e Z N I T a s T d I r Indian Institute of Sexology Bhubaneswar H e Z N I T H a s T d I r Indian Institute of Sexology Bhubaneswar Sexually Transmitted Diseases An update Indian Institute of Sexology Bhubaneswar Advisor Dr. Santosh Kumar Mishra Editorial Advisory Board Members Dr. Adarsh Tripathi Dr. Bandna Gupta Executive Editor Dr. Sujit Kumar Kar Guest Editor Dr. T.V. Ram Kumar Editorial Board Members Dr. Maheswar Satpathy Dr. Lalatendu Swain Dr. Samir Anil Singru Language Editor Mr. Manash Ranjan Debata Publication Editor Dr. Saumya Ranjan Mishra Since ages, sexually transmitted diseases have haunted mankind as a major public health concern. Even ancient literature resounds with descriptions on sexually transmitted diseases. As such sexually transmitted diseases are not bound by and limited to just reproductive ages. Other age groups too have been found to be victims of this universal scourge, regardless of their sex. The invention of penicillin is a turning point in the history of sexually transmitted diseases and their treatment. The post penicillin era saw a signiicant reduction in the incidence of sexually transmitted diseases, particularly, syphilis. Likewise, issues of other sexually transmitted diseases of bacterial, fungal and viral etiology came to be tackled well with the invention of generations of highly potent antibiotics, antifungal and antiviral drugs. Safe sexual practices and awareness campaigns too went a long way in ensuring signiicant grip and control over the spread of sexually transmitted diseases. However, the emergence of AIDS on the medical horizon has hurled renewed challenges at the medical fraternity, with the re-emergence of these conditions along with it. Indian Institute of Sexology Bhubaneswar Sanjita Maternity Care and Hospital, Plot No-1, Ekamra Marg, Unit-6, Bhubaneswar-751001, Odisha, India E mail - sexualityinfo@gmail.com www.iisb.org In terms of area affected, sexually transmitted diseases may also involve and colonize other organ systems of the body. Hence, there is an urgent need to develop clear understanding and actionable insights into sexually transmitted diseases beyond genital transmission and manifestations. This calls for a multidisciplinary approach and integrated care for the holistic management of sexually transmitted diseases. An important speed-breaker in the ield of proper treatment of these diseases has been social stigmas. Cutting across cultures and geographies, stigmas are found to be closely associated with sexually transmitted diseases. Fear of discrimination often restrains affected individuals to seek timely medical help. And if, at all, they seek help, their apprehension about conidentiality tempts them to hide relevant and critical information, further delaying correct diagnosis. Another major factor that affects the treatment of sexually transmitted diseases is their prevalence among high-risk population (migrants, truckers, intravenous drug users, trans-genders, gays, lesbians and commercial sex workers). Risky sexual behavior of these groups paves the way for higher prevalence of sexually transmitted diseases among them. Targeted intervention is an important method to combat the problem. There is a need to expand the process of identiication and enrollment of these people to the treatment plan for arresting the spread of sexually transmitted diseases. Efforts have also been made at multiple levels (government, non-government organizations, and international bodies) to combat sexually transmitted diseases. These infections, it is felt, need to be addressed at an early stage to obtain improved and better outcomes. It is good to note that many adolescent clinics, these days, are offering tests for easy diagnosis of sexually transmitted infections. Besides, high-risk population groups need to be brought under the sensitization ambit. There is a need to sensitize migrant labor population regarding the risks, and healthy practices. Likewise, sex workers, and trans-genders should be made to attend education camps, and be encouraged to undergo periodical health screening and use barrier contraceptives. To sign up, imparting sex education, creating health awareness, restricting substance use, targeting vulnerable populations and adopting safe and healthy sexual practices can create a collective front to prevent and effectively checkmate the spread of sexually transmitted diseases. It’s, as they say, a stitch in time saves nine. Indian Institute of Sexology Bhubaneswar Sanjita Maternity Care and Hospital, Plot No-1, Ekamra Marg, Unit-6, Bhubaneswar-751001, Odisha, India E mail - sexualityinfo@gmail.com www.iisb.org 5 Clinical Manifestations of Sexually Transmitted Diseases : An Overview Dr. Surabhi Dayal | Dr. Kirti Dudeja | Dr. Priyadarshini Sahu 12 Diagnostic Approach to A Patient with Sexually Transmitted Disease Dr. Pritilata Panda | Dr. Sarvodaya Tripathy 17 Laboratory Detection of Sexually Transmitted Diseases Dr. Bhawna Nagel | Dr. Kangana Sengar 24 Management of Sexually Transmitted Diseases Dr. Priyadarshini Sahu | Dr. Shruti Sharma 34 Sexually Transmitted Infections in Children and Adolescents Dr. T.V. Ram Kumar 40 Neurosyphilis : Current Understandings Dr. Ravi Uniyal | Dr. Nidhi Tejan Dr. Ravindra Kumar Garg | Dr. Vimal K Paliwal 47 Sexually Transmitted Disease and Mental Illnesses : Understandings and Implications Ms. Deblina Roy | Dr. Sujit Kumar Kar 55 Prevention of Sexually Transmitted Diseases Dr. Neelam Gautam 60 STI/RTI Prevention and Control Programme in India Dr. S.K. Singh | Dr. Abhishek Gupta | Dr. Uday Mohan 67 Sexually Transmitted Diseases in Ayurveda Dr. Swapnil Saxena 72 Fear of Getting HIV Infection : A Case Study from Psychiatric Clinical Practice Dr. Divyesh Vernwal Clinical Manifestations of Sexually Transmitted Diseases : An Overview Dr. Surabhi Dayal | Dr. Kirti Dudeja | Dr. Priyadarshini Sahu Abstract The global health burden of sexually transmitted infections including Human Immune Deiciency Virus (HIV) is large and ever increasing. The world health organization estimates that there are around 498 million people aged 15-49 years who are infected each year with chlamydia, gonorrhoea, syphilis and chancroid. Various taboos and stigmas associated with these diseases negatively impact on the treatment seeking behavior and delay the treatment. Reporting of less number of cases also reduces the resources allocated for their control. Introduction Sexually transmitted infections are infections that are transmitted by sexual contacts. It is a broad term which includes infections by bacteria, virus, protozoa that result in clinical manifestations involving genitalia and other parts of the body in sexual interaction. In this article we are going to discuss about clinical presentations of six main sexually transmitted diseases which are commonly seen in clinical practice. An overview of chlamydia and gonorrhea infection is also given as these are of common occurrence in dermatology outpatients. Syphillis Syphillis also known as ‘Great imitator’ is a chronic systemic infectious disease caused by 6 June | 2017 Indian Institute of Sexology | Bhubaneswar spirochaete Treponema pallidum subspecies pallidum. Based on the modes of the transmission, it is classiied into acquired type and congenital type. Acquired type can be early acquired or late acquired. 2. Congenital Early congenital Late congenital Classiication 1. Acquired A. Early Acquired 1.Primary 2.Secondary 3.Early latent Pathogenesis The clinical course of syphilis is extremely varied and is interrupted by various phases of variable duration. Although the exact course of disease is not yet clear, report of Oslo study [1] describes the natural course of disease as follows. B. Late Acquired 1. Late latent 2. Tertiary syphilis Benign tertiary Cardiovascular Neurosyphillis Exposure to Treponema pallidum (after unprotected sex 1/3 of exposed get infected) ↓ Primary chancre (heals in 3-8 weeks) ↓ Secondary syphilis (heals in 3-9 months) ↓ Early latent syphilis (relapse may occur in 25% cases) ↓ Late latent (>2 years from onset)  Remission (2/3 cases) Primary chancre It presents as a well-deined ulcer with regular raised or rolled out edges and a clean base. Indurated base of chancre giving the feel of a button entitles it with the term hard chancre. Lymph nodes enlarge in 7-10 days, initially unilateral but ↓  Tertiary (1/3 cases) - Late - Cardiosyphilis - Neurosyphilis soon become bilateral and appear small, discrete, non-tender, irm, and rubbery. Chancre may be tender due to secondary bacterial infection and may occur in extragenital sites like oral, anorectal, breast and digits. Proctitis has been reported among homosexuals [1]. 7 June | 2017 Indian Institute of Sexology | Bhubaneswar Secondary Syphilis Initially it presents with a rash which is nonvesicular, non-pruritic and bilaterally symmetrical. ‘Macular syphilide’ is the earliest generalized syphilide which appears as pinkish to coppery red non-scaly macules on trunk, palms and soles soon converting into papular syphilide that presents as annular or discrete circular, corymbose papules. Papules in moist intertriginous areas coalesce to form leshy, lat topped, broad base masses which are highly contagious are known as condyloma lata. At times they have been reported independent of appearance of skin rash [2]. Other signs and symptoms are as follows• Hair – Irregular patches of non-scarring hair loss in occipital and parietal region, popularly known as ‘Moth eat on alopecia’. • Nail – Lusterless, brittle with pitting, splitting and onycholysis. • Mucous membrane – Irregular serpiginous erosions or ulcers known as ‘Snail track ulcers’. • Constitutional symptoms like fever, malaise, arthralgia, myalgia, and headache are common. • Bilaterally symmetrical non tender, discrete, mobile, non suppurative irm lymph nodes. • Anemia, leukocytosis, raised erythrocyte sedimentation rate may be seen in this stage. • Signs of meningitis may occur. Early latent syphilis No clinical signs are appreciated in this stage, however the reaginic and speciic tests are positive. Early relapsing syphilis 25% latent cases relapse back with clinical signs 8 and symptoms due to which this phase is known as ‘chancre redux’. Late syphilis After 2 years disease enters into a non-infective phase. Reaginic test is positive in low dilution but neurosyphilis needs to be excluded by cerebrospinal luid (CSF) examination. Tertiary syphilis Characteristic lesion is gumma