seeks to determine the prevalence of factors associated with the hepatitis C (HCV) and B (HBV) virus in Spanish prisoners. Methods This was an observational, cross-sectional study which randomly selected 18 Spanish prisons to participate, with 21 prisoners per centre. Results There were 378 prisoners selected, 370 of whom had serological HCV and 342 had HBV data. The HCV population was predominantly male (91.6%), middle age (66.7% ≤ 40 years of age), of Spanish origin (60.5%), with a history of injection drug use (IDU; 23.2%), in prison <5 years (71.2%) and having entered prison after 2006 (51.9%). The prevalence of HCV was 22.7% (n = 84; 95% CI, 18.3-27.1) and HBV was 2.6% (n = 9; 95% CI, 0.2-4.9%). Of the patients with HCV, 40.5% were co-infected with HIV, 0.3% co-infected with HBV, and 1.5% with triple virus co-infection (HBV + HCV + HIV). The three markers of HB had been measured in 99 inmates: 32.1% had post-vaccination immunity (antiHBS+) and 30.4% contact status with HBV (HBcAb + and/or HBsAg+), while 37.5% were susceptible to HB. Conclusions The prevalence of HBV and HCV has decreased in the Spanish prison population, probably as a result of decrease in IDU transmission, and an increase in immigrant prisoner population that does not have this risk behaviour.

[What do prison doctors think about HIV infection control in Spanish prisons?: Results of the study of the Spanish Society of Prison Health Working Group on Infectious Diseases (GEISESP)]. / ¿Qué opinan los médicos penitenciarios sobre el control de la infección por el VIH en las prisiones españolas?: Resultados del Estudio del Grupo de Trabajo en Enfermedades Infecciosas de la Sociedad Española de Sanidad Penitenciaria (GEISESP).

We present the results of the study carried out by The Spanish Society of Penitentiary Health Working Group on Infectious Diseases (GEISESP) on the opinion of prison doctors concerning the suitability of undertaking or not undertaking controls of HIV infection in prisons and about the difficulties, efforts, needs and responsibilities that this activity may involve. This study was carried out in 2007 using an ad hoc survey designed and sent to doctors at 73 prisons in Spain. 116 valid questionnaires were received. It was considered that the data received could be applied to the whole population with a level of trust of 95% and an 8% margin of error. Half the doctors referred to prescribing antiretroviral treatments, though only 10% admitted prescribing rescue combinations. It should be noted that only of half the doctors consider themselves to be appropriately prepared to deal with patients infected by the HIV virus, though half of them admit to having received specific postgraduate training on this subject. Generally speaking, doctors consider that the quality of the health care received by the HIV-infected population is quite good.

¿Qué opinan los médicos penitenciarios sobre el control de la infección por el VIH en las prisiones españolas? Resultados del Estudio del Grupo de Trabajo en Enfermedades Infecciosas de la Sociedad Española de Sanidad Penitenciaria (GEISESP) / What do prison doctors think about HIV infection control in Spanish prisons? Results of the study of the spanish society of prison health working group on infectious disease (GEISESP)

Se presentan los resultados del estudio realizado por el Grupo de Enfermedades Infecciosas de la SociedadEspañola de Sanidad Penitenciaria (GEISESP) sobre la opinión de los facultativos penitenciarios en cuanto a laconveniencia o no de realizar el control de la infección por el VIH en el medio carcelario y sobre las dificultades,esfuerzos, necesidades y responsabilidades que esta actividad puede suponer. Este estudio se efectuó en elaño 2007 utilizando una encuesta diseñada ad hoc remitida a todos los facultativos de 73 centros penitenciariosespañoles. Se recibieron 116 cuestionarios válidos, estimándose que los datos obtenidos podían aplicarse al totalde la población con un nivel de confianza del 95% y un margen de error del 8%. La mitad de los médicos refirieronprescribir tratamientos antirretrovirales, aunque sólo el 10% decían prescribir combinaciones de rescate.Es de destacar también que sólo la mitad de los médicos se consideran formados adecuadamente para atenderpacientes infectados por el VIH, aunque la mayoría afirma haber hecho formación específica de postgradoen esta materia. En general, los médicos consideran que la calidad de la asistencia recibida por los infectados porel VIH en prisión es buena (AU)

