Year : 2007 | Volume
: 52 | Issue : 2 | Page : 78--82
Sexually transmitted infections in India: Current status (except human immunodeficiency virus/acquired immunodeficiency syndrome)
Devinder Mohan Thappa, Sowmya Kaimal
Department of Dermatology and STD, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry - 605 006, India
Devinder Mohan Thappa
Department of Dermatology and STD, JIPMER, Pondicherry - 605 006
Sexually transmitted infections (STIs) are more dynamic than other infections prevailing in the community. It is important that such dynamic epidemiological changes in STIs are acknowledged and kept track of in a vast and populous developing country like India, particularly in this HIV era. It is with this aim that the authors have reviewed the relevant literature in STI epidemiology in India during the past 25 years. Admittedly, there has been heterogeneity of data to account for the subcontinental dimension of this country. But a basic pattern in the changing epidemiology is discernible. Like the developed countries, in India too the bacterial STIs like chancroid and gonorrhea are declining, while viral STIs like HPV and herpes genitalis are on an upswing. The overall decline in the prevalence of STIs has to be interpreted with caution, however. This may partially reflect the improved facilities of treatment in the peripheral centres that obviates the need of many patients in attending the STD clinics in the tertiary centres. Also, the improved pharmacotherapy of many of the bacterial STIs may result in partial clearance and non-reporting of many of these infections.
|How to cite this article:|
Thappa DM, Kaimal S. Sexually transmitted infections in India: Current status (except human immunodeficiency virus/acquired immunodeficiency syndrome).Indian J Dermatol 2007;52:78-82
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Thappa DM, Kaimal S. Sexually transmitted infections in India: Current status (except human immunodeficiency virus/acquired immunodeficiency syndrome). Indian J Dermatol [serial online] 2007 [cited 2020 Nov 23 ];52:78-82
Available from: https://www.e-ijd.org/text.asp?2007/52/2/78/33283
The older terminology of "venereal diseases" (VDs) largely has been superseded in the past 50 years by "sexually transmitted diseases" (STDs), and more recently by "sexually transmitted infections" (STIs).  To some, venereal diseases came to be viewed as a narrow and pejorative term limited to gonorrhea, syphilis, chancroid, lymphogranuloma venereum, and granuloma inguinale, and related VD control laws. The term sexually transmitted diseases more easily incorporate the many newly discovered sexually transmitted agents and syndromes. , STD include diseases that are transmitted by sexual intercourse. Sexual transmission requires the agent to be present in one partner, the other partner to be susceptible to infection with that agent and that the sex partners engage in sexual practices, which can transmit the pathogen. STIs differs from STD in that STD conventionally includes infections resulting in clinical diseases that may involve the genitalia and other parts of the body participating in sexual interaction e.g., syphilis, gonorrhea, chancroid, donovanosis, nongonococcal urethritis, genital warts, herpes genitalis etc. STI, in addition, includes infections that may not cause clinical disease of genitals, but are transmitted by sexual interaction e.g., all STD and hepatitis B, human immunodeficiency virus (HIV), HTLV-1 etc. Nowadays, the term STI is preferred, since it covers all the diseases that can be transmitted by sexual intercourse. However, for all practical purposes, both STI and STD terms are used synonymously. 
STIs are more dynamic than other diseases prevailing in the community.  Their epidemiological profile varies from country to country and from one region to another within a country, depending upon ethnographic, demographic, socioeconomic and health factors. The clinical pattern is also a result of the interaction among pathogens, the behaviors that transmit them and the effectiveness of preventive and control interventions.
STDs remain a major public health challenge in the United States.  While substantial progress has been made in preventing, diagnosing, and treating certain STDs in recent years, CDC estimates that 19 million new infections occur each year, almost half of them among young people aged 15 to 24. Chlamydia remains the most commonly reported infectious disease in the United States. It is estimated that there are approximately 2.8 million new cases of chlamydia in the United States each year. The increases in reported cases and rates are likely to reflect the continued expansion of screening efforts and increased use of more sensitive diagnostic tests; however, this trend may also reflect an actual increase in infections. Women, especially young women, are hit hardest by Chlamydia and the long-term consequences of untreated disease are much more severe for women.
