Research Article, J Womens Health Issues Care Vol: 5 Issue: 1
Prevalence and Pattern of Sexually Transmitted Infections/HIV among the High Risk Groups in Dakshina Kannada District (Rural), India
|Shreyaswi Sathyanath M1* and Rashmi K2|
|1Assistant Professor, Department of Community Medicine, A.J Institute of Medical Sciences, Mangalore, Karnataka, India|
|2Professor, Department of Community Medicine, K S Hegde Medical Academy, Deralakatte, Mangalore, Karnataka, India|
|Corresponding author : Shreyaswi Sathyanath M
Assistant Professor, Department of Community Medicine, A.J Institute of Medical Sciences, Mangalore, Karnataka, India
E-mail: [email protected]
|Received: May 30, 2015 Accepted: February 01, 2016 Published: February 05, 2016|
|Citation: Sathyanath SM, Rashmi K (2016) Prevalence and Pattern of Sexually Transmitted Infections/HIV among the High Risk Groups in Dakshina Kannada District (Rural), India. J Womens Health, Issues Care 5:1. doi:10.4172/2325-9795.1000217|
Introduction: Human Deficiency Virus and other sexually transmitted infections (STIs) often coexist and share common modes of transmission. High risk groups (HRGs) under National AIDS Control Programme in India include Female Sex Workers (FSWs), Men having Sex with Men (MSMs) and Intravenous Drug Users (IDUs).
Objectives: This study assessed the pattern of Sexually Transmitted Infections (STIs) among the high risk groups including Female Sex Workers (FSWs) and Men Having Sex with Men (MSMs) using the syndromic management approach.
Methodology: STI clinics were conducted on a monthly basis by a NGO working in 100 high risk villages in Dakshina Kannada district. These HRGs were treated using syndromic management for STIs and also provided referral to Integrated Counseling and Testing Centres (ICTCs) for HIV/ AIDS. Syndromic management is a comprehensive approach for STI/RTI control endorsed by the World Health Organization. A questionnaire was used to include the socio-demographic characteristics of HRGs and the diagnoses made. The data sheet did not contain any personal details, maintaining complete anonymity of the study participants. Statistical tests used were proportions to assess proportion and patterns; t-test for difference in proportions among the subgroups of HRGs.
Results: The most common diagnosis was vaginitis followed by urethritis, cervicitis, PID and inguinal bubo. The prevalence of STIs was significantly higher among FSWs than MSMs.
Conclusion: Sexually transmitted infections continue to persist in high risk groups and hence require sustained strategies for prevention under the framework of existing national programmes.
Keywords: Sexually transmitted infections; HIV/AIDS; Female sex workers; High risk
|Sexually transmitted infections; HIV/AIDS; Female sex workers; High risk|
|Human Immunodeficiency Virus (HIV) and other Sexually Transmitted Infections (STIs) are linked causatively (biological and behavioural) and it has been recognized that STIs facilitate the transmission of HIV . The importance of linking sexual and reproductive health (SRH) and HIV is widely recognized. The global strategy provides evidence that prevention and control of sexually transmitted infections are core aspects of sexual and reproductive health, and thus it complements the reproductive health strategy. Also, STI prevalence is a good marker for HIV, as both share common modes of transmission . To achieve Millennium Development Goals (MDGs), universal access to SRH and HIV prevention, treatment, care and support is essential .|
|Acquired Immune Deficiency Syndrome (AIDS) continues to be a major global health priority. Although striking gains have been made towards many of the 2015 targets and elimination commitments, significant challenges remain and India is estimated to have the third highest number of estimated people living with HIV/AIDS, after South Africa and Nigeria as mentioned in the United Nations (UN) Global report on AIDS 2013 . The epidemic in India is concentrated among High Risk Groups (HRGs) and heterogeneous in its distribution with different vulnerabilities in different parts of the country. The HIV prevalence among the HRGs is about 20 times higher than the general population. The primary drivers of HIV epidemic in India are commercial female sex workers (FSWs), unprotected sex between men who have sex with men (MSMs) and injecting drug users (IDUs). At national level, HIV prevalence is highest amongst the transgender population Followed by IDUs, MSMs at 6.82% and FSWs at 5.92%. HIV prevalence amongst IDU, MSM AND FSW is 14.92%, 10.31% and 9.48% respectively .|
|It is estimated that more than 340 million new cases of curable sexually transmitted infections, namely those due to Treponema pallidum (Syphilis), Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis, occur every year throughout the world in men and women aged 15-49 years, with the largest proportion in the region of south and south-east Asia . Sexually transmitted infections cause considerable mortality and morbidity in both adults and new born infants and amplify the risk of HIV transmission. They constitute a huge health and economic burden, especially for developing countries where they account for 17% of economic losses caused by ill-health.|