which is single or multiple, varying in size from pin head to a few centimeres and has a central area of tissue necrosis resembling casseous material surrounded by a granulation tissue with a tough outer ibrous border. It heals with central scar. Psoriasiform or scaly lesions may be seen in this stage. Other structures like bones, muscles, joints may be involved. Important organs involved are as followsCardiovascular syphilis Symptoms appear after 10-40 years from the onset of disease. Great vessels like aorta, pulmonary artery may show thickening, median wall destruction followed by dilatation of vessel. Aortic aneurysm is seen in 20% of cases. Chest X-ray may show egg shell calciication. Neurosyphillis Features of meningitis may suggest its onset with CSF examination showing high cell count (predominantly lymphocytes) and raised proteins. Herpes Genitalis It is one of the commonest occurring sexually transmitted disease, which is caused by Herpes virus hominis. There are two types of Herpes June | 2017 Indian Institute of Sexology | Bhubaneswar simplex viruses HSV1 and HSV2. HSV 2 is more commonly seen in genital area, however genital HSV1 is being commonly seen in young adults now-a-days [3]. Pathogenesis Herpes virus infects epidermal cells leading to ballooning degeneration of cells. The outcome of this change is formation of multinucleate giant cells with intranuclear inclusion bodies which is one of the golden sign for making the diagnosis. Primary genital herpes The primary lesions occur usually with constitutional symptoms like fever, malaise, headache, myalgia followed by skin lesions. The lesions start as grouped vesicles which soon rupture to form erosions coalescing together to form supericial ulcers with polycyclic margins. New lesions continue to occur for 8-10 days and viral shedding usually continues for the irst 2 weeks. Scarring is uncommon. First episode of genital herpes may lead to • Secondary bacterial infection • CNS involvement like Aseptic meningitis, Transverse myelitis, Sacral radiculopathy • Extragenital lesions frequently seen on thighs, buttocks and groins Recurrent genital herpes Episodes are milder and last for only 5-7 days. Over 90% patients have prodromal symptoms varying from mild tingling sensation to shooting pain prior to appearance of lesion. Healing is usually complete in 7-10 days. Herpes genitalis infection in HIV positive patients Atypical presentations are common with deep progressive ulcers. Continuous and prolonged viral shedding is the commonest sequelae. Hemorrhagic deep ecthyma like ulcer may form. Systemic involvement like hepatitis, pneumonitis is more common in such immunocompromised state. Anogenital Warts It is caused by human papilloma virus (HPV) which is a DNA virus. Both cell mediated immunity and humoral immunity are hampered. Lesions appear after the incubation period of 1-8 months with an average duration of 3 months. In males, genital warts appear most commonly in subprepucial region, frenulum followed by glans and coronal sulcus. In females, common sites involved are posterior part of introitus, labia, perineum, and perianal area. Various clinical presentations are as follows [4]. 1. Condyloma accuminata - Lesions are pedunculated caulilower like with issures and irregular surface. 2. Papular wart - Non pedunculated dome shaped papules are located in fully keratinized skin. 3. Verruca vulgaris type - Firm papular lesions with slightly rough horny surface with no pedicle are seen. 4. Flat topped papules 5. Bowenoid papulosis - It is a variant of papular wart characterized by hyperpigmented, dome shaped, smooth, lat topped papules. It is caused by HPV 16 and shows high grade squamous intra-epithelial neoplasia. 6. Buschke Lowenstein tumor - It is a verrucous hyper-keratotic exophytic growth in genital and perianal area. 9 June | 2017 Indian Institute of Sexology | Bhubaneswar Chancroid Chancroid, also known as ‘soft sore’ is an acute infectious disease caused by gram negative bacillus Haemophillus ducreyi. It’s Incubation period is usually short, ranging from 1-14 days. Initially, it starts with a small inlammatory papule surrounded by erythema which progresses to form a well circumscribed painful ulcer covered with purulent exudates. Base of the ulcer is non-indurated and has ragged undermined edges. Removal of the exudate reveals unevenly distributed, highly vascular granulation tissue which may bleed on scraping or gentle manipulation. Painful inguinal lymphadenopathy is seen. Nodes are mostly unilateral and matted together. They may suppurate and form an abscess. If untreated these may rupture through the skin with formation of a single sinus which may breakdown to form a chancroidal ulcer. Other complications include phimosis, paraphimosis and urethral istula. Clinical variants of chancroid include • Giant chancroid • Phagedenic chancroid • Follicular chancroid • Popular chancroid • Dwarf chancroid Lymphogranuloma Venereum Lymphogranuloma venereum (LGV) is a sexually transmitted infection caused by gram negative intracellular bacilli Chlamydia trachomatis serovars L1, L2, L3. It is also known as ‘Tropical bubo’. Incubation period varies from 1-2 weeks. There are three stages of infection [5,6]. 1. Primary 2. Secondary (inguinal) 3. Tertiary (complication) 10 Primary stage Primary lesion mostly goes unnoticed but about ¼ of the patients may present with a papule, a vesicle, an erosion or an ulcerated area at the site of inoculation. Secondary stage Characteristic unilateral inlammatory swelling of inguinal and their draining lymph nodes is seen which may be bilateral in about 1/3 of the cases. Lymph nodes may get matted and overlying skin becomes thick, dusky and it soon ruptures [7,8]. In 20% of the patients femoral group of lymph nodes are also involved separated from inguinal lymph nodes by pauparts ligament giving the term ‘groove sign of greenblat’ [8]. Fever, sweating, malaise may be present. Rupture of the lymph nodes form multiple sinus and get resolved after some time. Complications • Lymphatic obstruction leads to elephantiasis of the genitals. • In males, chronic massive oedema may give rise to ‘ram horn penis’ and ‘saxophone penis’. • Likewise in females chronic edema may cause enlargement of the vulva giving it a fancy name ‘esthiomene’ [8,9]. Donovanosis Also known as ‘Granuloma inguinale’, it is a slowly progressive, chronic, mildly contagious ulcerative disease caused by Calymmatobacterium granulomatis. One of the characteristic histopathological feature is the presence of intracytoplasmic structure, known as ‘Donovan bodies’. Incubation period ranges from 3 days to 3 months. June | 2017 Indian Institute of Sexology | Bhubaneswar It begins as single or multiple irm papules, which rupture to form a well-deined painless ulcer with beefy red color and granulomatous base and bleeds easily on touch. Phimosis or lymphoedema may occur in active stage only. Lymph nodes are less commonly involved but secondary infection may cause them to appear. However lesions present in the groins may give the appearance of an enlarged lymph node, popularizing the term ‘Pseudo bubo’. Other sites like perianal, inguinal region may be involved in 10-20% of cases. Other morphological variants are• Classical or leshy exuberant type - Most commonly seen variant with a characteristic inding of exuberant beefy red granulation tissue over the top of the lesion. • Hypertrophic type - Raised warty looking appearance of the lesion. • Sclerotic or cicatricial type - Extensive ibrous tissue is present which may lead to deformity of external genitalia. • Destructive or necrotic type - mainly associated with super-added anaerobic infection. Gonorrhoea It is caused by gram negative diplococci Neisseria gonorrhoeae. Incubation period ranges from 1 to 14 days. Mucopurulent discharge per urethra is the most common complaint in men. Over a span of 1-2 days this discharge becomes thick, profuse and purulent with increased tendency of burning micturition [10]. In females, moderate degree of burning micturition, frequency and urgency is the earliest complaint. However scanty mucoid discharge may follow. Complications include epididymitis, prostatitis in men and salpangitis and bartholin abscess in women. Chlamydia Chlamydia trachomatis serovar B, D, E, F, G, H, I, J and K is one of the commonest cause of nongonococcal urethritis now a days. Incubation period ranges from 7 to 21 days. Dysuria followed by mild urethral discharge is the commonest complaint in most of the cases. Some patients may present with hematuria owing to the involvement of bladder. Without proper treatment other organs may get involved and can lead to epididymitis, prostatitis and proctitis in men and cervicitis, endometritis and salpingitis in women. Conclusion Sexually transmitted diseases are caused by a diverse group of organisms. Many individuals have asymptomatic early infections, and this favours onward transmission. Various complications leading to infertility, postabortal and postpartum infections and signiicant discomfort to the normal sexual life of a person is a matter of concern. A coordinated approach is therefore required to reverse the rising trend of sexually transmitted infections. This approach will be effective if signs and symptoms of infections are recognized early, correct diagnosis is done and treatment is given according to accepted protocol. Please send your article for our year - end publication 2017. Your article should reach us by 30th September 2017. You can send articles for web publication in www.iisb.org throughout the year. For standard article format please visit www.iisb.org. 11 June | 2017 Indian Institute of Sexology | Bhubaneswar References 1. 6. Br Med Bull. 1983; 39:151-4. Klausner JD, Kohn R, Kent C. Etiology of clinical proctitis among men who have sex with men. Clinical 2. 7. In: Valia RG, Valia AR, eds. IADVL Textbook and color Mushel DM. Early syphilis. In: Homes KK, Marth PA, atlas of Dermatology. 2nd edn. Mumbai: Bhutani Publishing House;2001: p1466-75. 8. edn. New York: Mcgraw- Hill,1999.p. 479-85. Robert CM, Pister JR, Spear SJ. Increasing population In: Holmes KK, Sparling PF, Mardh PA, et al, eds. Sexually transmitted diseases.3rd ed. New York: Mcgraw Hil; 1999.p 423-32. 9. 