Pattern of sexually transmitted infections in a Muslim majority region of North India.

BACKGROUND: Changing trends of sexually transmitted infections (STI) and HIV/AIDS has been noted in the literature over years, depending to some extent on the geographical and cultural factors of the region. In Kashmir Valley also, the pattern of STI may be different from the rest of the country. AIMS OF THE STUDY: The aim was to present the experience with patterns of STI in Kashmir.
MATERIALS AND METHODS: Retrospective hospital-based study carried out by detailed analysis of case records of 5-year period.
RESULTS: A total of 184 patients, 100 males and 84 females, had specific STI. Genital ulcer disease was the presentation in 54 patients (29.35%), out of which herpes genitalis was found in 27 patients (50%), followed by chancroid in 13 (24.07%) and syphilis in 10 (18.52%) patients. 42 female patients (22.83%) presented with vaginal discharge, out of which, 24 (57.14%) had vaginal candidiasis. 24 males (13.04%) presented with urethral discharge, out of which, 15 (62.5%) had nongonococcal and 9 (37.5%) gonococcal urethritis. Genital molluscum contagiosum (MC) was found in 19 patients (10.33%), and warts in 15 (8.15%). HIV positive serology was detected in 3 patients (1.63%).
CONCLUSION: The most common STI encountered in our study was genital ulcer, followed by vaginal discharge, urethritis, genital MC, and genital warts. Herpes genitalis was the commonest genital ulcer; candidiasis was the most common cause of vaginal discharge and nongonococcal urethritis the most common cause of urethritis. These findings are by and large similar to those noted in other parts of our country.

INTRODUCTION

Jammu and Kashmir is a state of low incidence and prevalence for sexually transmitted infections (STI) and HIV, especially the Muslim-majority Kashmir Valley. This may not be the actual situation on the ground, and low reported prevalence may be because of under-reporting or syndromic management at the primary healthcare levels.[1] Kashmir Valley has quite different geographical, cultural and religious conditions than the rest of India. Being a conservative society and Muslim majority region, the prevalence and patterns of STI may be different. So far no study in this regard has been undertaken in this part of north India. This encouraged us to undertake this retrospective study in order to evaluate the patterns and trends of STI in this part of the country, and present our experience along with a thorough review of the literature.

MATERIALS AND METHODS

Case records maintained in the STI clinic attached to the outpatient department (OPD) of our tertiary care center were retrospectively studied. The cases are mostly screened in the OPD and record maintenance is done in the STI clinic after a detailed history, clinical examination and relevant investigations. Case records of 5-year period, from 2009 to November 2013 were thoroughly studied. Data was collected, compiled and subjected to statistical analysis, wherever required.

RESULTS

Out of a total of 840 cases, 423 males and 417 females, referred to the STI clinic, 184 had specific STI after thorough case record analysis.

Out of 184 patients, 100 were males (54.35%) and 84 females (45.65%), with a male:female (M:F) sex ratio of 1.19:1.

Ninety-eight patients were married and 86 unmarried.

The age of patients ranged from a minimum of 3 years to a maximum of 65 years, with an average age of 29.97 years.

There were 34 patients (18.48%), 18 male and 16 female, in the age group ≤20 years and 121 patients (65.76%), 73 male and 48 female, in the age group 21–40 years. 27 patients (14.67%), 9 male and 18 female, were in the age group 41–60 years, and 2 patients (1.09%), all females in the age group ≥61 years.

There were 151 (82.07%) native Kashmiri (locals), 79 males and 72 females, and 33 (17.93%) nonlocals, 21 males and 12 females. Nonlocals included defense personnel, central government employees, skilled and unskilled workers, tourists, drivers, from outside the state, along with the family members of each group of occupations.

Among 151 locals, there were 143 Muslims (94.70%), 74 males and 69 females, and 8 non-Muslims (5.30%), 5 male and 3 female. Among the 33 nonlocals, there were 21 Muslims (63.64%), 10 males and 11 females, and 12 non-Muslims (36.36%), 11 males and 1 female.

