Evaluation of risk factors in patients attending STI clinic in a tertiary care hospital in North India

Abstract

Background:

In the past few years, the interest in STDs and their management has increased tremendously because of their proven role in facilitation of HIV infection, which, in turn, also increases the risk of acquiring STIs. Sexually transmitted diseases (STDs) are a major health problem affecting mostly young people, not only in developing, but also in developed countries Male circumcision is being considered as strategy to reduce the burden of HIV/AIDS.

Aims:

(i) To screen the new patients attending the STI clinic for bacterial causes of STIs (Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum and Gardnerella vaginalis) and (ii) to evaluate the role of various risk factors in the prevalence of STIs.

Materials and Methods:

The present study was conducted on 200 patients attending the STI clinic. They were evaluated for the prevalence of HIV and bacterial STIs (Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum and Gardnerella vaginalis) along with the role of risk factors particularly circumcision.

Results:

The prevalence of HIV was 7% and prevalence of other STI was 20%. The causative agents were Chlamydia 8%, Gonorrhea 7.5%, Bacterial Vaginosis 2.7% and Syphilis 2%.

Conclusion:

The factors found to be significantly associated with the prevalence of STI were circumcision, positive HIV status, education, religion, multiple sexual partners, contact with Commercial sex workers (CSW), non use of contraception, profession involving long stay away from home, and past history of STI. The present study suggests that circumcision is a protective factor for acquisition of STIs but other factors like sexual behavior, use of barrier contraceptives, drug abuse etc., also play a role.

INTRODUCTION

Sexually transmitted diseases (STDs) are a major health problem affecting mostly young people, not only in developing, but also in developed countries (STDs).

STDs are not only a cause of acute morbidity in adults but also results in complications with sequelae such as infertility in both men and women, ectopic pregnancy, congenital abnormalities, low birth weight, prematurity etc.[1] In the past few years, the interest in STDs and their management has increased tremendously because of their proven role in facilitation of HIV infection, which, in turn, also increases the risk of acquiring sexually transmitted infections (STIs). It is estimated that, approximately 340 million new cases of the four main curable (STIs) viz., gonorrhea, chlamydial infection, syphilis and trichomoniasis occur every year worldwide and 75-85% of them occur in developing countries.[2]

Multiple epidemiological and behavioral studies in India demonstrate that due to large numbers of commercial sex workers, migrant labourers and a high prevalence of STDs, the Indian epidemic is spreading at a prolific rate.[3]

Male circumcision has been shown to be associated with STD acquisition. Many studies have been conducted but the results have been inconsistent.[4] Male circumcision is being considered as an HIV prevention strategy in countries where HIV/STI prevalence is high and circumcision prevalence is low.[5]

AIMS AND OBJECTIVES

This study was conducted (i) to screen the new patients attending the STI clinic for bacterial causes of STIs (Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum and Gardnerella vaginalis) and (ii) to evaluate the role of various risk factors in the prevalence of STIs.

MATERIALS AND METHODS

The study was conducted in the ICTC, Department of Microbiology and STI clinic, Department of Dermatology and Venereology, LHMC, from November 2011 to March 2013. A total of 200 cases of the age group, 15-49 years who visited the STI clinic during the study period were included in the study.

Specimens collected were blood, urethral swab, vaginal swab, endocervical and rectal swab (in cases with recent anal intercourse).

NACO guidelines (strategy III) were used for diagnosis of HIV. Chlamydia was diagnosed using commercially available one step rapid antigen detection kit (Standard Diagnostics, Inc., Korea) and antibody detection kit (IgM and IgG) (DRG Diagnostics, Germany), according to the manufacturer's guidelines. For the diagnosis of Gonorrhea, Gram stain was made and culture was done on chocolate agar. Syphilis was diagnosed using RPR (Span Diagnostics, India). A Gram stain was made for diagnosis of Bacterial Vaginosis using Nugent's criteria.

