| Abstract|| |
Venereology-the study of venereal diseases or more recently, the sexually transmitted infections (STI) includes a variety of pathogens namely viruses, bacteria, fungi and protozoa for which the common factor is the mode of transmission and acquisition: Sexual relations between human beings. Medical and other historians have often suggested that well-known diseases such as syphilis, gonorrhea, chancroid and lymphogranuloma venereum have existed since earliest times. However, it is difficult to identify modern disease entities based on written historical record. Studying the origin of STIs helps us to learn the political, economic and moral conditions that led to the disease. Effective management of STI rests on three pillars of diagnosis, prevention and treatment. For most of past 50 years in India, the diagnostic pillar has been the least well-supported. Until well into present century, diagnosis of STI in India was clinical. Treatment of STIs in India followed the methods used in England. Of course in the 19th century, in many parts of the world, only a few had access to modern methods of treatment; in India, there was extensive use of Ayurvedic treatment with traditional medicines. This article thus gives just an overview and evolution of venereology in India with regard to venereal diseases (now more often known as STIs/disease), control measures, academic, association and journal development and finally future perspective.
Keywords: Control program, historical aspects, India, sexually transmitted infections/disease, venereal diseases, venereology
|How to cite this article:|
Thappa DM, Sivaranjini R. Venereology in India. Indian J Dermatol 2011;56:363-7
| Introduction|| |
Venereology-the study of venereal diseases or more recently, the sexually transmitted infections (STI) includes a variety of pathogens namely viruses, bacteria, fungi and protozoa for which the common factor is the mode of transmission and acquisition: Sexual relations between human beings.  The Webster's online dictionary rightly states- 'Venereology' is used about 13 times out of a sample of 100 million words spoken or written in English and ranks 97,576 as against 'Dermatology' which is used about 30 times ranking 63,341. This attitude toward venereology exists even within medical profession as among lay people. However, venereology is no longer considered unworthy of special study as its impact on morbidity, fertility and economy are being recognized in a wider horizon. This has led to the emergence of venereology as a distinct branch in the field of medicine. However, the word 'venereology' has been replaced over years with 'genitourinary medicine' and 'STIs/STD" over time. Obviously these names will be used more often as compared to 'venereal' which is now old or out of fashion.
Understanding the evolution of diseases, past successes and trends in various facets of venereology provides a better insight into the lacunae in this field and enables us to formulate dynamic policies toward the same.
| Arrival of STIS in India|| |
Medical and other historians have often suggested that well-known diseases such as syphilis, gonorrhea, chancroid and lymphogranuloma venereum (LGV) have existed since earliest times. However, it is difficult to identify modern disease entities based on written historical record. Studying the origin of STIs helps us to learn the political, economic and moral conditions that led to the disease.
Syphilis, known in India as Portuguese disease or firanga or firangi roga reached the subcontinent in early 16 th century and soon became widespread.  Spanish writers described Indians as lascivious and promiscuous. Untouched by Christianity, Indians were portrayed as incestuous savages whose lack of sexual control produced disease.  The British Army in India also deflected the blame for spread of disease from them and projected it onto distant people they hoped to conquer. The disease infliction in this group amounted to loss of effective manpower.
Authentic records of gonorrhea and chancroid in India can only be found during the British Empire in India, although it was decided to ignore the latter as not of public health importance in the run-up up to the Royal commission of 1916.  Historically, donovanosis, formerly called as granuloma inguinale was first recognized in Madras, India in 1881 by Kenneth Mc Leod, a Scot under the name of 'serpiginous ulcer'. The organism was identified by Colonel Charles Donovan and he described the intracellular 'Donovan bodies' in the exudates from an oral lesion of disease in a ward boy of general hospital in Madras.
In 1902, Caddy was the first to record cases of LGV in India under the title 'Climactic bubo', a disease that was thought to be due to climactic influences (mainly tropical). 
