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CORRESPONDENCE
Year : 2011  |  Volume : 56  |  Issue : 2  |  Page : 239-241
Trend of sexually transmitted infections in HIV seropositive and seronegative males: A comparative study at a tertiary care hospital of North East India


Department of Dermatology and STD, North Bengal Medical College, West Bengal, India

Date of Web Publication5-May-2011

Correspondence Address:
Sabyasachi Banerjee
Department of Dermatology and STD, North Bengal Medical College, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.80441

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How to cite this article:
Banerjee S, Halder S, Halder A. Trend of sexually transmitted infections in HIV seropositive and seronegative males: A comparative study at a tertiary care hospital of North East India. Indian J Dermatol 2011;56:239-41

How to cite this URL:
Banerjee S, Halder S, Halder A. Trend of sexually transmitted infections in HIV seropositive and seronegative males: A comparative study at a tertiary care hospital of North East India. Indian J Dermatol [serial online] 2011 [cited 2020 Feb 17];56:239-41. Available from: http://www.e-ijd.org/text.asp?2011/56/2/239/80441


Sir,

World Health Organization estimated that approximately 340 million new cases of four main curable sexually transmitted infections (STIs), viz., gonorrhoea, syphilis, chlamydial infection, and trichomoniasis occur every year, nearly 80% of which in developing countries. [1] Moreover, the interest in STIs and their management have increased tremendously because of their proven role in facilitation of HIV infection. [2] which, in turn, also increases susceptibility to other STIs. Most of the STIs, both ulcerative and nonulcerative, are prevalent in India and constitute one of the major health problem. [3] The profile of various diseases is variable, depending upon the socioeconomic, cultural, geographic and environmental factors prevalent in different parts of the country. [4],[5] On the other hand, South Asia is currently home to more than 2.5 million HIV infected persons, 95% of whom are from India. [6] Incidence of various sexually transmitted infections has fluctuated over past several decades all over the world and shown some interesting long-term trends. In industrialized countries, the bacterial STI (syphilis, gonorrhoea, chancroid) declined from the peak during the Second World War till up to the late fifties, then increased during the sixties and early seventies, and they have been decreasing again from the late seventies till the present. In the industrialized world, diseases due to Chlamydia trachomatis, genital herpes virus, human papillomaviruses, and human immunodeficiency virus are now more important than the classical bacterial ones; both groups remain major health problems in most developing countries. [7]

However, not much data is available regarding the current trend of STIs in this part of the world, and how their epidemiological and clinical picture is being modified in the context of ongoing HIV/AIDS epidemic, especially during the last decade. Aim of the present work is to study the pattern of STIs among HIV positive and HIV negative male patients attending STI clinic and to observe whether there is any difference between these two groups. Consecutive male patients referred to STD clinic of North Bengal Medical college from the ART center (known HIV positives, either taking ART or under supervision) were taken up for history taking, clinical examination and laboratory examination. Two hundred of them who were diagnosed as suffering from STI were included in the study. Similarly, consecutive new male patients attending the STD clinic with unknown serological status were examined and sent for HIV antibody test with ELISA combo kit. First two hundred of them who were diagnosed as having STI but tested negative for HIV were taken up for study. The data on socio-demographic status and high-risk behavior were collected in predesigned performa. In our study, high-risk behavior was defined as practice of unprotected penetrative sex with multiple partners, exposure to commercial sex workers, or with individuals with STI. For diagnosis of STI in both the study groups, importance was given on history of high-risk activity. When that history was denied, cases were included only when there was very high index of clinical suspicion. VDRL test from blood sample was done in all cases. In cases of non-herpetic genital ulcer, Gram staining of smear from ulcer was done. Cotton swab from urthral discharge was collected from all patients with discharge and sent for gram staining to detect Gonococcus infection. The patients who showed urethral discharge of clinical examination but had no gram-negative diplococcus on gram-stained smear were diagnosed as having non-gonococcal urethritis. Dark ground illumination microscopy, herpes simplex virus-2 (HSV-2)- IgM ELISA, direct fluorescent antigen test for Chlamydia were not available in hospital set-up. All suspected cases of candidal balanitis were subjected to microscopical examination of KOH preparation. Among them, those showing fungal element on microscopy as well as having definite history of high-risk exposure was included in the study. CD4 + T-cell count was done in all HIV positive patients under study.

Mean age of patients in HIV positive group was 30.60 years (range: 16−54 years) and in HIV negative group was 27.75 years (range: 13−57 years). 50.5% of HIV positive men with STI were between 21 and 30 years of age while 47.5% of their HIV negative counterpart belonged to the same age group.