2003; 30: 797-800. Rajnarayan, Kar HK, Gautam RK, et al. Pattern of sexually transmitted diseases in a major hospital in 5. Peerine PL, Stamm WE. Lymphogranuloma venerum. of herpes simplex virus type 1as a cause of genital herpes infection in college students. Sex Transm Dis. 4. Siddappa K,Rangaiah PN. Lymphogranuloma venerum. Infectious Diseases 2004;38: 300-2. Sparling, PF et al.eds: Sexually transmitted diseases.3rd 3. Schachter J, Osoba AO. Lymphogranuloma venereum. Gupta S, Gupta U, Gupta DK. A gigantic esthiomene. Indian J sex Transm Dis 1997; 18: 75-6. 10. Gonorrhea in males. In: King A, Nicol C, Rodin P eds. Delhi. Indian J Sex Transm Dis. 1996;17:76-8. Venereal diseases. 4TH edn. London: ELBS; 1980.p. Schachter I, Caldwel KD. Chlamidiae. Ann Rev Microbiol 200-213. 1980; 34: 285-309. Our Vision Harmonious existence between male and female leading the mankind towards ultimate bliss Our Goals IndIan InstItute of sexology BhuBaneswar (IIsB) • Aims to facilitate the integration of knowledge and expertise across various disciplines like medicine, psychology, sociology, law and ethics for greater understanding of complexities of human sexuality • Aims to adequately address the individual sexual problems and social issues Objectives • To bring experts of diferent disciplines to a common platform for sharing of knowledge and views on human sexuality • To promote research on human sexuality • To impart training on ‘Sexology’ and strengthen the discipline of ‘Sexual Medicine’ • To encourage medical professionals to choose ‘Sexual Medicine’ as a career • To create public awareness on human sexuality and gender issues • To advocate any social change for betterment of mankind 12 June | 2017 Indian Institute of Sexology | Bhubaneswar Diagnostic Approach to A Patient with Sexually Transmitted Disease Dr. Pritilata Panda | Dr. Sarvodaya Tripathy Abstract Sexually transmitted diseases (STDs) carry signiicant public health importance. After emergence of Acquired Immune Deiciency Syndrome (AIDS), there is an increased reporting of STDs. Understanding about the STDs is highly essential for prescribing correct treatment. Evaluation of a patient suffering from sexually transmitted disease needs speciic considerations and due cautions. Like any other medical illnesses, sexually transmitted diseases need thorough evaluation by careful history taking, detailed physical examination with focus on local (examination of the lesion and genitalia) examination and speciic microbiological investigation. There is a need for collaborative approach between the microbiologist and the clinicians for holistic assessment of the patients with sexually transmitted diseases. Introduction The terms ‘Sexually transmitted diseases’ and ‘Sexually transmitted infections’ are frequently used interchangeably; however, there exists conceptual differences between these two terms. Sexually transmitted infections (STIs) refer to ‘Infections caused by microorganisms that can be transmitted from one person to another through sexual contact’ [1]. When associated with genital symptoms and complications, these STIs are called as sexually transmitted diseases (STDs). According to World Health Organisation (WHO), approximately 357 million new cases 13 June | 2017 Indian Institute of Sexology | Bhubaneswar of the four main (gonorrhoea, chlamydia, syphilis and trichomoniasis) curable sexually transmitted infections are detected every year [2]. National Family Health Survey 2 (NFHS 2) has revealed that the prevalence of symptoms of STI in women and men vary signiicantly [1]. It ranges from 23% to 43% in women and 4% to 9% in men [1]. Existing clinical services are struggling to meet the needs to control STIs. Often the high risk population is deprived of the services, which is a potential challenge to STI control programs. The majority of STIs have no symptoms or only mild symptoms that may be dificult to recognize. These asymptomatic carriers are an important source of transmission in the community. These carriers can be evaluated systematically for the early detection of STIs. Regular community surveillance are going on through various programmes under WHO and Centre for Disease Control & prevention (CDC) in collaboration with Government of India and various Non-Government Organizations (NGOs) at the grass root level. A lot of emphasis has been given to clinical assessment of patients with STDs and it requires speciic skills. So programs have given importance to train doctors and paramedical staffs in fundamental clinical skills for diagnosing and treating STDs. History taking in STDs History taking is a very important aspect of evaluating a patient with sexually transmitted disease. Assuring the patient of privacy and conidentiality is of utmost importance to obtain adequate and correct information from the patient. Building a good rapport, making the patient comfortable and use of culturally acceptable questions are emphasized by the National AIDS Control Organization (NACO), while approaching 14 a patient with STD. A respectful, empathetic and understanding attitude of the examiner towards the patient is essential. As suggested by NACO, a standard check list may be used for patients with STDs. Some of the important aspects of history in patients with STD are [1] : • General information including marital status, contraceptive use, menstrual history (in females) • Duration of symptoms • Contact history including current partners, new partners in last 3 months • Assessing high risk behaviour (adolescent sex, multiple sex partners, unnatural sexual practices, unprotected sexual activity, drug abuse) • Past history of similar illness • Treatment history for both present and past STDs • Drug allergies, if any History taking also needs to emphasize on various social factors that are likely to have impact on development of STDs. Social factors inluence gender role as well as sexual practices [1]. Physical examination Physical examination should be done in a welllighted room with adequate privacy. Examination room should have an examination table. The patient needs to be examined in lying down position, after obtaining informed consent. The part of the body to be examined should be adequately exposed. The examiner should take appropriate protective measures while conducting the physical examination. Following points are to be taken into account during physical examination [1] : June | 2017 Indian Institute of Sexology | Bhubaneswar • • • • General examination should include vital signs, inspection of skin and mucosal lesions if present. Inspection and palpation of genital lesions and surrounding areas for swellings and discharge. Pubic hair should be examined for pediculosis, matting of hair, folliculitis etc. Inguinal lymph nodes should be examined for swelling, consistency, number, arrangement, ixity to deeper structure and signs of inlammation. Per-abdomen, per-speculum and bimanual examination for females should be conducted. Specimen collection Ulcerative lesions are caused by Treponema pallidum, Haemophillus ducreyi, Klebsiella granulomatis and Herpes simplex infection. Chancre that occurs in syphilis as an indurated painless ulcer, is gently abrade with dry gauze, blood-stained exudate is wiped and gentle pressure is applied till clear serous luid exudes. This luid is collected in a capillary tube or a coverslip. Ends of capillary tube and edges of the coverslip are sealed with petroleum jelly to maintain anaerobic environment. This luid can be tested for live T. pallidum [3, 4]. Chancroid caused by H. ducreyi can be sampled after cleaning supericial debris with gauze. Specimen is collected from the undermined edge or base of the ulcer. For donovanosis caused by K. granulomatis, tissue cut from the border of the ulcer can be taken as sample and impression smear can be prepared from the inner surface of the cut tissue. The smear can then be examined by Giemsa or Leishman staining. Tzanck smear followed by Giemsa stain can be used for Herpes, Molluscum and for Chancroid [3, 5]. Intact bubo aspirate can be used for demonstration of H. ducreyi and Chlamydia. Non locculent bubo of syphilis can also be aspirated and T. pallidum can be demonstrated. Urethral discharge can occur in gonorrhoea and non-gonococcal urethritis caused by Chlamydia trachomatis, Mycoplasma hominis and Ureaplasma urealyticum. Urethral discharge may be collected after thorough cleaning of the urethral meatus. Urethral massage against the pubic symphysis in females should be done to express the urethral discharge, which need to be collected by using a swab. Alternatively, a lexible swab can be inserted 2cm deep into the urethra, rotated and then withdrawn. The procedure should be done very gently to avoid any injury to the tissues. First void urine (20ml) in males, as a sample for microbiological examination has also been recommended [5, 6]. The presence of intracellular gram-negative diplococci in smears is considered positive diagnosis. Urethral smears from symptomatic men has a sensitivity of > 95% and in women it ranges between 30–50% [7]. Rectal smear and pharyngeal smear sensitivity is low. Isolation of N. gonorrhoeae, is still considered necessary for the conirmation of the diagnosis of gonorrhoea, whenever the resources are available. The sensitivity of culture is thought to be 80–100% [7], but is dependent on a good specimen and isolation procedure. Secretions from the vagina can be collected using a sterile swab moistened with normal saline, inserted into the posterior fornix of vagina. Cervical secretions are to be collected using a speculum without any lubrication. Swab can be inserted deep into the endo-cervical canal [5]. 