However, no description of genital warts, herpes genitalis and trichomoniasis is found in the comparatively modern Indian literature of early 20 th century. Genital herpes, which was recognized as a venereal disease as late as in 1966, is presently the most common STD in parts of India. Others like bacterial vaginosis are being recognized more often than ever and accounts for majority of infection (26%) among women attending reproductive health clinic in New Delhi in 2000. 
| Burden of STIS and trends|| |
Estimates of STI burden are less reliable in countries with less socioeconomic status because of lack of consistent survey and reporting methods.  The lack of good data and notification systems has often been overcome by prevalence studies. Such information is useful but limited since it is not totally representative of the population as it is obtained from atypical, high risk and usually consulting group of individuals and/or patients.  WHO estimated that approximately 340 million new cases of the four main curable STIs namely gonorrhea, chlamydial infection, syphilis and trichomoniasis occur every year, 75-85% of them in developing countries. 
Tracing the burden of STI in the years of Raj, The First World War and the years immediately following that recorded an increase in the STI rate, as expected during such war conditions. In 1912 the admissions to hospital for the treatment of venereal diseases were 52.0 per 1000 of strength, but by 1921 the figure had risen to 110.4.  In 1923 the levels of infection had reduced by 50% due to better social hygiene and prophylaxis. The proportion of syphilis to gonorrhea was much higher in Indian than in British troops; attributed to the fact that Indian soldiers made no use of prophylactic treatment rooms, which were particularly effective against syphilis.
Until the Second World war 1939-45 there was a decline in STIs in the armies, only to be followed by the resurgence of the problems. However, facilities for the treatment of common venereal infections were much improved. But, the civilian population continued to be badly served. With the departure of British troops after independence, the system for control of STI also weakened. The new Indian government did not prioritize STI control over other health needs. A report on prevalence of venereal diseases from different states in India between 1949 and 1958 showed syphilis to be the most common STI followed by gonorrhea, chancroid and other venereal diseases. In 1970, an estimate of incidence of STIs in India was around 8-10% of population. 
With the advent of HIV infection in 1986 among Madras sex workers in India, a changing trend in the profile of STI was observed. In a study on changing trends in STI in a Regional STD center in North India over a 15-year period (1990-2004), showed a gradual decline in the occurrence of new cases. During the initial study period genital discharge cases were higher; however, during the consecutive periods, genital ulcer diseases dominated. A significant rise in the cases of viral STIs and secondary and early latent syphilis contrasted with reduction in the rest. The association of HIV seropositivity was more in patients with genital ulcers. 
India continues to be the third largest contributor to the global HIV burden after South Africa and Nigeria. National adult HIV prevalence is 0.36%. The states with highest estimated prevalence were Manipur, Nagaland and Andhra Pradesh. The states with highest burden were Andhra Pradesh, Maharashtra, Karnataka and Tamil Nadu. Injecting drug use seems to be playing bigger role in India's epidemic than previously thought. 
| Trends in diagnostics of STI|| |
Effective management of STI rests on three pillars of diagnosis, prevention and treatment. For most of past 50 years, the diagnostic pillar has been the least well-supported.  Until well into present century, diagnosis of STI in India was clinical. Harrison, a bacteriologist recorded his examination of cervical smears from prostitutes in India in 1903. Culture of Neisseria More Details gonorrheae as a diagnostic aid was not at all used in India at this time. Darkground microscopy and Wassermann reaction were available after 1906, but technical problems and poor microscopy delayed their use in the army. Ultimately, when proper training in venereology started in 1910, microscopy and serology came into general use throughout the Empire.  Before this, many cases of early syphilis were either diagnosed as chancroid or missed altogether. To come to a diagnosis, doubtful atypical cases were at times left untreated to see whether or not they developed secondary syphilis. Non-gonococcal urethritis was common, but was not recorded in statistics then.
When microscopy became available, Gram-stained smear of an endocervical swab could be used to diagnose gonorrhea. Facilities for culture, antigen detection or nucleic acid amplification tests are available only in major urban centers in our country.
