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Table of Contents
REVIEW ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 3-7

Situation analysis of sexually transmitted infections in India


Department of Community Medicine, SBKS Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, Gujarat, India

Date of Web Publication05-Nov-2018

Correspondence Address:
Dr. Niraj Pandit
Department of Community Medicine, SBKS Medical Institute and Research Centre, Sumandeep Vidyapeeth, Piparia, Vadodara, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JIHS.JIHS_12_18

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  Abstract 


Sexual and reproductive health is important component of well-being of human health. It has close relationship with responsible, safe, and satisfying reproductive life. Unaccountable sexual health results in sexual and reproductive ill-health. HIV/AIDS is recently found pandemic disease, but sexually transmitted infections (STIs) are present since ancient time. The history of reproductive tract infection (RTI)/STIs is interesting from name change to treatment change strategy. It is very important to know the historical changes of disease and pattern of disease in country. The present review article is trying to evaluate various aspects of RTI/STIs including historical studies and SWOT analysis for the future challenges.

Keywords: HIV/AIDS, reproductive health, sexually transmitted infections


How to cite this article:
Pandit N, Chhaya J. Situation analysis of sexually transmitted infections in India. J Integr Health Sci 2018;6:3-7

How to cite this URL:
Pandit N, Chhaya J. Situation analysis of sexually transmitted infections in India. J Integr Health Sci [serial online] 2018 [cited 2018 Nov 13];6:3-7. Available from: http://www.jihs.in/text.asp?2018/6/1/3/245024




  Background about Sexually Transmitted Infections Top


Sexual and reproductive health is important component of well-being of human health. It has close relationship with responsible, safe, and satisfying reproductive life. If the person is not responsible to sexual health, that make them vulnerable to sexual and reproductive ill-health.[1] In the past three decades, sexually transmitted infections (STIs) have undergone dramatic transformation. In the previous century, word “Venereal disease” was changed to “Sexually Transmitted Diseases (STDs)” and now it is replaced by Sexually Transmitted Infection (STIs). Second, previously it was focused on diseases limited to five; now focus in infections which are more than 30 in numbers.[2] The pandemic of HIV/AIDS has changed the epidemiology and prevention of STI.

HIV/AIDS is recently found pandemic disease, but STIs are present since ancient time. Just HIV/AIDS has made focus on these group of infections. STIs are those infections which are spread from one person to another predominantly through sexual contact including vaginal, anal, and oral sex. Some STIs may transmitted through blood or blood product or from mother to child during pregnancy or childbirth.[3]

There are more than 30 types of viruses; bacteria and parasites are popularly known agents which are responsible for STI. Of them, four most common and incurable infections are hepatitis B, herpes simplex infection, HIV, and human papillomavirus.[3] Thus, the spectrum of STIs is ranging from simple curable infections such as giardiasis to incurable infection such as HIV.

This group of infections is unique as the infection may present without any symptoms of disease. The common presentation of STIs is nonspecific such as abdominal pain and discharge from vagina or urethra or burning pain. The specific symptoms are genital ulcer, wart, and enlarge bubo. Many time people are neglecting such symptoms. Neglecting is one of the reasons for the delay in the diagnosis which is very common. The impact of nondiagnosis or delay diagnosis of STIs may be adversely affecting the reproductive health of families such as infertility, urethral stricture, complication during pregnancy, complication to infant, and cancers.[4]

Most interesting part of STIs is that they are 100% preventable. Simple tool like condom, if uses properly and consistently, all STIs can be preventable. The STIs are more social and behavioral problem rather medical problem. Social factors which are playing an important role in STIs are prostitution pattern in society, broken home, sexual disharmony, easy money, emotional immaturity, urbanization and industrialization, social disruption, international travel, social stigma, alcoholism, and many more.[2]

Looking at this background of STIs, it is important to know about the history to the current status of disease in the country India.


  Problem Statement Top


As per the WHO factsheet, every day more than 1 million STIs are added in pool of infections, with estimated 357 million new infections every year in the world. Key infections are chlamydia, gonorrhea, syphilis, and trichomoniasis. More than 500 million people are living with genital herpes simplex virus (herpes) infection. At any point in time, more than 290 million women have human papillomavirus (HPV) infection, one of the most common STIs.[3] Global estimates of syphilis and associated adverse outcome report 2012[5] reported that more than 0.9 million pregnant women were infected with syphilis and 0.35 million adverse birth outcome recorded including stillbirth.