All the patients denied of being homosexual or bisexual, and most denied having premarital or extramarital sexual contact. This may not be the actual fact, and denial could be just for the sake of avoiding further questioning and fear of embarrassment. No patient gave a history of drug abuse.

Regarding the occupations of the patients, 57 were housewives and those doing house hold work, 40 patients were students, preschool children and toddlers, 26 were skilled and unskilled workers and laborers, 18 were in defense services, 16 in civilian services, 11 were business men, 10 drivers, 4 farmers, and 2 tourist guides.

There was an increasing trend in the number of cases registered during the 5 years, when the year wise distribution is considered. During 2009, 2010, 2011, 2012, and till November 2013, number of cases registered were respectively 22, 24, 42, 47, and 49.

Genital ulcer disease was the presentation in 54 patients (29.35%). Out of these herpes genitalis was found in 27 patients (50%), chancroid in 13 (24.07%), syphilis in 10 (18.52%), lymphogranuloma venereum (LGV) in 3 (5.56%) and donovanosis in 1 (1.85%). Out of 10 patients of syphilis, 4 had secondary syphilis, 3 had primary chance, and 3 had latent syphilis. 2 female patients, one with latent and the other with secondary syphilis, were pregnant.

Forty-two female patients (22.83%) presented with vaginal discharge. Out of these, 24 (57.14%) had vaginal candidiasis, 10 (23.81%) had trichomoniasis, 4 (9.52%) had bacterial vaginosis, 2 (4.76%) gonococcal urethritis, and 2 (4.76%) mixed infection.

24 males (13.04%) presented with urethral discharge. Out of these, 15 (62.5%) had nongonococcal and 9 (37.5%) gonococcal urethritis.

Genital molluscum contagiosum (MC) was found in 19 patients (10.33%) [Figure 1], warts in 15 (8.15%) [Figure 2], and MC and warts together in 2 patients (1.09%).

Figure 1

Molluscum contagiosum on male (a) and female (b) genitilia

Figure 2

Verrucae (warts) on female genitilia

Pediculosis (pthirus) pubis was the presentation in 13 patients (7.07%) and genital scabies in 8 (4.35%). Candidal balanoposthitis and idiopathic scrotal swelling were found in 3 (1.63%) males each, and lower abdominal pain syndrome in one female (0.54%).

No patient in our study had >1 STI in the same patient.

HIV positive serology was detected in 3 patients (1.63%). 2 of these were local unmarried Muslim females, and both presented with vaginal candidiasis. One of these patients had received blood transfusion few years back. The third patient was a nonlocal married non-Muslim male working in defense force, who presented with recurrent herpes genitalis.

The details of patterns of STI are shown in Table 1.

Table 1

Details of the patterns of STIs

DISCUSSION

Sexually transmitted infections and sexually transmitted disease (STD) are sometimes used synonymously for diseases transmitted by sexual intercourse. STD includes infections that result in clinical diseases involving genitalia and/or other body parts, and STI, in addition, includes infections that may not cause clinical disease.[1]

In Kashmir Valley, prevalence of STI, STD and HIV/AIDS is low. No study has so far been conducted to evaluate the prevalence of STI in this region. Our retrospective study included 184 cases of specific STI of 5-year period, out of 840 cases referred to STI clinic. In a previous study of patterns of dermatoses in our center, STI accounted for 0.3% of dermatoses.[2] About 54.35% patients were males and 45.65% females, with M:F sex ratio of 1.19:1. Male predominance was in accordance with previous studies.[345]

Ninety-eight patients were married and 86 unmarried. More married patients were also found in the literature.[4]

Average age of patients in our study was 29.97 years, ranging from 3 to 65 years. Most of the patients, 65.76%, were in the sexually active age group of 21–40 years, followed by 18.48% ≤20 years and 14.67% in the age group 41–60 years. The predominant involvement of this age group was seen in previous studies in the literature as well.[356]

Among 151 locals, there were 143 Muslims (94.70%), and 8 non-Muslims (5.30%). Among the 33 nonlocals, there were 21 Muslims (63.64%) and 12 non-Muslims (36.36%). This is in accordance with the Muslim majority status of Kashmir Valley.