15 June | 2017 Indian Institute of Sexology | Bhubaneswar Blood can be collected for serological diagnosis and nucleic acid testing [5]. Specimens should be packed and transported properly ensuring the safety of people involved in handling and packaging of the specimens and the viability of the material. Amie’s medium and Stuart’s medium can be used for transportation of specimens collected in swabs [5]. Diagnosis and management of STDs The major objectives of management of STDs are early detection, appropriate and holistic treatment, treatment of partners and modiication of risky sexual behaviour. There are two main approaches for the management of STDs [1]. Etiological approach – Based on the laboratory tests, deinite causative agent is identiied and treatment, speciic to that particular agent is then suggested. Treatment starts only after laboratory conirmation; so over-treatment of patient and partner can be avoided. However, drop-out of patient in follow up is there. In this type of approach trained technician and infrastructure is needed for conducting the laboratory tests, so the overall cost of management becomes relatively high. The organism can be visualized under the microscope from the direct sample [5, 6]. The important ones being • Motile parasites of Trichomonas vaginalis • Clue cells in Bacterial vaginosis • Budding yeast cells in Candida infection seen by potassium hydroxide mount and gram stain • Dark ield microscopy for Treponema pallidum • Tzanck smear for herpetic lesions can show inclusion bodies Culture can be done for the following organisms [5] : 16 • N. gonorrhoea in chocolate agar and selective media (like lysed blood agar with speciic antibiotics). Identiication can be done by colony morphology, staining, oxidase test. Antibiotic testing must be done since antibiotic resistance are reported in gonococci. • Candida can be cultured in Sabouraud’s dextrose agar • Enriched gonococcus agar and enriched Muller Hinton agar can be used for culture of H. ducreyi. • Tissue culture on Mc coy, Hep 2 and Hela cell lines for Chlamydia trachomatis. Human diploid ibroblast, Vero cell line can be used for herpes viral infection if available. Diamond’s Trichomonas medium can be used for T. vaginalis. But these techniques an technically demanding and costly. So diagnosis is done mostly by serological methods, nucleic acid ampliication test, and rapid point of care tests (immuno-chromatographic tests, dipstick tests etc.) [5]. Amsel’s criteria and Nugent scoring applied for diagnosis of bacterial vaginosis [5]. Syndromic approach – In resource scarce settings like primary health centre, treatment is recommended on the basis of clinical manifestations. Treatment can be initiated at the irst visit itself. This approach is relatively inexpensive because laboratory tests are not done for initiating treatment. Evidences suggest that syndromic approach is helpful in low socioeconomic countries especially for high risk groups and symptomatic individuals [8]. This approach has also been recommended by WHO in such countries [8]. Following are the seven major STI syndromes that are included in the National Guidelines on June | 2017 Indian Institute of Sexology | Bhubaneswar Management of STI [1]. • Urethral discharge • Vaginal discharge • Vesicular and/or non-vesicular genital ulcers • Inguinal bubo • Lower abdominal Pain • Acute scrotal pain or swelling • Genital skin conditions The guidelines of NACO describes the step-wise approach and management of STDs on the basis of speciic set of symptoms [1]. Conclusion In tertiary care hospitals patients with STDs most often visit to departments of obstetrics and gynaecology, dermatology. However they may consult in outpatient departments of medicine, paediatrics and surgery. Patients with STDs are usually referred for microbiological evaluation. There is a need of collaboration between the microbiologist and the clinician to evaluate the patient at irst consultation. This collaboration and a collective effort will facilitate the holistic approach towards the patients with STDs. References 1. 2. 3. 4. 5. National Aids Control Organisation (NACO). Training of Medical oficers to deliver STI/RTI services. http:// naco.gov.in/sti-training-modules [Last accessed on 30.04.2017] World Health Organisation. Sexually transmitted infections (STIs). Factsheet. Updated Aug 2016.http:// www.who.int/mediacentre/factsheets/fs110/en/ [Last accessed on 30.04.2017] Kaimal S, Thappa DM. Methods of specimen collection for the diagnosis of STIs. Indian Journal of Dermatology, Venereology, and Leprology. 2007 Mar 1;73(2):129. Stokes EJ, Ridgway GL, Wren MWD. Clinical Microbiology. Edward-Arnold. 1993. Laboratory manual for diagnosis of sexually transmitted If you have any comments or suggestions, please do share with us. Write a mail to sexualityinfo@gmail.com or drop a letter to Indian Institute of Sexology Bhubaneswar, Sanjita maternity care & hospital, Plot No-1, Ekamra Marg, Unit-6, Bhubaneswar-751001, Odisha, India. 6. 7. 8. and reproductive tract infections. Department of AIDS control. Ministry of Health and Family Welfare, Government of India. 2014. http://naco.gov.in/sites/ default/iles/STI_Lab%20manual_09-01-2014.pdf [Last accessed on 30.04.2017]. Tille P. Bailey & Scott’s Diagnostic Microbiology. Elsevier Health Sciences; 2013 Aug 13. Topley WW, Carlton WW. Topley &Wlson’s microbiology & microbial infections. Hodder Arnold;2005. Redwood-Campbell L, Plumb J. The syndromic approach to treatment of sexually transmitted diseases in low income countries: issues, challenges and future directions. Journal of Obstetrics and Gynaecology Canada 2002 May 31;24(5), 417-24. Please join hands with us. We need experts in every aspects of ‘Human Sexuality’. We need editorial advisors and members for editorial board. 17 June | 2017 Indian Institute of Sexology | Bhubaneswar Laboratory Detection of Sexually Transmitted Diseases Dr. Bhawna Nagel | Dr. Kangana Sengar Abstract Laboratory investigations required to diagnose STDs in a developing country like India are not always feasible or cost effective. Traditionally, diagnosis and treatment of STDs has been dependant on syndromic approach based on clinical symptoms but strengthening lab services for speciic diagnosis is important to prevent overtreatment and development of antimicrobial resistance. Rapid and cost effective POC (point of contact) tests with reasonable sensitivity and speciicity are being developed to address STDs at primary health care level and are especially useful in centres with low patient return rate. More speciic, tedious, quality controlled procedures like culture and NAAT (nucleic acid ampliication technique) assays can be carried out in reference laboratories with high sample load and high throughput. Introduction Sexually transmitted diseases are a major health concern in a developing country like India and pose number of challenges from diagnosis to treatment. Sexually Transmitted Diseases (STDs) can be caused by a variety of pathogens including bacteria, virus, fungus and protozoa. Excluding HIV, recent trends report a decline in bacterial STDs like gonorrhoea and chancroid with an upswing in viral STDs like herpes genitalis and condyloma acuminata [1]. Although both men and women are affected, the morbidity, complications and sequelae are much more signiicant in women like pelvic inlammatory disease (PID), ectopic pregnancy, infertility, cervical cancer etc. In the recent years, 18 June | 2017 Indian Institute of Sexology | Bhubaneswar syndromic approach was devised by World Health Organisation (WHO) for diagnosis and treatment of STDs in resource poor settings to circumvent expensive and laborious lab testing and has been successfully adopted by National AIDS Control Organisation (NACO) in India. Nevertheless, lab services need to be strengthened because apart from diagnosing STDs, lab tests also serve as useful tools for antimicrobial susceptibility testing, validation of syndromic management algorithms, screening of asymptomatic at risk individuals, disease surveillance and quality assurance [2]. In this review article, we discuss lab diagnosis of individual pathogens under three main headings according to presenting complaints and their differential diagnosis. 1.Patients presenting with cervicitis, vulvovaginitis, urethritis, proctitis and pharyngitis 1.1 Gonorrhoea Gonorrhoea and chlamydia are the most common bacterial STDs prevalent worldwide [3]. The causative gram negative bacteria Neisseria gonorrhoea leads to lower urogenital infections, predominantly urethritis in males and cervicitis in females with purulent discharge. Proctitis and pharyngitis are seen more commonly in homosexual males. Conjunctivitis in adults and ophthalmia neonatorum in newborn (perinatal infection) is also seen. Microscopy is highly sensitive and speciic for urethral discharge samples in symptomatic males. Gram stained smears prepared from the discharge demonstrates intracellular gram negative diplococcii polymorphs. It is not recommended for rectal and pharyngeal samples due to lower sensitivity and large number of other obscuring organisms. Culture of causative organism is inexpensive, highly sensitive and speciic and also allows for antimicrobial susceptibility testing which is of utmost importance in gonorrhoea due to frequent emergence of antimicrobial resistance [4,5]. NAAT (nucleic acid ampliication test) which detect speciic DNA (deoxyribonucleic acid) or RNA (ribonucleic acid) sequences of the bacteria have been developed and are more sensitive than culture, especially for rectal and pharyngeal specimens but may lead to false positives (cross reactivity with commensal Neisseria species) which can be reduced by conducting a second NAAT using a different target sequence. Since no internationally licenced NAATs are yet available, they need to be validated in-house within the laboratories [2]. The ideal sample is irst void urine from asymptomatic males and vaginal/cervical swab in females. Serological tests and rapid POC (point of contact) tests are not yet approved and commercially available and are under research. 