We present the results of the study carried out by The Spanish Society of Penitentiary Health Working Group on InfectiousDiseases (GEISESP) on the opinion of prison doctors concerning the suitability of undertaking or not undertakingcontrols of HIV infection in prisons and about the difficulties, efforts, needs and responsibilities that this activity may involve.This study was carried out in 2007 using an ad hoc survey designed and sent to doctors at 73 prisons in Spain. 116valid questionnaires were received. It was considered that the data received could be applied to the whole population with alevel of trust of 95% and an 8% margin of error. Half the doctors referred to prescribing antiretroviral treatments, thoughonly 10% admitted prescribing rescue combinations. It should be noted that only of half the doctors consider themselves tobe appropriately prepared to deal with patients infected by the HIV virus, though half of them admit to having received specific postgraduate training on this subject. Generally speaking, doctors consider that the quality of the health care receivedby the HIV-infected population is quite good (AU)

Características y situación clínica de la población reclusa infectada por el VIH de los centros penitenciarios españoles / Characteristic and clinicla situation of the HIV infected inmate population in spanish prision

Objetivos: Conocer características sociodemográficas/clínicas de los presos VIH +Pacientes y Método: Estudio observacional de tipo transversal. Se selecciona a los 25 primeros pacientes de 8 CentrosPenitenciarios que pasaron consulta un día designado de julio de 2003. Se analizan 199 pacientes.Resultados: El 76,4% llevan ingresados en prisión más de 3 años. Presentan antecedentes UDI el 92,5%. Un 21,6% (47)refieren consumo actual de heroína y/o cocaína. En tratamiento con metadona están 132 (66,3%). 32 pacientes han padecidoTBC y el 35,2% ITL. 178 de 193 (92%) presentaban anticuerpos de VHC, 150 de 189 (79,3%) presentaban HBC Ac. positivo.11 de 186 (5,9%) HBSAg positivo. De 178 pacientes coinfectados por VHC, tienen realizada PCR de virus C 65 (36,5%)y es positiva en 62 (95,4%). Cumplen criterios de SIDA 44 (22,3%). 32 (16,8%) presentaban CD4<200. La media de CD4 esde 443,3 (±251,0). 110 (55,3%) han recibido algún TARV. 106 (54,8%) reciben TARV actualmente y de los 192 que tienenrealizada una CV de VIH en 82 (42,7%) es < 400.Conclusiones: El control de la infección VIH es correcto en el medio penitenciario, presentando los pacientes una buenasituación clínica de media. Es necesario el establecimiento de programas para el control y tratamiento de las hepatitisvirales (AU)

Background: We set out to establish the socio-demographical and clinical characteristics of HIV infected inmates. Patients and Methods: Cross-sectional observation study. The first 25 patients in 8 diffferent prisons were selected during surgery time on a designated day in July 2003. 199 patients were analysed. Results: 76.4% had been in prison for more than 3 years. 92.5% had an IDU history. 21.6% (47) required consumptionof heroin and/or cocaine at the time. 66.3% (132) were receiving methadone treatment. 32 patients had TB and 35.2% LTI.178 out of 193 (92.2%) had HCV antibodies, 150 out of 189 (79.4%) were HBC Ac positive. 11 out of 186 (5.9%) were HBSAgpositive. Out of the 178 HIV co-infected patients, 65 (36.5%) carried out PCRof virus C and were positive in 62 cases(95.4%). AIDS criteria were complied with in 44 cases (22.3%). 32 (16.8%) showed CD4<200. The CD4 mean was 443.3(± 251.0). 110 (55.3%) had received some type of ARVT. 106 (54.8%) were receiving ARVT at the time and out of the 192 thathad recived an HIV VC the result was <400 in 82 (42.7%) of them (AU)

Prevalence of HIV-1 drug resistance mutations among Spanish prison inmates.