Gonorrhea is the second most commonly reported infectious disease in the United States.  Following a 74 percent decline in the rate of reported gonorrhea from 1975 through 1997, overall gonorrhea rates appear to have reached a plateau in recent years. Like chlamydia, however, gonorrhea is substantially under-diagnosed and under-reported, and approximately twice as many new infections are estimated to occur each year as are reported. African Americans remain the group most heavily affected by gonorrhea, with a rate in 2005 that was 18 times greater than the rate for whites. Ethnic minorities in the United States have traditionally had higher rates of reported gonorrhea and other STDs, which presumably reflect limited access to quality health care, poverty, and higher prevalence of disease in these populations.
The rate of primary and secondary syphilis-the most infectious stages of the disease decreased throughout the 1990s, and in 2000 reached an all-time low.  However, over the past five years, the syphilis rate in the United States has been increasing. Between 2004 and 2005, the national syphilis rate increased 11.1 percent, from 2.7 to 3.0 cases per 100,000 population. The syphilis rate among men is now nearly six times the rate among women, whereas the rates were almost equivalent a decade ago. Additionally, prior CDC research has estimated that more than half of syphilis cases in recent years have occurred among men who have sex with men (MSM). Although wide disparities persist, racial gaps in syphilis rates are narrowing. While syphilis rates remained substantially lower among females than males, rates among females increased for the first time in over a decade, with an increase of 12.5 percent from 2004 to 2005.
In Europe, data on Chlamydia often reflect testing patterns and not true incidence rates.  It is primarily transmitted among young people and is probably the most common STD all over Europe. Estimates indicate that 70-75% of women infected with Chlamydia trachomatis are symptom-free. 
Like Chlamydia infection, gonorrhea also often goes undetected, especially in women.  Significant decreases in the incidence of gonorrhea have been noted in all regions of Europe since 1980, and the disease is now mainly seen in young homosexual men, highly sexually active individuals and socio-economically deprived communities. In the last 8-10 years, a parallel trend has been noted for gonorrhea and HIV infection, reflecting a common mode of transmission, and similar risk groups for both infections.
The incidence of syphilis decreased dramatically during the 1980s, stabilized in the 1990s, and has recently increased since 1999/2000.  This increased incidence may be attributable to better surveillance systems and case detection. Episodic outbreaks of syphilis occur in certain high-risk populations, such as men who have sex with men (MSM), commercial sex workers and drug users.
Very few European countries routinely collect data on herpes simplex and human papilloma virus infections.  Of the countries that report to the WHO, high levels of incidence (20-70/100 000) have been reported over the last five years in the United Kingdom and the Russian Federation, among others. The highest levels of HPV infection have been reported in the United Kingdom (80-120/100000) and Ireland (100/100000) in 2000. Recently, several outbreaks of lymphogranuloma venereum have been noted in several countries, including Europe, the United States and Canada. It is primarily reported in MSM, among whom the majority is HIV positive.
Current Trends in India
STDs constitute a major public health problem for both developing and developed countries. The emergence of HIV infection has increased the importance of measures aimed at control of STDs. A proper understanding of the patterns of STDs prevailing in different geographic regions of a country is necessary for proper planning and implementation of STD control strategies. It is with this aim that the authors have reviewed the relevant published literature from India over the past 25 years.
In the year 1987, a retrospective, data analysis of sexually transmitted diseases was carried out to study the pattern of these diseases in a tertiary care center in Chandigarh.  One thousand five hundred and seventy one patients were seen from January 1977 to October 1985. Males constituted 95.5% of this group and females the remaining 4.5%. Commonest age group affected was 20-29 years in both sexes. Condyloma acuminata was the commonest STD (21.40/o), followed by gonorrhea (16.9%), chancroid (12.2%), genital herpes (11.4%), syphilis (10.4%), non-specific ulcers (7.1%), donovanosis (6.3%), mixed infections (5.3%) and NSU (4.1%). What was obvious from this study is that viral STDs have started showing their dominance in an otherwise dominant bacterial STDs scenario. But if we look at the scenario of STDs in and around Udaipur,  the relative incidence of chancroid was found to be higher (37.7%) than syphilis (32.4%), followed by gonorrhea (24 7%) mixed infections (3.38%), donovanosis (1.1%) and lymphogranuloma venereum (0.3%) in 1093 STD cases attending this clinic in the past 10 years. Here bacterial STDs were still common.