1.2 Chlamydia Chlamydia trachomatis has 3 biovars based on tissue tropism, those that cause endemic blinding trachoma (serovar A-C), sexually transmitted urogenital infections (serovar D-K) and invasive lymphogranuloma venereum (serovar L1,L2,L3). Internationally approved NAAT assays are the recommended test of choice for diagnosis and screening of both genital and extragenital chlamydial infections wherever feasible and are preferred over culture methods as they are more sensitive, do not require invasive sampling (urine or vaginal swabs can be used instead of urethral 19 June | 2017 Indian Institute of Sexology | Bhubaneswar or endocervical swabs) or stringent transport and storage (not dependant on organism viability), have lesser turn around time and can test for both chlamydia and gonorrhoea simultaneously [6]. In addition, antimicrobial susceptibility testing which requires culture is not routinely advised in chlamydia. Although NAATs may not be feasible in resource constrained settings, the problem can be addressed by creating regional reference labs especially in high prevalence areas where testing of large sample load and high through put automation will help reducing costs and turn around time while maintaining quality reporting. Despite being less sensitive, POC tests which are ELISA (enzyme linked immunosorbent assay) based methods, offer the ability to test and treat the patient on site which is extremely valuable in resource poor, high prevalence settings and where patient follow up rate is low [7]. Serology measures antibody response to chlamydial antigens which may be delayed or not measurable in case of uncomplicated urogenital infections. It can be used for diagnosing complicated infections, LGV and neonatal pneumonia where antibody titres are high. 1.3 Trichomoniasis It is the commonest non viral, non bacterial STD prevalent worldwide caused by lagellated protozoan Trichomonas vaginalis leading to cervicitis and frothy white discharge in females and urethritis in males. The ratio of infection in females to males is 4:1 [8,9]. Majority of infections are asymptomatic [10], yet lab diagnosis is important as trichomonas infection signiicantly increases the risk of HIV transmission and requires treatment to reduce genital compartment viral load. 20 Microscopy serves as a useful irst line diagnostic test being highly speciic but negative tests require further evaluation. Sensitivity is highest in symptomatic females. Vaginal swab in females and urine sediment in males is examined by wet mount microscopy for motile trichomonads within 10 minutes of collection. POC tests are antigen detection assays and are more sensitive than microscopy but most of these can be used only for symptomatic females. Culture is more sensitive than microscopy and POC tests but is more tedious and time consuming. Moreover, routine antimicrobial susceptibility testing is also not recommended. Hence, NAATs which are most sensitive tests and offer greater lexibility in sample collection are recommended. In addition, there are NAATs which test for gonorrhoea, chlamydia and trichomonas simultaneously. 1.4 Mycoplasma Mycoplasma genitalium is causative organism of non gonococcal urethritis, cervicitis and upper genital tract infection in women while Mycoplasma hominis and Ureaplasmas are commensals. NAAT is the only practical method for diagnosis but no assay has been FDA (Food and Drug Administration) approved yet and hence requires in-house validation. Sample preparation and assay sensitivity should be optimal since concentration of mycoplasma is 100 fold lower than chlamydia with multiplex assays having slightly lower sensitivity [2]. Due to high frequency of resistance to macrolides and luoroquinolone, antimicrobial susceptibility testing is also recommended by using broth dilution minimal inhibitory concentration determination and detecting mutated sequences using molecular methods. June | 2017 Indian Institute of Sexology | Bhubaneswar 1.5 Bacterial Vaginosis Bacterial vaginosis is not a sexually transmitted disease but sexual activity increases its risk of acquisition [11]. It’s the most common cause of vaginal discharge in women of reproductive age group. Amsel’s criteria [12] used for diagnosing bacterial vaginosis include: 1. Homogenous greyish white adherent discharge 2. Vaginal pH of more than 4.5 measured by pH indicator strips (most sensitive but least speciic as raised pH may occur due to contamination of vaginal luid with cervical mucus, semen or menstrual blood and in T. vaginalis infection) 3. Release of ishy amine odour from vaginal luid when mixed with 10% KOH (potassium hydroxide) solution 4. Clue cells on microscopic examination of vaginal luid. Gram stained vaginal smears under microscope are the preferred method for lab diagnosis and are interpreted using Ison-Hay criteria or Nugents score. Culture is of no diagnostic value. 2. Patients presenting with ulcers or lesions 2.1 Syphilis Venereal transmission of the causative agent Treponema pallidum occurs through direct contact with treponeme rich ulcers of primary and secondary syphilis. Direct diagnostic methods 1. Demonstration of motile T. pallidum by darkield microscopy remains the simplest and reliable method, especially in treponeme rich ulcers of primary stage and immunodeicient individuals [13]. 2. Direct luorescent antibody (DFA) test employs luorescein isothiocyanate-labelled antibody against treponemal antigen and does not require motile treponemes but it cannot differentiate venereal syphilis from endemic syphilis (yaws, pinta) [14]. 3. PCR (polymerase chain reaction) based methods detect T. pallidum DNA with high sensitivity and speciicity are test of choice for congenital syphilis, neurosyphilis and early primary syphilis [15, 16]. Multiplex PCR assays which detect T. pallidum, H. ducreyi and HSV simultaneously are also available now. Indirect diagnostic methods 1. Non treponemal serologic tests are rapid, simple, inexpensive micro-locculation tests and include VDRL (venereal disease research laboratory) slide test and rapid plasma reagin (RPR) card test. These tests help to establish a baseline titre for evaluation of recent infection, response to treatment and detecting reinfection/relapse in persons with persistently reactive titre. Sensitivity is reduced in primary syphilis and late latent syphilis. Prozone reactions and cross reactivity lead to false negative and positive results respectively. [17]. 2. Treponemal serological tests include Treponema pallidum particle agglutination (TP-PA), EIA (enzyme immune-assay) and western blot tests. These tests are more speciic but may remain reactive for years and do not differentiate venereal syphilis from endemic syphilis. Hence, these tests are used mainly to verify reactivity in non treponemal tests. 21 June | 2017 Indian Institute of Sexology | Bhubaneswar 2.2 HSV Herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) are large double-stranded DNA viruses with the former acquired in childhood causing oral lesions while the latter causes sexually transmitted vesicular genital lesions. Direct cytological examination is not used for diagnosis owing to low sensitivity and speciicity. Detection of viral antigen in lesional material is done using direct immunoluorescence (IF), immunoperoxidase (IP) staining or capture ELISA. Direct IF and IP staining have similar sensitivity but the former is more time-consuming and expensive (requires luorescence microscope). Capture ELISA has comparable or higher sensitivity than culture for typical presentations but lower when cervical or urethral swabs are used. Culture and molecular methods are the mainstay for diagnosis [18]. Cell cultures demonstrating cytopathic effects are further conirmed and typed using direct IF, IP staining or NAAT assay. Sensitivity of culture decreases as lesions begin to crust. NAAT assays are most sensitive and even detect asymptomatic HSV shedding. Serological assays are only used for screening of HSV exposure in high risk group like HIV infected individuals and asymptomatic partners of HSV infected individuals. 2.3 Chancroid Chancroid is caused by Haemophilus ducreyi and produces painful penile, perianal and vulval ulcers alongwith suppurative inguinal lymphadenitis. Unlike syphilitic ulcer, chancroid ulcer is painful, irregular with undermined edges and usually not indurated. Direct microscopy has very low sensitivity and speciicity due to secondary contamination of 22 ulcer by polymicrobial lora. Bacteriological culture and biochemical reactions for H. ducreyi remains the gold standard for diagnosis of chancroid [19]. Successful culture is critically dependent on using freshly made media (ideally fewer than 7 days old) and correct incubation conditions. H. ducreyi colonies are positive for oxidase, nitrate reduction and porphyrin test and negative for catalase, indole and urease tests [20]. Serological assays and molecular methods are not yet commercially available and are under research. 2.4 Donovanosis Donovanosis or granuloma inguinale is caused by Klebsiella granulomatis, a Gram-negative bacterium leading to beefy red, hypertrophic, granulomatous genital ulcers. Pseudo-buboes are formed after secondary infection. Laboratory diagnosis depends on the visualization of ‘Donovan bodies’ within cytoplasmic vacuoles of histiocytes, plasma cells and polymorphs in smears prepared from lesions or histological sections of tissue biopsies stained using Warthin–Starry silver impregnation reagent [21]. The ‘Donovan bodies’ appear as blue to purple coloured organisms surrounded by a prominent clear to acidophilic pink capsule and resemble closed safety pins. Culture is tedious and done only in specialist centres. NAAT or serological assays are currently not available to assist in diagnosis [22]. 2.5 HPV Human papillomavirus is divided into high risk (HR HPV – 16,18,31,33 etc) and low risk (LR HPV6,11) types with the former causing precancerous and cancerous anogenital lesions while the latter June | 2017 Indian Institute of Sexology | Bhubaneswar causing anogenital warts (condyloma acuminata) and non-precancerous lesions. It is a fairly common sexually transmitted, transient infection with slow clearance following cell mediated immune response [23]. Persistent infection is a prerequisite for development of cancer. The humoral response mounted after infection is neither able to clear the virus, nor useful diagnostically but may be used for surveillance purpose. Since the virus is not readily cultivable, diagnosis mainly relies on molecular methods for demonstration of HPV DNA and have excellent negative predictive value. When combined with cytology (pap smear), HPV DNA testing becomes more cost effective for screening of cervical carcinoma [24, 25]. 3. HIV HIV is transmitted through body luids via sexual route or contaminated blood products. The two major types of virus, HIV-1 (sub types A-K, N and O) and HIV-2 cross react heavily and require speciic antigen testing for differentiation. Diagnostic tests for HIV are mainly serological and include: 3.1 Enzyme immunoassays (EIA) The latest third and fourth generation assays can detect Ig M antibodies and viral antigen respectively in addition to viral antibodies thereby enhancing chances of detection in the window period. 3.2 Rapid tests These are based on same principle as EIA but provide faster results due to utilisation of high antigen concentration and more sensitive colour References 1. Narayanan B. A retrospective study of the pattern of sexually transmitted diseases during a ten year period. Indian J Dermatol 2002;47:10-8. detection reagents. Being highly sensitive, these tests are the irst line of investigation with negative results reported as negative and positive results repeated with kits using different antigens and other conirmatory assays [26, 27]. 