|Keeping in mind the interaction between HIV and other STIs as well as the higher burden of these among the High Risk Groups as defined by India’s National AIDS Control Program, we conducted a study aimed to assess the proportion of High Risk Groups who develop Sexually Transmitted Infections and pattern of such infections among these groups.|
Materials and Methods
|This was a community based cross-sectional study done in the rural areas of Dakshina Kannada district. The study population included India’s National AIDS Control Organization (NACO) defined High Risk Groups (HRGs) but excluding Intravenous Drug Users (IDUs). The core HRG of individuals who are most at risk for HIV include: Female sex workers (FSW); Men who have sex with men (MSM) and transgender (TG) and Injecting drug users (IDU) . Due to feasibility reasons, the population that was included in the study was Female Sex Workers (FSWs) and Men having Sex with Men (MSM) only. The general population and the vulnerable population who also attended the clinics were excluded from the study.|
|The data was collected from a Non-Governmental organization (NGO) that was working among the HRGs for HIV/AIDS. The organization was conducting STI camps with a specialist taking part in it in every high risk village, every month. These high risk villages were selected as per an initial survey based on the HIV prevalence among antenatal women, local leaders’ knowledge on high risk groups and focus group discussions among the known and identified HRGs. The NGO had divided the area into 4 clusters for operational feasibility. These were Mangalore taluk as Mangalore cluster, Bantwal taluk as Bantwal cluster, Belthangady taluk as Belthangady cluster and Puttur and Sulya taluks as Puttur/Sulya cluster. Each cluster had an almost equal number of high risk villages selected as per an initial survey which was done by some organization selected by NACO. Dakshina Kannada district had such 100 high risk villages out of which each cluster had around 25 (23 to 27) villages. We collaborated with the Project director of the NGO and attended the STI clinics to collect the data. All the HRGs who had attended the STI clinics which were conducted about 15 times a month for 1 year by a Nongovernmental Organization were included; these Female sex workers were identified by the link worker and the doctor (if necessary) as per the NACO guidelines. By record review we could see that in last 1 year around 410 HRGs had attended the STI clinic run by the NGO and formed our study sample.|
|This was an unlinked anonymous study and the data collected from the above mentioned STI clinics during the clinic attendance was analyzed. A questionnaire to include the socio-demographic characteristics of HRGs, diagnosis and patterns of STI based on Syndromic management scale, diagnosis of HIV based on ICTC was used. Syndromic case management (SCM) with appropriate laboratory tests is the cornerstone of STI/ RTI management. SCM is a comprehensive approach for STI/RTI control endorsed by the World Health Organization (WHO) . The data sheet did not contain any personal details, maintaining complete anonymity of the study participants. Statistical tests used were simple percentages to assess proportions and patterns and t-test for difference in proportion of subgroups of HRGs who developed STIs. Statistical analysis was done using SPSS software. Ethical clearance was obtained from the institutional ethics committee before starting the study.|
|Out of the 716 HRGs referred to STI clinics, 349 attended of which 286 (81.94%) were FSWs and 63 (18.05%) were MSMs. The majority of HRGs was in the 25-34 years age group (52.72%). More than half the FSWs were in the 25-34 years age group (52.09%). There was one FSW in the 55-64 years age group. More than half MSMs were also in 25-34 age groups (55.55%). Most of the FSWs (69.93%) were married, 64 (22.37%) were unmarried, 20 (7%) were widows while 2 (0.7%) were married but separated from their husbands. Most of the MSMs were unmarried (Table 1).|
|Table 1: Distribution of HRGs according to type, age and marital status.|
|Among the FSWs, 76.92% were also engaged in some occupation other than sex work. Maximum number of FSWs (80.9%) worked for daily wages. 12.69% of MSMs was unemployed. Most of the MSMs (30.09%) worked for daily wages. Majority of FSWs (35.66%) were educated up to middle school whereas 12.23% were uneducated. There were 5 graduates among FSWs. Among the MSMs, 38.09% were educated up to middle school. Two were graduates (3.2%) and four (6.3%) were uneducated (Table 1).|
|Out of the 716 HRGs referred, a total of 410 HRGs developed STIs out of which 349 were treated once and 61 were treated twice. Hence the proportion of HRGs with STIs was 57.26%, of which 348 FSWs (84.88%) and 62 MSMs (15.12%) developed STIs. There was a significant difference between the two proportions of HRG subgroups who developed STIs with standard error of difference between the two proportion (t test) = 4.99 and observed difference between two proportions=69.76 (p=0.05); since the observed difference is more than twice the standard error of difference, we concluded that there is evidence of difference in the proportion of the 2 subgroups of HRGs with STIs. Hence the observed difference is significant and not due to chance (Figure 1).|
|Figure 1: Proportion of HRGs with STIs (n=716).|