The circumcision status of males was observed and recorded in the proforma. For females, circumcision status of their male partner was recorded.

Statistical analysis of data was performed using SPSS software (version 20). P < 0.05 was considered as significant.

RESULTS

A total number of 200 patients were included in the study. Out of which, 128 (64%) were males and 72 (36%) females. The prevalence of STIs and HIV was 20% and 7% respectively. The most common diseases were Chlamydia 8% followed by Gonorrhoea 7.5%, HIV 7%, Syphilis 2% and Bacterial Vaginosis 1% [Figure 1].

Figure 1.

Distribution of cases with sexually transmitted infections

The prevalence of STI in circumcised cases (males and females with circumcised male partners) was found to be 14% as compared to 42.7% in uncircumcised cases.

Sexually transmitted infections were most common in the age group of 25-35 years. The factors found to be significantly associated with the prevalence of STI were illiteracy, religion, low Socio economic status, multiple sexual partners, contact with CSW, non use of contraception, profession involving long stay away from home and past history of STI [Figure 2 and Tables 1–3].

Figure 2.

Demographic factors affecting prevalence of Sexually transmitted infections

Table 1.

Factors affecting the prevalence of STIs Demographic factors

Table 3.

Other factors affecting prevalence of STIs

Table 2.

Sexual behaviors affecting the prevalence of STIs

Other factors studied were age, gender, marital status, drug and alcohol abuse. These factors were not found to be significantly associated [Tables 1–3].

DISCUSSION

Patients visiting the STI clinic constitutes a high risk group for acquisition of HIV and STIs. STI facilitate HIV transmission by breaching protective mucosal barriers and recruiting susceptible immune cells (eg, CD4 T-helper cells, macrophages) to the site of infection. STI also create portals of entry for HIV to access susceptible cells.[6] Thus, patients with STI have a higher prevalence of HIV as compared to the general population. This was seen in our study where the prevalence of HIV in patients attending STI clinic was found to be 7%. Patients with one of the STI had a significantly higher prevalence of HIV as compared to those who did not have any STI (P < 0.05).

In our study, the prevalence of STI in patients attending STI clinic was found to be 20% which was in concordance with the study conducted by Ray et al. in Delhi and Thomas et al. in Chennai who reported the prevalence of STI in STI clinic attendees to be 16.2%[2] and 14.6%, respectively.[7]

In the present study, the most common STIs in patients attending STI clinic was Chlamydia (8%), followed by Gonorrhoea (7.5%), HIV (7%), Syphilis (2%), Bacterial Vaginosis (1%).

Manju Bala et al. also reported the prevalence of gonorrhea to be 6% which is close to our prevalence of 7.5%,[8] Malhotra et al. reported the prevalence of Syphilis to be 1.8% and Gonorrhea 0.7% in females.[9] These results are also similar to our results. However, in a study at Kottayam by Narayanan the prevalence of Gonorrhoea was reported as 10% in STI attendees, which is higher than that found in our study.[10]

The role of circumcision in prevention of HIV/STIs is still controversial. Some studies have claimed that penile foreskin provides a portal of entry for pathogens, including HIV, as it is more susceptible to trauma during intercourse, the inner mucosa of the foreskin has less keratinization and a higher density of target cells for HIV infection,[11] moreover, the microenvironment in the preputial sac between the unretracted foreskin and the glans penis may be conducive to viral survival. All these factors support the role of circumcision in prevention of HIV/STIs. This was proven in our study where, the prevalence of STI and HIV was found to be 14% in circumcised cases and 42.7% in uncircumcised. This difference was statistically significant (P < 0.0001). This was in accordance with the study done by Gray et al., Bailey et al., Auvert et al. and Rodrigues et al.[12,13,14,15] The results of our study differed in studies done by Cook et al., Carael et al., Barongo et al., Chao et al. and Grosskurth et al. who found that lack of circumcision is not associated with risk of HIV and STI.[16,17,18,19]

Young adults of the age group 25-35 years, particularly unmarried males bore the brunt of the disease as this group is the most vulnerable for high risk sexual practices. Similar results were reported by Bala et al., Erbelding et al. and Malhotra et al.[8,9,20]

In the present study, it was found out that Muslims had a low prevalence of STI as compared to other religions. The ritual of circumcision may be one of the reasons for low STI prevalence in the Muslim population. Such distribution of data according to the religion is not available in studies conducted in India.