3.3 Conirmatory assays IFA (Immunoluorescence assay) have been largely replaced by WB (Western Blot) and LIA (Line Immunoassays). But unlike EIA, none of these can detect Ig M antibodies or viral antigens and are more expensive, hence serial or parallel EIA testing algorithms can sufice at a much reduced cost in resource poor settings. 3.4 Molecular methods like RT (reverse transcriptase) PCR and NAAT are used for detecting viral RNA, DNA, enzymes and proteins. These methods are useful for early diagnosis in infants born to seropositive mothers [28], diagnosing acutely infected individuals in window period and assessing viral load for follow-up of infected patients. For monitoring HIV infection, CD4 counting is done by low cytometry. Conclusion Simple, cost effective and sensitive lab tests should be selected for screening followed by repeat testing or testing with more speciic methods like culture or PCR for conirmation of diagnosis. Collecting the sample from ideal site, ensuring optimal transport conditions and maintaining strict quality control in labs are essential for maintaining quality reporting which has direct effect on patient care. 2. WHO – Lab diagnosis of sexually transmitted infections, including human immunodeiciency virus 2013. http://who.int/reproductivehealth/publications/ rtis/9789241505840/en/ [Last accessed on 07-042017]. 23 June | 2017 Indian Institute of Sexology | Bhubaneswar 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Global incidence and prevalence of selected curable sexually transmitted infections —2008. Geneva, World Health Organization, 2012. http://www.who.int/ reproductivehealth/publications/rtis/stisestimates/en/ [Last accessed on 07-04-2017]. Tapsall JW, Ndowa F, Lewis DA et al. Meeting the public health challenge of multidrug- and extensively drugresistant Neisseria gonorrhoeae. Expert Review of AntiInfective Therapy,2009, 7(7):821–834. Ohnishi M, Golparian D, Shimuta K et al. Is Neisseria gonorrhoeae initiating a future era ofuntreatable gonorrhea?: detailed characterization of the irst strain with high-level resistance to ceftriaxone. Antimicrobial Agents and Chemotherapy, 2011, 55(7):3538–3545. Association of Public Health Laboratories (APHL). Laboratory diagnostic testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Expert consultation meeting summary report, 13–15 January 2009 Atlanta, GA. Silver Spring, MD, APHL, 2009. https://www.aphl.org/programs/ infectious_disease/std/Documents/ID_2009Jan_ Laboratory-Guidelines-Treponema-pallidum-MeetingReport.pdf [Last accessed on 07-04-2017]. Gift TL, Pate MS, Hook EW et al. The rapid test paradox: when fewer cases detected lead to more cases treated: a decision analysis of tests for Chlamydia trachomatis. Sexually Transmitted Diseases, 1999, 26(4):232–240. Van Der Pol B, Kraft CS, Williams JA. Use of an adaptation of a commercially available PCR assay aimed at diagnosis of chlamydia and gonorrhea to detect Trichomonas vaginalis in urogenital specimens. Journal of Clinical Microbiology, 2006, 44(2):366–373. Miller WC, Swygard H, Hobbs MM et al. The prevalence of trichomoniasis in young adults in the United States. Sexually Transmitted Diseases, 2005, 32(10):593–598 Seña AC, Miller WC, Hobbs MM et al. Trichomonas vaginalis infection in male sexual partners: implications for diagnosis, treatment, and prevention. Clinical Infectious Diseases, 2007, 44(1):13–22. Bradshaw CS, Morton AN, Hocking J et al. High recurrence rates of bacterial vaginosis over the course of 12 months after oral metronidazole therapy and factors associated with recurrence. Journal of Infectious Diseases, 2006, 193(11):1478–1486. Amsel R, Totten PA, Spiegel CA et al. Non speciic vaginitis. Diagnostic criteria and microbial and epidemiologic associations. American Journal of Medicine, 1983, 74(1):14–22. Wheeler HL, Agarwal S, Goh BT. Dark ground microscopy and treponemal serological tests in the diagnosis of early syphilis. Sexually Transmitted Infections, 2004, 80(5):411–414. Hook EW III, Roddy RE, Lukehart SA et al. Detection of 24 Treponema pallidum in lesion exudate with a pathogenspeciic monoclonal antibody. Journal of Clinical Microbiology, 1985, 22(2):241–244. 15. Gayet–Ageron A, Ninet B, Toutous-Trellu L et al. Assessment of a real–time PCR test to diagnose syphilis from diverse biological samples. Sexually Transmitted Infections, 2009, 85(4):264–269. 16. Liu H, Rodes B, Chen CY et al. New tests for syphilis: rational design of a PCR method for detection of Treponema pallidum in clinical specimens using unique regions of the DNA polymerase I gene. Journal of Clinical Microbiology, 2001, 39(5):1941–1946. 17. Ratnam S. The laboratory diagnosis of syphilis. Canadian Journal of Infectious Diseases and Medical Microbiology, 2005, 16(1):45–51. 18. Centers for Diseases Control, Sexually transmitted diseases treatment guidelines 2010. Morbidity and Mortality Weekly Report, 2010, 59(RR–12). https://www.cdc.gov/mmwr/pdf/ rr/rr5912.pdf [Last accessed on 07-04-2017]. 19. Lewis DA. Diagnostic tests for chancroid. Sexually Transmitted Infections, 2000, 76(2):137–141. 20. Morse SA, Trees DL, Htun Y et al. Comparison of clinical diagnosis and standard laboratory and molecular methods for the diagnosis of genital ulcer disease in Lesotho: association with human immunodeiciency virus infection. Journal of Infectious Diseases, 1997, 175(3):583–589. 21. Freinkel AL. Histological aspects of sexually transmitted genital lesions. Histopathology, 1987, 11(8):819–831. 22. Carter JS, Bowden FJ, Sriprakash KS et al. Diagnostic polymerase chain reaction for donovanosis. Clinical Infectious Diseases, 1999, 28(5):1168–1169. 23. Stanley M. Immunobiology of HPV and HPV vaccines. Gynecologic Oncology, 2008, 109(2 Suppl):S15–21. 24. Ronco G, Giorgi-Rossi P, Carozzi F et al. Eficacy of human papillomavirus testing for the detection of invasive cervical cancers and cervical intraepithelial neoplasia: a randomised controlled trial. Lancet Oncology, 2010, 11(3):249–257. 25. Cuzick J, Arbyn M, Sankarnarayanan R et al. Overview of human papillomavirus-based and other novel options for cervical cancer screening in developed and developing countries. Vaccine, 2008,26(Suppl 10):K29–K41. 26. WHO, UNAIDS, CDC. HIV rapid testing: training package. Atlanta, GA, USA, Centers for Disease Control and Prevention, 2006. 27. WHO, UNAIDS. HIV assays: operational characteristics (phase 1). Report 14, simple/rapid tests. Geneva, World Health Organization, 2004. http://apps.who.int/iris/bitst ream/10665/43059/1/9241592370.pdf [Last accessed on 07-04-2017]. 28. Ou CY, Fiscus S, Ellenberger D et al. Early diagnosis of HIV infection in the breastfed infant. Advances in Experimental Medicine and Biology, 2012, 743:51–65. June | 2017 Indian Institute of Sexology | Bhubaneswar Management of Sexually Transmitted Diseases Dr. Priyadarshini Sahu | Dr. Shruti Sharma Abstract Sexually transmitted diseases (STD) are a variety of infections which are caused by the microorganisms including viruses that are acquired through sexual contact. These infections are manifested as various group of symptoms or syndromes. Early diagnosis and complete treatment remains the keystone for reducing the burden and preventing transmission. Health care providers must be well versed with the strategy of treatment and prevention of these STDs. Complete treatment of some of these infections take months and hence close patient and contact follow up is required. Introduction The global health burden of sexually transmitted diseases and Human Immunodeiciency Virus (HIV) infections is large and increasing. Sexually transmitted infections are caused by diverse group of microorganisms. Many individuals have asymptomatic early infections which favor onward transmission and delay in diagnosis. Apart from the serious complications of sexually transmitted infections, the greatest threat is posed by the fact that they favor acquisition and transmission of HIV [1,2,3]. Therefore a coordinated multiagency approach involving health, education and other government departments is required with emphasis on behavior change and condom use during sex. This review discusses the diagnosis and treatment protocols of the major sexually transmitted infections – anogenital warts, genital ulcer diseases (herpes genitalis, chancroid, syphilis), granuloma inguinale, 25 June | 2017 Indian Institute of Sexology | Bhubaneswar lymphogranuloma venereum, gonorrhoea and genital chlamydia infections. Anogenital Warts Anogenital warts are caused by Human Papilloma Virus (HPV), more than 90% cases by HPV 6 and 11. Diagnosis Anogenital warts are diagnosed mainly by visual inspection. HPV tests should not be routinely done because results don’t influence clinical management. Biopsy is required in case of atypical presentation and uncertain diagnosis [1]. Treatment I. For external anogenital warts [1,4,5] Patient applied Provider administered Imiquimod 3.75% or 5% cream Cryotherapy with liquid nitrogen Or Podoilox 0.5 % solution/ gel Or Surgical removal by scissor/ shave excision, curettage, laser or electro surgery Or Sinecatechins 15% ointment Or Trichloroacetic acid (TCA)/ Bichloroacetic acid (BCA) 80-90% solution Or Podophyllin resin 10-25% in compound tincture of benzoin Or Intra-lesional interferons II. For urethral meatus warts [1, 5] : Cryotherapy with liquid nitrogen Or surgical removal III. For vaginal / cervical/ intra-anal warts [1, 5] : Cryotherapy with liquid nitrogen Or Surgical removal Or TCA/ BCA 80-90% solution Table showing treatment options for anogenital warts, regime, instructions and their adverse effects [1, 4] Regime Imiquimod 5% / 3.5% cream Special instructions 5% cream : once at Wash with soap and night time for 3 days water 6-10 hrs after per week for maximum application upto 16 weeks 3.5% cream: once daily at night time 26 Adverse effects Local irritation, redness, induration, vesiculation, hypopigmentation. Limited data in pregnancy June | 2017 Indian Institute of Sexology | Bhubaneswar Podoilox (podophyllotoxin) 0.5% solution or gel Twice daily for 3 consecutive days of week for maximum up to 4 weeks Total area should not exceed 10 sq. cm Total volume should not exceed 0.5 ml/day Sinecatechins (green tea extract) 15% ointment Thrice daily (0.5 cm strand of ointment is applied to each wart) for maximum up to 16 weeks Do not wash Avoid sexual contact while ointment is