Genital ulcer disease was the commonest presentation found in 29.35% of patients. 50% of these had herpes genitalis, 24.07% chancroid, 18.52% syphilis, 5.56% LGV and 1.85% had donovanosis. Narayanan B also found genital ulcer more common than warts (condyloma acuminata), similar to other studies.[46]

Herpes genitalis was the most common (50%) among the genetic ulcers as found in previous studies.[57] Increasing trend of herpes genitalis has been found in other studies as well.[789101112]

Our study found good number of chancroid patients (24.07%), in accordance with some previous studies.[313] However, overall a decreasing trend for bacterial infections like chancroid, syphilis, gonorrhea has been noted in the literature.[5]

Next most common presentation in our study was vaginal discharge found in 22.83% patients. 57.14% of these had vaginal candidiasis, 23.81% trichomoniasis, 9.52% bacterial vaginosis, 4.76% gonococcal urethritis, and 4.76% had mixed infection. Nair also found discharge as second most common presentation after genital ulcer.[14]

Candidiasis was the most common cause of vaginal discharge in our study (57.14%), in accordance with some previous studies in the literature,[14] whereas others found bacterial vaginosis commonly.[15]

Third most common presentation in our study was urethral discharge in males, found in 13.04% patients. Out of these, 62.5% had nongonococcal and 37.5% gonococcal urethritis. This is in accordance with some of the previous studies,[5] but against others.[14] Increasing trend of nongonococcal urethritis is being noted in various studies.[3]

About 10.33% patients had genital MC, 8.15% genital warts and MC and warts together in 1.09% patients. Rising trend of MC infection and condyloma acuminata was found in other studies also.[345791216171819]

Like the developed countries, in India as well, the bacterial STI like chancroid and gonorrhea are declining, whereas viral STI like human papilloma virus and herpes genitalis show an upward trend.[3419] This may be because of syndromic treatment in the peripheral centers thereby obviating the need of many patients to attend STD clinics in the tertiary centers, and also because of antibiotic therapy for other unrelated diseases which improves any simultaneous STI and so consequent nonreporting of many of these infections.[1]

7.07% patients in our study had pediculosis (pthirus) pubis and genital scabies in 4.35%.

Candidal balanoposthitis and idiopathic scrotal swelling were found in 1.63% patients each and lower abdominal pain syndrome in one female (0.54%). Less candidal balanoposthitis may be because of the circumcision, which is essentially carried out in Muslim males.

Considering the year-wise distribution, more cases were registered in 2011, 2012 and 2013 with an increasing trend than 2009, 2010 due to summer unrest in 2009 and 2010. This is contrary to some previous studies, which noted decreasing year-wise trend.[3414]

Three patients (1.63%) were HIV positive. Low prevalence of HIV is as per the previously reported low prevalence figures for Kashmir, as reported in a recent study by Mir et al.,[20] where 1141 patients clinically suspected of having HIV/AIDS were tested, and 26 found positive for HIV 1 (2.28%) and none for HIV 2.[20]

CONCLUSION

The trend of STI and HIV/AIDS in Kashmir by and large matches other parts of India. In order to determine any new dimensions, more wide scale studies are needed. Cultural mixing and chances of contact due to the inflow of tourists, defense personnel, laborers into Kashmir, and increasing movement of Kashmiri to other high risk areas of India results in indulgence in high risk behavior and chances of getting infected. This is largely due to increased globalization and easy accessibility. Awareness among common masses needs to be increased, clinicians have to be more cautious and authorities more determined if STI, and HIV/AIDS spread is to be effectively controlled.