In India, STIs and reproductive tract infections (RTIs) are one of the top ten diseases for which adult seeking primary care physician's visit. Furthermore, the National AIDS Control Organization (NACO) report 2016–17 reported that 6% of the adult population are getting RTI/STI every year in India.[6]

RTI/STIs are mainly reported and treated under the NACO which is government authority. NACO reported in 2011 that 6% of male and 12% of female attending primary care physician outpatient department with a complaint of STI, thus the prevalence of STI is around 5%–6% sexually active adult group. An estimated 30 million episodes occur in the adult population annually in India. Of which, 10 million seeks treatment from the government sector and another 20 million seeks care from private providers. NACO target is to manage 90 lakh episodes of ST/RTI in 2016–17, of which the program has achieved 39.93 lakh (43%) in September 2016.[7] A community-based STI/RTI prevalence study (2003) reported over 6% of the adult population in India suffers from one or the other STI/RTI episodes annually.[8]

Along with NACO, there were various studies conducted across India, and they reported various incidences and prevalences of STI/RTI. A study conducted at Haryana, North India, reported 41.7% of migratory factory workers had one STI symptom.[9] A study from Mumbai reported 64% of alcohol users had STI or HIV infections, and 92% of study participants had sex with female sex workers.[10]


  Incidence and Prevalence of Sexually Transmitted Infection in India Top


The WHO has reported in its global incidence and prevalence of selected STIs in 2008 report that 11% increase of four key STIs between 2005 and 2008.[11] However, numbers decrease in 2012 as reported in 2015.[12] [Table 1] shows more details.
Table 1: Global incidence estimates for 2005, 2008, and 2012 (millions of cases)

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Trends in STI/RTI in India – Thappa and Kaimal in 2007[13] wrote trend in STI/RTI in India. The salient points of that study are mentioned in [Table 2].
Table 2: Time trend analysis of STI/RTI situation in India.

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  Prevention and Control Strategy in India Top


Effective control of STI/RTI is a strong and most cost-effective strategy for reducing/preventing transmission of not only STI but also HIV.[8]

Counseling and behavioral approaches

Counseling and behavioral interventions offer primary prevention against STIs (including HIV), as well as against unintended pregnancies. These include:

  • Comprehensive sexuality education, STI and HIV pre- and posttest counseling
  • Safer sex/risk-reduction counseling, condom promotion
  • Interventions targeted at key populations, such as sex workers, men who have sex with men, and people who inject drugs
  • Education and counseling tailored to the needs of adolescents.


In addition, counseling can improve people's ability to recognize the symptoms of STIs and increase the likelihood they will seek care or encourage a sexual partner to do so.

Treatment of sexually transmitted infections – key is the syndromic approach

Effective treatment is currently available for several STIs. Syndromic approach is the key in treatment.

  • Three bacterial STIs (chlamydia, gonorrhea, and syphilis) and one parasitic STI (trichomoniasis) are generally curable with existing, effective single-dose regimens of antibiotics
  • For herpes and HIV, the most effective medications available are antivirals that can modulate the course of the disease, though they cannot cure the disease
  • For hepatitis B, immune system modulators (interferon) and antiviral medications can help to fight the virus and slow damage to the liver.


The resistance of STIs – in particular, gonorrhea – to antibiotics has increased rapidly in the recent years and has reduced treatment options. The emergence of decreased susceptibility of gonorrhea to the “last-line” treatment option (oral and injectable cephalosporins) together with antimicrobial resistance already shown to penicillins, sulfonamides, tetracyclines, quinolones, and macrolides make gonorrhea a multidrug-resistant organism.

In India, NACO through its network of 1160 designated STI/RTI clinics, named as “Suraksha Clinics,” is providing free standardized STI/RTI services based on syndromic case management. Syndromic management is simple, assures rapid, same-day treatment, and avoids expensive or unavailable diagnostic tests. However, this approach misses infections that do not demonstrate any syndromes – the majority of STIs globally.[14] Counseling services from trained counselors are also made available at these clinics.

Vaccines and other biomedical interventions

Safe and highly effective vaccines are available for 2 STIs: hepatitis B and HPV. These vaccines have represented major advances in STI prevention. The vaccine against hepatitis B is included in infant immunization programs among 187 countries by 2017[15] and has already prevented an estimated 1.3 million deaths from chronic liver disease and cancer.

HPV vaccine is available as the part of routine immunization programs in 80 countries by 2017,[15] most of them high and middle income.


  Challenges in Current Efforts Top


  1. Behavior change is complex: despite considerable efforts to identify simple interventions that can reduce risky sexual behavior, behavior change remains a complex challenge. Research has demonstrated the need to focus on carefully defined populations, consult extensively with the identified target populations, and involve them in design, implementation, and evaluation
  2. Health services for screening and treatment of STIs remain weak: people seeking screening and treatment for STIs face numerous problems. These include limited resources, stigmatization, poor quality of services, and little or no follow-up of sexual partners. Partner notification is key strategy for providing services to STI clients. A study from Tamil Nadu by Arunkumar et al.[16] reported that only around 52% of STD patients reported partner notification. The challenges for noncompliance were extramarital affair or premarital affair, sex with commercial sex workers, distance area, or sex assault


    • In many countries, STI services are provided separately and not available in primary health care, family planning, and other routine health services
    • In many settings, services are often unable to provide screening for asymptomatic infections, lacking trained personnel, laboratory capacity, and adequate supplies of appropriate medicines
    • Marginalized populations with the highest rates of STIs – such as sex workers, men who have sex with men, people who inject drugs, prison inmates, mobile populations, and adolescents – often do not have access to adequate health services.