on skin Cryotherapy Once per week Local anesthesia might facilitate if area is large Pain during and after application, necrosis, blistering TCA, BCA 80-90% solution Once per week Use small amounts Allow to dry before patient sits/stands If applied in excess or in case of pain, neutralize with soda bicarbonate, liquid soap or talc Spreads to adjacent tissues Podophyllin 10-25% in compound tincture of benzoin Once per week Wash after 1-4 hrs Use <0.5 ml per session and on <10 sq. cm area of warts Treatment area should not have open wounds/ friable tissue Local inlammation Due to systemic toxicity, no longer recommended Not safe in pregnancy Chancroid Chancroid is a genital ulcer disease caused by bacterium Haemophilus ducreyi. Diagnosis: All persons with genital/ anal/ perianal ulcers should be evaluated and following investigations should be done [6,7,8] : 1. Test for Haemophilus ducreyi - Direct smear is recommended as the irst step, although it Local irritation with mild to moderate pain Contraindicated in pregnancy Local inlammation Not given in HIV, pregnancy, genital herpes lacks both sensitivity and speciicity for deinite diagnosis. Smear is taken from the base of the ulcer and stained with Gram’s or Giemsa stain. The bacilli are seen as gram negative coccobacilli, with a typical ‘school of ish’, ‘rail-road track’ or ‘inger prints’ appearance. A deinite diagnosis require growing of organism in culture which include gonococcal agar base 27 June | 2017 Indian Institute of Sexology | Bhubaneswar with 2% bovine hemoglobin and 5% fetal calf serum and Mueller-Hinton agar with 5% chololatized horse blood. 2. Syphilis serology / dark ield examination/ Polymerase Chain Reaction (PCR) for treponema pallidum deoxyribo-nucleic acid (DNA) 3. Culture / PCR for genital herpes For clinical purposes, diagnosis of chancroid is made if all of the following criteria are met [1,7] : 1. One or more painful genital ulcers 2. Painful genital ulcer with regional lymphadenopathy (typical for chancroid) 3. No evidence of treponema pallidum by dark ield examination of ulcer exudates or by serologic test for syphilis performed at least 7 days after onset of ulcer 4. Negative Herpes Simplex Virus (HSV) culture / PCR Treatment The sexually transmitted diseases guidelines, 2015 by Centers for Disease Control and Prevention (CDC) [1,5] recommends the following regimens: Azithromycin 1g orally single dose Or Ceftriaxone 250 mg intramuscular injection single dose Or Ciproloxacin 500 mg twice a day orally for 3 days Or Erythromycin 500 mg thrice a day orally for 7 days Incision and drainage of bubo is preferred over needle aspiration. Sex partners should be treated if there is history of sexual contact during 10 days preceding onset of symptoms in patients. In pregnancy, Ciproloxacin is avoided but antimicrobials like Erythromycin and Ceftriaxone can be used for its treatment. 28 In HIV infected person same drugs are used, however, treatment for longer period may be required. Genital Herpes Genital herpes is mostly caused by Herpes Simplex Virus 2 (HSV2). However cases caused HSV1 have been reported recently. Diagnosis: HSV infection can be diagnosed by the following investigations [1,6,8]: 1. Tzanck smear: Smear is taken from the base of a vesicle or erosion and stained with Giemsa stain which may show multinucleated giant cells. But this test is usually insensitive and may be negative in later lesions. 2. Viral culture from vesicle luid: It is not done routinely as the viral cultures are not available in most laboratories. 3. Immunoluorescence can be done to demonstrate viral antigen but it lacks sensitivity. 4. PCR for HSV DNA is the most reliable test and also the investigation of choice for herpes encephalitis and aseptic meningitis. 5. Type speciic serology is indicated in case of recurrent symptoms but with negative HSV PCR/ culture. Treatment The regimen recommended by CDC 2015 guidelines [1,9,10] for herpes genitalis is as follows: A. First clinical episode Acyclovir 400 mg orally thrice daily for 7-10 days Or Acyclovir 200 mg 5 times a day for 7-10 days Or Valacyclovir 1g twice daily orally for 7-10 days June | 2017 Indian Institute of Sexology | Bhubaneswar Or Famcyclovir 250 mg thrice daily orally for 7-10 days B. Episodic therapy for recurrent genital herpes Acyclovir 400 mg thrice daily orally for 5 days Or Acyclovir 800 mg twice daily orally for 5 days Or Acyclovir 800 mg thrice daily for 2 days Or Valacyclovir 500 mg twice daily orally for 3 days Or Valacyclovir 1g once daily for 5 days Or Famcyclovir 125 mg twice daily for 5 days Or Famcyclovir 1g twice daily for 1 day C. Suppressive therapy for recurrent genital herpes Acyclovir 400 mg twice daily F. Suppressive therapy in pregnant women with recurrent genital herpes Antivirals should be started at 36 weeks gestation for prevention of neonatal herpes Acyclovir 400 mg thrice daily orally Or Valacyclovir 500 mg twice daily orally G. Neonatal Herpes [1,11,12] 1.Scenario 1 : When mother develops primary genital herpes at the time of delivery  Maximum chances of transmission from mother to child (50%)severe and fatal neonatal herpes  Or Valacyclovir 1g once daily Caesarean section done and I/V Acyclovir to child is given Or Famcyclovir 250 mg twice daily D. In severe disease/ disseminated disease/ Central nervous system(CNS) complications Acyclovir 5-10 mg/kg intravenous 8 hourly for 2-7 days followed by oral antiviral to complete at least 10 days of total therapy (21 days of I/V therapy in HSV encephalitis).  Treatment of mother with oral Acyclovir E. In persons with HIV Acyclovir 2. Scenario 2 : When mother develops primary genital herpes in third trimester Foetal growth retardation and premature birth Episodic treatment Suppressive therapy 400 mg thrice daily orally for 5-10 days 400-800 mg 2-3 times daily 3. Scenario 3 : If mother has history of genital herpes but no active infection during pregnancy monitor the baby and test for HSV.  Or Valacyclovir 1g twice daily for 5-10 days 500 mg twice daily Treatment of neonatal herpes: intravenous Acyclovir 60 mg / day in 3 divided doses for 2-3 weeks followed by oral Acyclovir for 6 months. Or Famcyclovir 500 mg twice daily for 5-10 days 500 mg twice daily Syphilis Syphilis is caused by spirochaetal bacterium Treponema pallidum. 29 June | 2017 Indian Institute of Sexology | Bhubaneswar Diagnosis: Following investigations can be done for diagnosis of syphilis [1,2,5,13,14,15]: Presumptive diagnosis is made by: NON TREPONEMAL TESTS TREPONEMAL TESTS Titres correlated with disease activity and used to follow up treatment response. 4-fold change in titre is signiicant Once positive remains positive throughout life VDRL (Venereal disease research laboratory) FTA-Abs (Fluorescent treponemal antibody absorbed test) TPPA (Treponema pallidum passive particle agglutination assay) RPR (Rapid plasma reagin) EIA (Enzyme immunoassay) TPHAI (Treponema pallidum haemaglutination assay) Deinite diagnosis is made by: 1. Dark ield examination 2. PCR for treponemal DNA Screening is performed by either EIA or combined VDRL/ TPHA. Positive results are conirmed by treponemal test of different type. It is essential to conirm presumptive serological diagnosis of syphilis on second specimen. Diagnosis of neurosyphilis is made by a combination of abnormal cerebro spinal luid (CSF) cell count/ protein, reactive CSF VDRL (highly speciic but insensitive), reactive serologic test in the presence of neurological signs and symptoms. Treatment [1,2,5,13,15] A. First line 1) Early Syphilis (Primary, secondary, early latent) Benzathine penicillin G 2.4 mega units intramuscular (I/M) injection single dose Or Procaine penicillin G 0.6 mega units I/M once daily for 10 days 30 2) Late latent and cardiovascular syphilis Benzathine penicillin G 2.4 mega units I/M weekly for 3 weeks (days 1, 8, 15) Or Procaine penicillin G 0.6 mega units I/M daily for 17 days 3) Neurosyphilis Procaine penicillin 2 g I/M daily + Probnecid 500 mg four times a day for 17 days Or Benzyl penicillin 18-24 mega units daily, given as 3-4 mega units I/V every 4 hrs for 17 days B. Second line 1) Early syphilis Doxycycline 100 mg twice daily orally for 14 days Or Erythromycin 500 mg four times a day for 14 days Or Azithromycin 500 mg once daily for 10 days Or Ceftriaxone 500 mg I/M inj. daily for 14 days (if no allergy to Penicillin) 2) Late latent and cardiovascular syphilis, neurosyphilis June | 2017 Indian Institute of Sexology | Bhubaneswar Doxycycline 200 mg twice daily for 28 days (if allergic to Penicillin) Or Amoxicillin 2 g thrice daily + Probnecid 500 mg QID for 28 days First line in pregnancy: Procaine penicillin G Follow up: Two years follow up is advised in latent or tertiary syphilis. Quantitative non treponemal test is repeated at 3 months, 6 months and each 6 months thereafter. Follow up for life is advised for cardio/ neurosyphilis. Doxycycline 100 mg orally twice daily for 21 days Or Erythromycin 500 mg four times a day for 21 days Or Azithromycin 1g orally once a week for 21 days Sex partners who have had contact within 60 days before onset of patient’s symptoms should be examined and tested for urethral/ cervical/ rectal chlamydial infection. Presumptive treatment with Azithromycin 1 g orally single dose should be given. Drug of choice in pregnancy is Erythromycin. Lymphogranuloma Venereum (LGV) LGV is caused by one of the three serovars (L1, L2, L3) of Chlamydia trachomatis. It is clinically characterized by tender inguinal and /or femoral lymphadenopathy- usually unilateral, with or without genital ulcer/ papule. Proctocolitis is a primary manifestation in those engaged in anal intercourse. Outbreaks of proctocolitis have been reported in men having sex with men (MSM). Diagnosis: Keeping in mind the clinical picture of patient and epidemiological information in the area, diagnosis is usually made by excluding all other differential diagnosis. Genital lesions/ rectal specimens/ lymph node aspirate can be tested for Chlamydia trachomatis by culture/ direct immunoluorescence/ nucleic acid ampliication test. PCR based genotyping can differentiate between LGV and Non- LGV Chlamydia trachomatis in rectal specimen. Complement ixation test more than or equal to 1:64 and microimmunoluorescence more than or equal to 1:256 support diagnosis [1,16,17]. Treatment [1,16,17] Incision and drainage of bubo/ aspiration AND Granuloma Inguinale It is genital ulcerative condition caused by Klebsiella granulomatis