The aim of this cross-sectional study was to analyse the prevalence of HIV-1 drug-resistance mutations among HIV-1-infected prison inmates in Spain. Treatment-naive and treatment-experienced patients with an HIV RNA viral load of >/=2,000 copies/ml were included. To ensure that the study population was representative of the entire HIV-infected Spanish inmate population, a two-stage conglomerate for selection of the sample was used. In the first stage, 15 prisons were randomly selected, and in the second stage, 38 patients (30 treatment-experienced and 8 treatment-naive) per centre were randomly selected. Genotyping was performed by automatic sequencing. Resistance testing was performed on viral strains from 184 inmates from 12 prisons. Valid sequences were obtained from 133 inmates (90 treatment-experienced and 43 treatment-naive inmates). Most (92.5%) were men and had acquired HIV infection by intravenous drug use (91%); their mean age was 35 years. One or more key resistance mutations were detected in 5 (11.6%) treatment-naive and in 35 (38.6%) treatment-experienced patients. Among treatment-naive and treatment-experienced patients, resistance to nucleoside reverse transcriptase inhibitors was found in 3 (6.9%) and in 20 (22.2%) patients, respectively, resistance to non-nucleoside reverse transcriptase inhibitors in 3 (6.9%) and in 21 (23.3%) patients, and resistance to protease inhibitors in 3 (6.9%) and in 14 (15.5%) patients. Multidrug resistance was detected in 1 of the 43 (2.3%) treatment-naive patients. These findings support the use of resistance testing in HIV-infected inmates who must begin antiretroviral therapy, given the high rate of primary resistance to drugs frequently included in the initial treatment regimens.

Características y situación clínica de la población reclusa infectada por el VIH de los centros penitenciarios españoles / Characteristics and clinical situation of the HIV infected inmate population in spanish prisons

Objetivos: Conocer características sociodemográficas/clínicas de los presos VIH +Pacientes y Método: Estudio observacional de tipo transversal. Se selecciona a los 25 primeros pacientes de 8 Centros Penitenciarios que pasaron consulta un día designado de julio de 2003. Se analizan 199 pacientes.Resultados: El 76,4% llevan ingresados en prisión más de 3 años. Presentan antecedentes UDI el 92,5%. Un 21,6% (47) refieren consumo actual de heroína y/o cocaína. En tratamiento con metadona están 132 (66,3%). 32 pacientes han padecido TBC y el 35,2% ITL. 178 de 193 (92%) presentaban anticuerpos de VHC, 150 de 189 (79,3%) presentaban HBC Ac. positivo. 11 de 186 (5,9%) HBSAg positivo. De 178 pacientes coinfectados por VHC, tienen realizada PCR de virus C 65 (36,5%) y es positiva en 62 (95,4%). Cumplen criterios de SIDA 44 (22,3%). 32 (16,8%) presentaban CD4<200. La media de CD4 esde 443,3 (±251,0). 110 (55,3%) han recibido algún TARV. 106 (54,8%) reciben TARV actualmente y de los 192 que tienen realizada una CV de VIH en 82 (42,7%) es < 400.Conclusiones: El control de la infección VIH es correcto en el medio penitenciario, presentando los pacientes una buena situación clínica de media. Es necesario el establecimiento de programas para el control y tratamiento de las hepatitis virales

Background: We set out to establish the socio-demographical and clinical characteristics of HIV infected inmates.Patients and Methods: Cross-sectional observation study. The first 25 patients in 8 diffferent prisons were selected during surgery time on a designated day in July 2003. 199 patients were analysed.Results: 76.4% had been in prison for more than 3 years. 92.5% had an IDU history. 21.6% (47) required consumptionof heroin and/or cocaine at the time. 66.3% (132) were receiving methadone treatment. 32 patients had TB and 35.2% LTI. 178 out of 193 (92.2%) had HCV antibodies, 150 out of 189 (79.4%) were HBC Ac positive. 11 out of 186 (5.9%) were HBSAg positive. Out of the 178 HIV co-infected patients, 65 (36.5%) carried out PCRof virus C and were positive in 62 cases (95.4%). AIDS criteria were complied with in 44 cases (22.3%). 32 (16.8%) showed CD4<200. The CD4 mean was 443.3 (± 251.0). 110 (55.3%) had received some type of ARVT. 106 (54.8%) were receiving ARVT at the time and out of the 192 thathad recived an HIV VC the result was <400 in 82 (42.7%) of them.Conclusions: Controls of HIV were adequate for the prison population. Inmates showed a good mean clinical condition. The establishment of viral hepatitis control and treatment programs are necessary