  3. Refusal to sex education: this is again the challenge of diversified country. Culturally, the sex education is still not acceptable for many communities. Various nongovernmental organizations and Government are trying to implement with some alternatives
  4. As discussed above, increase resistance to drug is also important challenge
  5. STI/RTI is silent epidemic. This is most important challenge.


SWOT analysis of current efforts to prevent STIs:

  • Strength, Weakness, Opportunity and Threat (SWOT) analysis of current efforts related to prevent sexual transmitted infections (STIs) was described in [Figure 1].
Figure 1: SWOT analysis for sexually transmitted infection but with all limitation, National AIDS Control Organization and various nongovernmental organizations are trying best for the program to reach at remotest level

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Available from: http://www.who.int/reproductivehealth/publications/sexual_health/defining_sexual_health.pdf. [Last accessed on 2017 Sep 06].  Back to cited text no. 1
    
2.
Park K. Park's Text Book of Preventive and Social Medicine. 20th ed. Jabalpur: Bhanto Publication; 2013. p. 303-13.  Back to cited text no. 2
    
3.
World Health Organization | Sexually Transmitted Infections (STIs). World Health Organization. Available from: http://www.who.int/mediacentre/factsheets/fs110/en/. [Last accessed on 2017 Sep 06].  Back to cited text no. 3
    
4.
World Health Organization Technical Report. World Health Organization Expert Committee on Venereal Diseases and Treponematoses. World Health Organization; 1986. Available from: http://www.apps.who.int/iris/bitstream/10665/39675/1/WHO_TRS_736.pdf. [Last accessed on 2017 Sep 06].  Back to cited text no. 4
    
5.
Newman L, Kamb M, Hawkes S, Gomez G, Say L, Seuc A, et al. Global estimates of syphilis in pregnancy and associated adverse outcomes: Analysis of multinational antenatal surveillance data. PLoS Med 2013;10:e1001396.  Back to cited text no. 5
    
6.
Available from: http://www.naco.gov.in/sites/default/files/NACO%20ANNUAL%20REPORT%202016-17.pdf. [Last accessed on 2017 Aug 31].  Back to cited text no. 6
    
7.
Operational Guidelines for Programme Managers and Service Providers for Strengthening STI/RTI Services. New Delhi, National AIDS Control Organisation. Ministry of Health and Family Welfare. Government of India. National AIDS Control Organisation; 2011.  Back to cited text no. 7
    
8.
STI/RTI Services | National AIDS Control Organization | MoHFW | GoI. Available from: http://www.naco.gov.in/sti-rti-services. [Last accessed on 2017 Sep 25].  Back to cited text no. 8
    
9.
Abdulkader RS, Kant S, Rai SK, Goswami K, Misra P. Prevalence and determinants of sexually transmitted infections (STIs) among male migrant factory workers in Haryana, North India. Indian J Public Health 2015;59:30-6.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Madhivanan P, Hernandez A, Gogate A, Stein E, Gregorich S, Setia M, et al. Alcohol use by men is a risk factor for the acquisition of sexually transmitted infections and human immunodeficiency virus from female sex workers in Mumbai, India. Sex Transm Dis 2005;32:685-90.  Back to cited text no. 10
    
11.
World Health Organization | Global Incidence and Prevalence of Selected Curable Sexually Transmitted Infections – 2008. World Health Organization. Available from: http://www.who.int/reproductivehealth/publications/rtis/stisestimates/en/. [Last accessed on 2017 Sep 26].  Back to cited text no. 11
    
12.
World Health Organization | Report on Global Sexually Transmitted Infection Surveillance 2015. World Health Organization. Available from: http://www.who.int/reproductivehealth/publications/rtis/stis-surveillance-2015/en/. [Last accessed on 2017 Sep 26].  Back to cited text no. 12
    
13.
Thappa DM, Kaimal S. Sexually transmitted infections in India: Current status (except human immunodeficiency virus/acquired immunodeficiency syndrome). Indian J Dermatol 2007;52:78.  Back to cited text no. 13
  [Full text]  
14.
STI/RTI Services | National AIDS Control Organization | MoHFW | GoI. Available from: http://www.naco.gov.in/sti-rti-services. [Last accessed on 2018 Feb 19].  Back to cited text no. 14
    
15.
Immunization Coverage. World Health Organization. Available from: http://www.who.int/news-room/fact-sheets/detail/immunization-coverage. [Last accessed on 2018 Aug 10].  Back to cited text no. 15
    
16.
Arunkumar S, Kamoji SG, Kasatti G. Partner notification and treatment institute of venereology-experience. Indian J Sex Transm Dis AIDS 2013;34:10-3.  Back to cited text no. 16
    


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    Tables

  [Table 1], [Table 2]



 

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