Moving on to another state, at Cuttack in Orissa, 516 patients with STD were analyzed during the period 1993 to 1994.  Herpes genitalis (21.89%) was found to be the commonest STD followed by syphilis (16.27%), chancroid (11.82%) and granuloma inguinale (7.55%), gonococcal urethritis and genital warts (3.87% each). LGV was found in 0.58% of cases, HIV infection in three cases only (0.56%). Other miscellaneous infections like candidiasis (13.75%), trichomoniasis (2.7%) and molluscum (2.14%) were responsible in 18% as a whole and nonspecific infection in 14%. Look at the trends of STDs at Vadodara, Gujarat  and they seem to be similar to that recorded at Cuttack. In the year 1995-96, 460 (2.45%) STD cases were recorded in this center. Frequency of different STDs observed in descending order was herpes genitalis (28.82%), gonorrhea (8.26%), granuloma inguinale (0.43%) and genital wart (8.9%). Other miscellaneous infections like candidiasis, trichomoniasis and molluscum constituted 18.47%. No HIV case was detected.
The relation between STDs and risk of HIV infection has been a subject of increasing interest. Hence, a study was conducted in the STD clinic of the department of dermatology and STD, JIPMER, Pondicherry, south India, between January 1993 and December 1997, to estimate the incidence of different STDs and frequency of HIV seropositivity among various STDs.  The patients were from the neighboring Tamil Nadu state and Pondicherry itself. The study group consisted of all new consecutive STD cases having high-risk behavior and/or having present or past history of STDs, irrespective of their age and sex. Out of the 1110 patients recorded, 168 were seropositive for HIV, giving a prevalence rate of 15.14%. Annual breakdown revealed an upward trend from 8.6% in 1993 to 23.52% in 1997. The mean age of the group was 29.8 years, with a male to female ratio of 3.63:1. When the STDs were broadly classified into ulcerative and nonulcerative groups, the prevalence of HIV was much higher in the group with ulcerative STDs (17.1%) than those with nonulcerative STDs (9.5%). Genital herpes was the commonest STD followed by syphilis, condyloma acuminata and others; 9.4% of the patients had concurrent infection with more than one STD.
A retrospective data analysis of one thousand STD patients from 1994 to 1998 at Medical College, Trivandrum was carried out.  Males constituted 61.1% and females 38.9% in the study. The commonest STD was syphilis, both in men and women, followed by herpes genitalis and condylomata acuminata. The prevalence of herpes genitalis and condylomata acuminata showed an increase with a definite decline in the prevalence of gonorrhea. HIV was detected in 3.2% of the patients.
A retrospective data analysis was carried out to find the trends in frequency and distribution of different STDs in North Eastern (NE) India during 1995-1999.  The commonest STD was chancroid (25.7%) followed by condylomata acuminata (CA), nongonococcal urethritis (NGU), lymphogranuloma venereum (LGV), syphilis, gonorrhea (GONO), herpes genitalis (HG), mixed infection (MI) and balanoposthitis (BP). HIV infection accounted for 9.62% of the total STD patients. A comparison of the present data with that reported a decade back (1986-1990) revealed a sharp decline in the incidence of syphilis, chancroid and GONO, whereas a conspicuous upward trend in CA and NGU. Similarly, a retrospective study was undertaken from the year 1988 to 1998 to study the pattern of sexually transmitted diseases in and around Lucknow.  Among 1890 patients examined, chancroid predominated followed by syphilis, gonorrhea, genital warts, herpes genitalis, LGV and nonspecific urethritis. The incidence of donovanosis was the lowest.
In a recently published study, data of 686 patients with STDs was studied to find the pattern of STDs and to analyze the changes during a ten-year period from 1990 among patients attending Medical College Hospital, Kottayam.  There were 504 males and 182 females in the total of 686 patients. Marital contact alone was reported by 123 (67.6%) female patients. Genital ulcer diseases (GUDs) accounted for the maximum number of STDs, with 504 cases (73.5%), followed by condylomata acuminata (17.5%) and gonorrhea (10.1%). Forty-three patients had multiple infections. The total number of patients during the first year of study was 129, while it was 41 during the last year. Bacterial STDs showed a striking reduction in numbers. The decline was less marked in the case of viral STDs.