[Table 1] illustrates the number of different STI cases found in our study in both HIV positive and negative groups.
Table 1: Number of different STI cases in HIV seropositive and seronegative groups


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Among the STI cases in HIV positive patients, herpes genitalis was the commonest, followed by condyloma acuminata and non-herpetic genital ulcer. However, among the HIV negative patients, urethral discharge syndrome (gonococcal and non-gonococcal urethritis) occupied the first position, followed by non-herpetic genital ulcer and herpes genitalis. Among the patients suffering from herpetic genital ulcer, 84.7% (n = 50) in HIV positive group and 75.5% (n = 28) in HIV negative group gave a history of similar episode in the past. Ten patients in HIV positive group and six in HIV negative group were harboring two STIs simultaneously. Commonest combination in the first study group was herpetic genital ulcer and condyloma acuminata (four cases) and in the second study group, urethral discharge and candidal balanoposthitis (two cases).

The ratio of genital ulcer disease and urethral discharge was 3:1 in HIV positive group (99 cases versus 32 cases) and roughly 2:1 in HIV negative group (91 cases versus 47 cases). This difference is largely due to high rate of herpetic genital ulcer among HIV positive males. Herpes genitalis contributed to 28.09% and 17.96% of STI cases in HIV positive and HIV negative groups, respectively. Secondary syphilis was found to occur more often in HIV negatives than in HIV serpositives (P<0.01).

VDRL test was conducted in all the cases under study an overall, 26 cases of seropositive group and 31 cases of seronegative group had positive VDRL test report. Among the persons with non-herpetic genital ulcer, 29 were reported as VDRL positive (36.25%). However, among the patient with ulcers clinically resembling primary syphilis, VDRL positivity was much higher (65.7%). There was no significant difference between the HIV positive and HIV negative groups in terms of vdrl0 positivity in non-herpetic genital ulcer (36.8% and 35.7%, respectively). VDRL tested positive in all the cased of secondary syphilis in both groups. In the present study, 112 patients (56%) of the HIV positives group had viral STI, while 70 patients of the HIV sernegative group (35%) had the same. Hence, viral STIs occurred at a significantly higher rate among HIV seropositives compared to the seronegatives (P<0.0001). Among the viral STIs, the HIV positive group had significantly higher incidence of herpes genitalis (P<0.02), condyloma acuminata (P<0.03) compared to the HIV negative group. However, the same was not true for genital molluscum contagiousm (P>0.2).

The following table [Table 2] illustrates break up of STI cases in three subgroups of HIV positive patients according to their CD4 + cell count at the time of presentation.
Table 2: STI cases in three subgroups of HIV seropositive cases according to CD4+ T-cell level


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Among viral STI cases occurring in seropositives, CD4 + T cell count was below 200/cu.mm in 37 cases, between 200 and 500/cu.mm in 54 cases and above 500/cu.mm in 21 cases. Hence, viral STIs occurred at a higher frequency in patients with lower CD4 + count (P for trend = 0.02033178).

In our study, most of the STI cases belonged to 21-30 year age group. This is the sexually active group and at a high risk of being behaviorally more vulnerable to STI acquisition, as they generally have higher number of sexual partners and more concurrent partnerships and change partners more often than the older age group. [8] This is also the predominant age group suffering from STI in other Indian studies. [9],[10]

Khanna from Delhi reported that chancroid and genital herpes continued to be most common between 1981 and 1992, but since 1995, herpes was commonest followed by genital warts and syphilis. [11] A study from Chandigarh [12] reported genital warts as the predominant infection followed by gonorrhea, chancroid, genital herpes, and syphilis. O'farrell [13] showed that while GUD attributable to HSV-2 was increasing, that caused by bacteria was decreasing. Marked decline in bacterial STIs, resulting in an apparent increase of viral STIs over past 10 years or so was reported from Kerala. [10] In our study also, viral STIs constituted a large chunk of cases in both the study groups. Fifty-six percent of the HIV positives group and 35% of the HIV negative group had viral STI. Both herpetic genital ulcer and condyloma acuminata occurred more frequently in HIV positive patients compared to the HIV seronegatives. This is not surprising because the viral STIs not only have high infectivity but also tend to be reactivated frequently in persons with immunocompromised state. Herpes simplex virus infection is common in patients with acquired immunodeficiency syndrome, with a prevalence of 18%-27%. [14] In a recent Indian study, 23% of STI cases had herpetic genital ulcer on clinical examination while 30% had IgM antibody against HSV1 and 2 in blood. [15] This is close to the result of our study (28.09% in HIV positive group and 17.96% in HIV negative group, on clinical examination).