Documento de consenso sobre el diagnóstico y tratamiento de la hepatitis C crónica en el medio penitenciario / Spanish consensus guideline about chronically hepatitis C diagnostic and treatment in the prison environment

La proporción elevada de internos con HCC en los CP españoles, sumado al alto porcentaje de coinfección por el VIH y el aumento progresivo de la esperanza de vida en los pacientes con infección por el VIH, hacen pensar que la incidencia de enfermedad hepática grave (EHG) asociada a VHC aumentará de forma progresiva en los próximos años en el medio penitenciario. Por ello hemos planteado este documento de consenso para el diagnóstico y tratamiento de la hepatitis C en las prisiones españolas, con la colaboración de expertos de diferentes sociedades científicas, siguiendo la metodología del NIH Consensus Statements(http://consensus.nih.gov/about/process.htm)

In Spanish prisons the incidence of serious liver illness associate to HCV, will increase in the next years because the high proportion of Hepatitis C in inmates, the high percentage of co-infected people by the HIV, and the progressive growth of life expectancy in patients with HIV infection. This consensus document for diagnosis and management of the hepatitis C, is presented with the experts contribution of different medical scientific Spanish societies using the methodology of the NIH Consensus Statements. (http://consensus.nih.gov/about/process.htm)

Estudio sobre el uso de antibióticos en infecciones respiratorias en el Medio Penitenciario / Study of the antibiotic treatments used for respiratory infections in prison’s settings

Se ha realizado un estudio descriptivo de los tratamientos antibióticos prescritos en las infecciones respiratorias en el medio penitenciario, así como de los medios diagnósticos que se usan y la evolución de estas infecciones. Se solicitó a 14 médicos de distintos centros penitenciarios distribuidos por toda España y cubriendo los diversos tipos de centros existentes siguiendo el modelo de médicos centinela, que cumplimentasen una encuesta diseñada para este estudio.Los resultados indican que los grupos farmacológicos de penicilinas y macrólidos suponen el 98,5% de las prescripciones en las infecciones respiratorias de vías altas tratadas, el 84,0% de las prescripciones en infecciones de las de vías bajas y el 33,3% en las neumonías típicas. Por otra parte las pautas de prescripción se acomodan notablemente a las recomendadas por guías de prescripción de atención primaria

A descriptive study of the antibiotic treatments used for respiratory infections in prison’s settings was done. The evolution of these infections and diagnostic techniques were also investigated. 14 doctors of the same number of prisons from all over Spain aswered a questionnaire specifically designed for this study. The selection of doctors was done following the methodologyof sentinel netwoks.Our results show that peniciles and macrolids are used in 98,5% of treated high respiratory tract infections, 84% of treated low respiratory tract infections and 33,3% treated pneumonias. Finally we observed that the used of antibiotics agree with the published guidelines for primary health care

Informe CAPRI sobre la calidad de la asistencia sanitaria en centros penitenciarios españoles / CAPRI report on the quality of health care in spanish prisons

Este artículo describe un estudio realizado mediante la técnica del Grupo Nominal con la finalidad de identificar y priorizar problemas de calidad asistencial en las prisiones españolas. La Sociedad Española de Sanidad Penitenciaria creó una serie de grupos de trabajo compuestos por médicos/as y enfermeros/as de prisiones, que contestaron una lista de problemas u oportunidades de mejora de calidad de la asistencia sanitaria de las personas recluidas. En este estudio han participado un total de 67 profesionales representando a 57 diferentes prisiones españolas. Se describen oportunidades de mejora estructurales que fueron principalmente la priorización de lo regimental frente a los asistencial, la escasez y desmotivación de los profesionales y la descoordinación con la red asistencial extrapenitenciaria, entre otras. Mientras que en área de los procesos, los tres problemas más frecuentemente descritos fueron: un inadecuado seguimiento de los pacientes con VIH y TBC, la cumplimentación insuficiente de los registros clínicos y la falta de implicación de algunos profesionales en su trabajo (AU)

Integración de la Sanidad Penitenciaria. Perspectivas de futuro

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