Changing trends of the profile of STIs and HIV seropositivity in STD clinic attendees over a 15-year period at a Regional STD Centre in New Delhi were analyzed.  The STI profile and HIV seropositivity were compared between 1990-1993 (A), 1994-1997 (B), 1998-2001 (C) and 2002-2004 (D). Antimicrobial resistance pattern of N. gonorrhoae was determined by standard techniques and compared between the last three periods. Of the 78,617 STD attendees, 12,709 (16.2%) had STIs. During period A, genital discharges and during B, C and D, genital ulcerative diseases were predominant. Syphilis was the commonest STI. There was significant rise in the cases of syphilis, herpes genitalis and genital warts and reduction in that of chancroid, lymphogranuloma venereum (LGV), donovanosis, candidiasis, trichomoniasis and bacterial vaginosis cases. The number of cases with primary syphilis diminished significantly ( P  reviewed the changing patterns of different STIs (excluding HIV infection) in India and their various risk factors. It was observed that most of the published data are institution based. There is a paucity of community-based data, except for information obtained from high-risk groups such as commercial sex workers, truck drivers, hotel workers and drug abusers. From the literature search undertaken, it was observed that during the 1960s and 1970s, bacterial infections including syphilis, chancroid and gonorrhea were the major STIs, while viral infections caused by herpes simplex virus and human papillomavirus were so rare that they merited publication as case reports. As in developed countries, there has been a rise in viral and chlamydial infections and a relative fall in the incidence of traditional infections.
To sum up, bacterial STDs like chancroid and gonorrhea are showing a declining trend, but the viral STDs like herpes genitalis and condylomata acuminata are showing upward trend.  There is a decline in the number of patients with STDs attending the hospital. Whether this is due to an actual decrease in the incidence of STDs or due to other factors is uncertain. The increased availability of facilities for treatment of STDs at peripheral centers might be a factor leading to a decline in the number of patients with STDs approaching higher centers like the teaching hospital where this study was undertaken. The emphasis on the syndromic approach to the management of STDs might have increased the accessibility to healthcare for these patients with STDs. Awareness about HIV and fear of contracting the STDs are likely to have influenced the risk-taking behavior of people, thereby reducing the likelihood of being infected with STDs. Another factor to be considered is the widespread use of antibacterials, including quinolones and the new macrolides, for the treatment of other diseases. This can result in partial treatment or modified course of the bacterial STDs, thereby leading to apparent reduction in the total number of cases of STDs attending STD clinics as well as a decrease in the proportion of bacterial to viral STDs. The evident decline of the bacterial STDs with an apparent increase of the viral STDs is the trend worth noting.  A word of caution need to be exercised in the interpretation of the above data which is institution or tertiary care centre based, hence many of the changing patterns of STIs may not be true. Readers may use their expertise in interpretation of this data.
Donovanosis will be eradicated in several nations; but syphilis eradication will only be successful by 2020.  Gonorrhea, chlamydia, chancroid and trichomoniasis may also persist despite their curability. With the exception of hepatitis B, HIV and other blood-borne pathogens will continue to flourish until blood supplies and medical injections as well as illicit drug use and tattooing are made safe. Genitoanal warts and herpes will also persist and possibly increase, as may candidiasis, vulvovaginitis, bacterial vaginosis, balanitis, prostatitis, sexual assault and other forms sexual abuse. The problems of spreading HIV epidemic, drug resistance, poor health facilities and financial constraints are definitely a great hindrance in achieving the desired reduction in the incidence and prevalence of STIs. In India, the main strategy aimed at achieving effective management for people with established infections has been to integrate STD services into the existing health care system, with a special emphasis on integration at the primary health care level. Syndromic management is recommended by the National AIDS Control Organisation (NACO) for case management at this level.  The effectiveness of syndromic management in women is currently under debate.  The NACO is now also focusing on women reproductive health issues and involving gynecologists.
Vast numbers of people in India are severely disadvantaged in terms of income, education, power structures and gender.  Addressing these basic issues of human rights lies at the core of achieving better health outcomes  (including reproductive and infectious diseases) in India. Such a challenge is formidable in terms of its required scope and coverage, but lies at the heart of improving sexual health for the greatest number of people in India.
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