Clinically 'determined' etiological diagnosis in patients with STI syndromes is often incorrect. Efforts to alter this with less expensive point-of-care (POC) tests are underway but, currently with the exception of rapid HIV test, none is commonly used. And most POC tests are neither sensitive nor specific. Thus WHO STD Diagnostic Initiative (SDI) has developed the ASSURED criteria as a benchmark to decide if tests address disease control needs: Affordable Sensitive Specific User-friendly Rapid and robust Equipment-free and Deliverable to end-users.  Simple rapid tests such as Rapid Plasma Reagin (RPR) or Venereal Disease Research Laboratory (VDRL) tests are used for prenatal screening. But decentralization of antenatal screening is not possible at Primary health center level because of lack of facility to refrigerate the required reagents and lack of centrifuge to separate sera from whole blood.
There is still a vast need for simple, yet sensitive test for diagnosis of genital chlamydial and gonococcal infections. In resource-poor settings, the WHO recommends a syndromic approach to STI management because access to laboratory services is limited. The syndromic approach works well for men with urethral discharge and genital ulcers, but evaluations showed that the algorithm for vaginal discharge lacks both sensitivity and specificity for identification of women with Chlamydia trachomatis and Neisseria gonorrhea infection. 
It is seen that evaluation of performance of the diagnostic tests in developing countries is biased and is being used without proof of effectiveness. All this demand an urgent need to understand the obstacles to the use of diagnostics of STI in our country and thus enable better care and prevention of the same.
| Evolution in treatment of STI|| |
Treatment of STIs in India followed the methods used in England. Of course in the 19 th century, in many parts of the world, only a few had access to modern methods of treatment; in India, there was extensive use of Ayurvedic treatment with traditional medicines.  For gonorrhea, various urethral antiseptics were used; astringents like alum or zinc sulfate used in early days were replaced by silver nitrate or organic silver salts. Undoubtedly, many cases developed epididymitis and urethral stricture.  Later, Janet's method of urethral irrigation with dilute potassium permanganate was widely used until the advent of sulphonamides in the late 1930s, and penicillin in 1944 and subsequently better antibiotics.
The mainstay of treatment of syphilis in the 19 th century was mercury in the form of inunctions, injections of mercuric chloride or calomel or 'grey oil'. Most of the cases were under treated and ended up with destructive lesions affecting the face, mouth and nasopharynx.  Arspheniramine was introduced by Ehrlich in 1910 with promising results initially. But because of the pressure for men to return to duty early, shorter duration of treatment was given resulting in increasing relapse rates.
The treatment of chancroid remained unchanged throughout the duration of Raj, consisting simply of regular bathing of ulcers with antiseptic solutions. Inguinal abscesses were treated by incision and drainage, replaced later by aspiration which gave better results. 
| Prevention of STI/AIDS|| |
Prevention is the primary goal of all public health; more so with STIs as they can have deleterious effect on pregnancy and the newborn (such as miscarriage, prematurity, congenital and neonatal infections).  However, in the history of STI it is a neglected science as were the behavioral sciences. 
STI control measures in 19 th century revolved around regulation of prostitutes. The Contagious Diseases Acts were promulgated between 1864 and 1869, whereby prostitutes were subject to compulsory medical examination and if found infected were confined to a lock hospital for up to 3 months after which they were regarded as cured.  This policy was not implemented to protect women involved in sex trade from contracting disease, but to protect their clients alone.  Thus rehabilitation and assistance for prostitutes was forgotten. These sexual double standards aroused a public outcry from women's groups. Eventually the act was repealed in 1888 and a series of cantonment acts were enacted from 1889 onwards which allowed authorities to impose restrictions on individuals suffering from certain diseases. But this received opposition from medical profession as they thought that compulsory notification might lead to concealment of the infection, and thus defeat the objective of legislation. 
After 1900, levels of STIs in the army in India began to fall.  Apart from better treatment for syphilis, reasons stated for the fall were introduction of health education, emphasis on sports and other recreation and personal prophylaxis. A 'prophylaxis package' was allowed for British forces, although not for Indian ones, which had permanganate solution or silver salt for instillation into urethra, along with calomel ointment for use after intercourse. In 1916, 'venereal ablution rooms' were established in British army units, where this postcoital prophylaxis could be performed under supervision.