|Out of the 716 HRGs diagnosed with STIs, most of them were diagnosed with vaginitis (42.93% FSWs diagnosed with vaginitis), followed by urethritis (9.27% HRGs diagnosed), cervicitis (25.37% FSWs diagnosed), PID (22.68% FSWs diagnosed) and inguinal bubo (1.46% HRGs diagnosed). There were no HRGs with non-herpetic GUD and there was no data on herpetic GUD since there was no kit supply (Figure 2). Out of 716 HRGs referred to ICTC, 363 HRGs attended ICTC clinics (50.7%) out of which 274 were FSWs (75%) and 89 (25%) were MSMs. 1 FSW was positive for HIV (0.27%) and was referred to the ART centre.|
|Figure 2: Types of STI among HRG (percentage of HRGs with the diagnosis).|
|The present study found that most of the high risk group persons belonged to reproductive age group between 25-30 year age group which is similar to other studies . Majority of FSWs (35.66%) were educated up to middle school whereas the percentage of uneducated was low, which was in contrast to other studies in which FSWs were found be mostly illiterate and having never attended school [7,8]. However another study found varying rates of literacy among states in South India . Most of the FSWs (69.93%) were married in the present study which is similar to other studies [7,8,10]; however other studies have found varying patterns of marital status . The present study did not analyze what proportion of FSW/ MSMSs were still living with their spouse.|
|In our study, majority of FSWs were also engaged in some occupation other than sex work of which most of them worked for daily wages; this was similar to other studies ; the proportion of FSWs with an additional source of income was earlier found to be higher in southern states compared to their northern counterparts .|
|In the present study, proportion of FSWs with STIs was found to be 48.6% and most of them were diagnosed with vaginitis (42.93%). Similar observation was made in other studies too. An earlier study conducted among female sex workers in a red light area (RLA) in Surat stated that 41.5% of sex workers reported symptoms of STI and 44.1% had one or more clinical sign suggestive of an STI with the most common diagnosis being the abnormal vaginal discharge syndrome (VDS) at 51.7% . Yet another study of female sex workers found that genital discharge syndrome was the most common diagnosis and more interestingly this study also found that the rate of GDS had remained stable over a period of 10 years . The pattern of STIs in a study among female sex workers in South India was also quite similar to the present study with the most common syndrome being vaginal discharge . According to WHO, in syndromic management, the most common causes of vaginal discharge associated with vaginitis are Trichomoniasis by Trichomonas vaginalis and Candidiasis by Candida albicans whereas with cervicitis are Gonorrhea by Neisseria gonorrhoeae and Chlamydia by Chlamydia trachomatis. Urethritis is also most commonly caused by Gonorrhea and Chlamydia whereas Inguinal bubo is caused by LGV (Lymphogranuloma Venereum by C. trachomatis) and Chancroid by Haemophilus ducreyi .|
|VDS has been found to be the most common syndromic diagnosis in other settings and study populations too- women in reproductive age  and in a tertiary care setting in Delhi including both sexes . This study has not attempted to compare syndromic management with laboratory diagnosis since laboratory services were not provided in the STI clinic; however, several studies have found variable sensitivity and specificity levels of the algorithm across various STIs [8,14]. Provision of STI services is aimed at preventing HIV transmission; however, in this study, out of 716 referred to ICTC, only 363 attended ICTC clinics (50.7%). One of the important roles of link workers under the LWS is to raise awareness and generate demand for HIV/AIDS related health services. This finding points towards the importance of increasing acceptance of HIV testing among the HRGs especially among MSMs.|
|Though the WHO has laid down guidelines for syndromic management and this can be highly effective in infectious diseases, in some cases it may result in overtreatment resulting in wasted resources or antimicrobial resistance or in other cases under treatment where asymptomatic infection is common or clinical features are nonspecific in which cases diagnostic tests become essential. Since the results of this study are based on syndromic management, these limitations have to be kept in mind. One of the methods to increase accuracy of syndromic management is to combine this with laboratory tests where feasible, especially point of care diagnostic tests to increase acceptance and prevent delays in treatment; this also facilitates identification of main pathogens associated with the symptoms observed under the syndromic management .|
|High Risk Groups who suffer from STIs continue to remain high, which point towards the need for sustained emphasis on prevention strategies. The better education status and occupation other than sex work among FSW may be favorable factors for reduction in prevalence of both STI and HIV in terms of acceptance and awareness of prevention strategies. However, treatment seeking rates for HIV remain low, and this may necessitate further operational research into the factors influencing the effectiveness and bottlenecks of implementation of the national programme among the high risk groups.|
|We acknowledge the cooperation of Dr. Kishore Kumar, DAPCU Officer, Dakshina Kannada district.|
|This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.|