People having contacts with multiple partners and those visiting CSW constitute another high risk group for acquiring HIV and STIs. CSW are responsible for a major burden of STI in our country as they have a much higher exposure rate, harbor many asymptomatic or symptomatic STIs and people visiting the CSW tend to avoid usage of barrier contraceptive. In our study, a significant higher STI prevalence was found in people with history of contact with multiple partners or visiting CSW as compared to people with no such history (P < 0.05). Similar findings have been reported earlier by Thomas et al., Rodrigues et al. and Erbelding et al.[7,15,20]

A history of STI puts an individual at a higher risk of acquiring STI in future also. In our study, it was seen that people with a past history of STI had higher prevalence of STI as compared to people without a past history. (P < 0.05) This finding was similar to that reported by Rodrigues et al., who reported that people with a past history of genital ulcer (P < 0.001), genital discharge (P < 0.006) were at a significant higher risk of developing an STI in future.[15]

It is a known fact that barrier usage is protective for STIs and HIV. This was proven by our study, where, people who did not use barrier contraceptive had a higher prevalence of STI and HIV (37.5%) as compared to people who use barrier contraceptive. Similar findings had been reported earlier by Thomas et al. and Weller and Davis-Beaty.[7,21] Our study emphasize the fact that barrier usage should be promoted strictly in young population, especially those at high risk of developing STIs and HIV.

Other factors like substance abuse, profession involving long stay away from home, lack of awareness of HIV/STIs were also found to be associated with HIV/STIs acquisition.

Men who have sex with men (MSM) are a vulnerable population for the spread of HIV and STI. Most MSM has bisexual behavior and are responsible for spread of STIs to males as well as females. Apart from being important for HIV transmission, they tend to have a different distribution pattern of STIs. A large number of studies on STI profile of MSM are available from western world but they cannot be applied to Indian scenario because of social and cultural differences. Our study found the prevalence of STI in homosexuals to be 33.3% as compared to a 26.5% in heterosexuals. Similar findings have been reported by many other workers.[22,23] MSM constitute a high risk population and require strict target interventions to control the spread of HIV and STIs.

All the high risk groups need special intervention and should be provided with packaged awareness programmes on the risk and vulnerability to STIs/HIV.

Limitations to the study were that only bacterial STIs were included in the study, the results could not be applied to all the other causes of STIs. Although circumcision was found to be associated with reduced burden of disease, it cannot be taken as the only factor responsible. All other factors play a role such as sexual behaviors, use of barrier contraceptives, drug abuse etc. The sample size was also not large enough to prove the association correctly. Therefore, a large study should be done including larger sample size to evaluate the effect of all the risk factors. This study does suggest that circumcision may have a role in reducing the disease burden.

CONCLUSION

This study suggested that there is a strong need to screen the patients visiting the STI clinic for HIV and other STIs. The sexual behavior in this population put them at a high risk of developing an STI. Most important of them being multiple sexual partners, contact with CSW, non use of contraception, profession involving long stay away from home and past history of STI. Another important factor that needs to be studied in detail is circumcision. From this study we can conclude that circumcision is a protective factor for acquisition of STI and male circumcision may reduce the risk of STIs. However, at the same time it is also important to target all the other risk factors associated with STI. Safe sex practices and awareness regarding HIV and STIs should be promoted particularly in the high risk group. Sexual education and routine counseling should be made compulsory in all parts of the country to control the current burden of STIs.