There were no control measures in India until 1949 when WHO sent a venereal disease demonstration team to establish a center for survey and mass treatment of syphilis in Himachal Pradesh. As a consequence of this, the percentage of seropositivity for syphilis fell from 40 to 45% in 1949-51 to 18% by 1959.  The team trained medical and paramedical personnel from different states in India and as a result, in 1953 alone 1,00,000 new cases of syphilis were identified and treated.
The Directorate General of Health Services took notice of the high incidence of venereal disease in the country and included certain measures for venereal disease control in first five-year plan. A full scale venereal disease organization came into existence in Himachal Pradesh along with a venereal disease training and demonstration center in New Delhi. In the second five-year plan, strengthening of state venereal disease organization with setting up of laboratories at headquarters of states, free supply of penicillin and training of health personnel were undertaken. In the third five-year plan, expanding existing facilities in view of improving epidemiological and health education with routine screening of pregnant women for syphilis and integration of venereal disease control program with existing public health services was done. The fourth five-year plan apart from setting up five-state headquarter venereal disease clinics, established four mobile units. Not until the threat of HIV/AIDS emerged in1980s, did governments begin to include systematic study of behavioral sciences in venereal disease control programs. The National AIDS Control Organization (NACO) was set up in 1992 and the National STD control program which was operational from 1946 came under the purview of NACO in 1992.  The Information, Education and Communication (IEC) programs came into being.
| Surveillance|| |
As is prevention, so is surveillance an important core in STI control. Although surveillance was a central part of STD control, the information generated by surveillance was not always used effectively. It has been said that for every single case that comes to light, there are atleast 20 or more undetected cases among public.  Contact tracing was impossible in circumstances prevailing in India under British rule.  Soldiers if they could remember who their contacts had been, refused to name them for fear that might be unregistered prostitutes, in which case they would be punished. A routine examination of servicemen for evidence of infection would have been useful because, even without laboratory tests, many STIs are easily identified in men than in women. However, this was ruled out on the grounds that it would destroy the men's self respect. The creation of WHO after Second World War with its division of STI has been the most beneficial development as far as it concerns resource poor countries as it recognized that the luxury of doctor led case finding method of managing these infections is not practical.  The notion of syndromic management has therefore been developed which apart from framing algorithms of care based on presenting symptoms and signs also incorporates counseling, education, condom use and partner notification.
| Evolution of academics, association and journal|| |
The Institute of Venereology in Madras Medical College was founded in the year 1952 and is thought to be the oldest venereology department in India.  Initially, though venereology was taught separately in India, but after independence, venereology developed along with dermatology in most parts of India.
The Indian Association for the Study of Sexually Transmitted diseases (IASSTD) came into existence in the year 1975. After the advent of AIDS in India, its name was changed to IASSTD and AIDS (1993). Since its formation, this association is organizing annual conferences. In 1980, this speciality, under the banner of IASSTD, started its own exclusive journal, the Indian Journal of Sexually Transmitted Diseases. The late Dr. Sardari Lal was its founder and editor and guiding force, who had already made a mark in the field of research, especially donovanosis. Dr. RC Sharma, Dr. Rishi Bhargava and Dr. YS Marfatia were the successors to Dr. Sardari Lal. The Indian Journal of Dermatology, Venereology and Leprology, the official journal of Indian Association of Dermatologists, Venereologists and Leprologists, actually evolved from Indian Journal of Venereology (a private publication of Dr. UB Narayan Rao in the year 1935).
| Future perspective and challenges|| |
Our population is so large that even low national prevalence of STI/HIV means many people are affected. During the past three decades, overall incidence of bacterial STIs have declined; however, there is an absolute increase in viral STIs, probably due to increased incidence of Herpes genitalis and genital warts. The magnitude of STI epidemics, including HIV demands a response to be based on research, dynamic policy making and intervention. The epidemic has ample scope for further growth if prevention efforts do not prevent onward transmission of HIV from drug injectors and the clients of sex workers to their other sex partners. But, introduction of new preventive and therapeutic interventions raises concern on potential for behavioral disinhibition. Added to this, emerging drug resistance may pose a problem. Thus we have to be equipped and self-sustained to face the challenges that may ensue and strive to make the vision of 2020 possible, which is a world with universal sexual healthy life style, as well as a world free of sexual ill-health. 
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