Candidal balanoposthitis was common in both the study groups and there was no significant difference in its incidence between two groups. This is a bit surprising because candidiasis is also supposed to follow the pattern of viral STIs. Probably, high incidence of candidal vaginal discharge among female sex partner, local factors like long prepuce, lack of hygiene played important role in its pathogenesis in our patients and hence seronegative patients were also frequently harboring this infection.

Though many cases of viral STI and candidiasis in HIV positive patients may be due to reactivation of previously acquired infection, number of preventable bacterial STIs is also quite large. 35.7% of total STI cases among them are due to bacterial infection and likely to have been recently acquired through high-risk sex practice. This fact is very alarming since these patients are known HIV positives, already counseled and under supervision of ART center. More care needs to be taken in order to inculcate safe sex practices and thereby reduce the incidence of preventable STIs in them, since intercurrent sexually transmitted infections are known to hasten the progress of HIV infection towards the stage of full blown AIDS. Moreover, STIs are sometimes difficult to diagnose and treat when it occurs as a co- infection with HIV.

 
   References Top

1.Global prevalence and incidence of selected curable sexually transmitted infection: Overviews and estimates. WHO/HIV-AIDS/2001-02. Geneva: World Health Organization; 2001.  Back to cited text no. 1
    
2.Wasserheit JN. Epidemiological synergy: Interrelationship between human immuno deficiency virus infection and other sexually transmitted disesases. Sex Transm Dis 1992;19:61-77.  Back to cited text no. 2
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3.Ray K, Bala M, Gupta SM, Khunger N, Puri P, Muralidhar S, et al. Changing trends in sexually transmitted infections at a regional STD center in North India. Indian J M Res 2006;124:559-68.  Back to cited text no. 3
    
4.Thapa DM, Singh S, Singh A. HIV infection and sexually transmitted diseases in a referral STD Centre in South India. Sex Trans Inf 1999;75:191-3.  Back to cited text no. 4
    
5.Khandpur S, Agarwal S, Kumar S, Sharma VK. Reddu BS. Clinico-epidemiological profile and HIV seropositivity of HIV patients. Indian J Sex Tansm Dis 2001;22:62-5.  Back to cited text no. 5
    
6.Joint United Nations Programme on HIV/AIDS/World Health Organization. Report on the global AIDS epidemic. Geneva: The Organization; 2006.  Back to cited text no. 6
    
7.De Schryver A, Meheus A. Epidemiology of sexually transmitted diseases: The global picture. Bull World Health Organ 1990;68:639-54.  Back to cited text no. 7
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8.Welling K, Nanchahal k. Macdowall W, McManus S, Erens B, Mercer CH, et al. Sexual behaviour in Britain early heterosexual experience. Lancet 2001;358:1843-50.  Back to cited text no. 8
    
9.Bairy I, Balachandran C, Shivananda PG. HIV seropositivity in STD clinic attendants. Ind J Sex Transm Dis 2001;22:6-9.  Back to cited text no. 9
    
10.Narayanan B. A retrospective study of the pattern of sexually transmitted diseases during a ten year period. Indian J Dermatol Venerol Leprol 2005;71:333-7.  Back to cited text no. 10
    
11.Khanna N. Sexually transmitted diseases in India. Indian J Sex Trans Dis 2002;232:58-66.  Back to cited text no. 11
    
12.Kumar B, Handa S, Malhotra S. Changing trend in sexually transmitted diseases in Chandigarh. Ind J Sex Transm Dis 1995;16:24-7.  Back to cited text no. 12
    
13.O'farrell N. Increasing prevalence of genital herpes in developing countries implications for heterosexual HIV transmission and STI control programme. Sex Transm Infect 1999;75:377-84.  Back to cited text no. 13
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14.Gilmore ES, Kulwichit W. Immunocompromised patients: Human immunodeficiency virus and non-human immunodeficiency virus positive. In: Arndt KA, Hsu JT, eds. Manual of Dermatologic Therapeutics. 7 th ed. Philadelphia: Lippincort Williams and Wilkins; 2007. p. 118-27.   Back to cited text no. 14
    
15.Choudhry S, Ramachandran VG, Das S, Bhattacharya SN, Mogha NS. Serological profile of HSV-2 in patients attending STI clinic: Evaluation of diagnostic utility of HSV-2 IgM detection. Indian J Pathol Microbiol 2009;52:353-6.  Back to cited text no. 15
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