characterized by subcutaneous granulomas (pseudo-bubo) and absence of lymphadenopathy. Diagnosis: Diagnosis is made by demonstration of dark staining ‘Donovan bodies’ on tissue crush preparation or biopsy. ‘Donovan bodies’ are found in large mononuclear cells of monocyte/ macrophage lineage, whose cytoplasm contains numerous organism 0.5-0.7 X 1-1.5 micrometer in size, that show bipolar staining (safety pin appearance). Successful culture of causative organism has been reported in human peripheral blood monocytes and Hep2 cells [1,18,19]. Treatment [1,18,19] Azithromycin 1g orally once a week or 500 mg daily Or Doxycycline 100mg twice daily Or Ciproloxacin 750 mg twice daily Or Erythromycin 500 QID For Foratleast 6 weeks atleastand 6 weeks until all and until lesions all completely lesions heal completely heal Or Cotrimoxazole 960 mg twice daily 31 June | 2017 Indian Institute of Sexology | Bhubaneswar Add Gentamycin 1mg/kg I/V 8 hourly if no response is seen within irst few days of treatment. Treat sex partners who have had contact within 60 days before onset of symptoms in patients. Erythromycin or Azithromycin can be given to treat granuloma inguinale in pregnancy and lactation Investigations: [20, 21] 1. Presumptive diagnosis by demonstration of Gram negative intracellular diplococci within phagocytes in stained smears from anogenital sites. Sensitivity is 90-95 % in males with urethral discharge. Gonorrhoea 2. Culture is the gold standard for diagnosing gonorrhea which is 100 % speciic. Gonorrhea is caused by Neisseria gonorrheae. It results in a number of clinical syndromes including urethritis, cervicitis, epididymoorchitis, pelvic inlammatory disease, disseminated gonococcal infection and ophthalmia neonatorum. 3. Nucleic acid ampliication test (NAAT) is more sensitive than culture. Treatment [22,23] First line Ceftriaxone 500 mg intramuscular injection + Azithromycin 2g orally stat dose Second line Ceftriaxone 500 mg I/M injection Or Spectinomycin 2 g I/M inj + Azithromycin 2 g stat orally Or Ceixime 400 mg orally stat + Azithromycin 2g orally stat Third line Ciproloxacin 500 mg orally + Azithromycin 2 g stat orally Gonococcal epididymoorchitis Ceftriaxone 500mg I/M + Azithromycin 2 g orally stat followed by Doxycycline 100mg twice daily for 10-14 days Pelvic inlammatory disease Ceftriaxone 500mg I/M + Azithromycin 2 g orally stat followed by Doxycycline 100mg twice daily for 10-14 days + Metronidazole 400 mg twice daily for 10-14 days Gonococcal conjunctivitis Azithromycin 2 g orally stat + Ceftriaxone 500 mg I/M once daily for 3 days Genital Chlamydia Infection Genital Chlamydia infection is caused by Chlamydia trachomatis and is characterized by inlammation of genital and rectal mucous membrane; conjunctiva often asymptomatic. Investigations: Nucleic acid ampliication test is 32 now the only recommended diagnostic test for Chlamydia. Genotyping will differentiate between LGV and non LGV infections. A irst void urine is the sample of choice in men and in females, a self-taken vaginal swab or endocervical swab is also acceptable [21]. June | 2017 Indian Institute of Sexology | Bhubaneswar Treatment [1, 5] First line Azithromycin 1 g orally stat (including in pregnancy) Second line Doxycycline 100 mg twice daily for 7 days Third line Oloxacin 200-300 mg twice daily for 7 days Or Amoxicillin 500 mg QID for 7 days ( in pregnancy only) Chlamydial PID Ceftriaxone 250 mg I/M injection single dose + Doxycycline 100 mg twice daily for 14 days + Metronidazole 400 mg twice daily for 14 days Epididymoorchitis Ceftriaxone 500 mg I/M single dose + Doxycycline 100 mg twice daily for 14 days Chlamydia associated with reactive arthritis Rest and Non-Steroidal Anti Inlammatory Drugs (NSAID) Conclusion Effective prevention and treatment of sexually transmitted diseases can be achieved using a combination of responses constituting the ‘public health package’. The essential components of this package are promotion of safe sex behavior, condom distribution program, promotion of health care seeking behavior, speciic services to population at risk such as female and male sex workers, comprehensive case management of sexually transmitted infections and early detection of symptomatic and asymptomatic infections. For comprehensive case management, it is essential that an early diagnosis is made through laboratory tests or syndromic appraoach. Patients should be informed the importance of taking full course of treatment. Counseling should be made available for cases where it is needed. Partner notiication and treatment are essential elements of any STI control programme. These actions should be carried out with sensitivity, taking social and cultural factors into account, in order to avoid ethical problems. References 1. 2. Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep 2015; vol 64 (No 3). World Health Organisation. Global strategy for the prevention and control of sexually transmitted infections:2006-15. Breaking the chain of transmission. Geneva: WHO Press;2007. 3. 4. Fleming DT, Wasserheit JN,. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect 1999;75:3-17. Vender R, Bourcier M, Bhatia N, Lynde C. Therapeutic options for external genital warts. J Cutan Med Surg 2013;17:S61-7. 33 June | 2017 Indian Institute of Sexology | Bhubaneswar 5. Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines,2010. MMWR 2010;59(RR-12):1-115. Suntoke TR, Hardick A, Tobian AA, et al. Evaluation of multiplex real time PCR for detection of Hemophilus ducreyi, Treponema pallidum, Herpes simplex virus type 1 and 2 in the diagnosis of genital ulcer disease in the Rakai district, Uganda. Sex Trans Infect 2009;85(2):97-101. Lewis DA. Chancroid: clinical manifestations, diagnosis , and management. Sex Transm Infect 2003;79:68-71. Wald A, Huang ML, Carrell D, et al. Polymerase chain reaction for detection of herpes simplex virus (HSV) DNAon mucosal surfaces: comparison with HSV isolation in cell culture. J infect Dis 2003;188:1345-51. Johnston C, Saracino M, Kuntz S, et al. Standard dose and high dose daily antiviral therapy for short episodes of genital HSV-2 reactivation: three randomized, open label, cross over trials. Lancet 2012;379:641-7. Patel R, Bodsworth NJ, Woolley P, et al. Valaciclovir for the suppression of recurrent genital HSV infection: a placebo controlled study of once daily therapy. International Valaciclovir HSV study group. Genitourin Med 1997;73:105-9. Corey L, Wald A. Maternal and neonatal herpes simplex infections. N Engl J Med 2009;361:1376-85. Hollier LM, Wendel GD. Third trimester antiviral prophylaxis for preventing maternal genital herpes simplex virus (HSV) recurrences and neonatal infection. Cochrane Database Syst Rev 2008:CD004946. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2011. Atlanta: US Department of health and human services, 2012. Centers for Disease Control and Prevention (CDC), 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. Association of Public Health Laboratories. Laboratory diagnostic testing for treponema pallidum. Expert Consultation Meeting Summary Report, January 1315,2009, Atlanta, GA. Kingston M, French P, Goh B, et al. UK National Guidelines on the Management of Syphilis 2008. Int J STD AIDS 2008;19:729-40. Mabey D, Peeling RW. Lymphogranuloma vereum. Sex Transm Infect 2002;78:90-2. White JA. Manifestations and management of lymphogranuloma venereum. Curr Opin Infect Dis 2009;22:57-66. Richens J. Donovanosis (granuloma inguinale). Sex Transm Infect 2006;82(suppl IV);iv21-iv22. O’Farrel N. Donovanosis. Sex Transm Infect 2002;78:452-7. Stewart CM, Schoeman SA, Booth RA, Smith SD, Wilcox MH, Wilson JD. Assessment of self taken swabs versus clinician taken swab cultures for diagnosing gonorrhea in women: single centre. Diagnostic accuracy study. BMJ 2012;345:E8107. Papp JR, Schachter J, Gaydos C, et al. Recommendations for the laboratory based detection of Chlamydia trachomatis and Neisseria gonorrheae2014.MMWR Recomm Rep 2014;63(No. RR-2). World Health Organisation, Global action plan to control the spread and impact of antimicrobial resistance in Neisseria gonorrhea, 2012. Martin IMC, Hoffman S, Ison CA. European Surveillance of sexually transmitted infections (ESSTI): the irst combined antimicrobial susceptibility data for Neisseria Gonrrhoeae in western Europe. J Antimicrob Chemother 2006;58:587-93. If you have scintillating ideas in line with the goals and objectives of IISB, Please do share with us at sexualityinfo@gmail.com or write to us at Indian Institute of Sexology Bhubaneswar, Sanjita Maternity Care & Hospital, Plot No-1, Ekamra Marg, Unit-6, Bhubaneswar751001, Odisha, India. 34 June | 2017 Indian Institute of Sexology | Bhubaneswar Sexually Transmitted Infections in Children and Adolescents Dr. T.V. Ram Kumar Abstract Sexually transmitted infections (STI) or venereal diseases are a group of infections that are transmitted due to sexual contacts. These occur in children and adolescents mostly as result of sexual assaults or abuses. Increasing number of cases are also seen in the sexually experienced older children. These infections can be asymptomatic or can have a speciic symptom complex. Few of these conditions can present with common symptoms like pain or discharge. Prompt recognition of these conditions have good prognosis. Human Immunodeiciency Virus (HIV) infection also has similar mode of transmission as other STIs and there is a role of post-exposure prophylaxis to eliminate the infection. A good psychosocial support and privacy to treatment is required to maintain productive social life. Introduction Sexually transmitted infections are usually seen in children who are victims of sexual abuse and in adolescents who have multiple sex partners [1]. Several of these infections may present with a common symptom complex or a single infection with different presentations. Prompt recognition and treatment of these infections result in effective cure and control of transmission of these diseases. Epidemiology Risk of acquiring STI follows oral, vaginal and anal sexual activity. Most of the cases 35 June | 2017 Indian Institute of Sexology | Bhubaneswar occur in Indian context as a result of sexual abuse and assault. The prevalence varies widely depending on the residential area of population. The prevalence is much higher in slums where migrant workers and transgender live and low socioeconomic conditions prevail [2,3]. The risk increases with increase in number of sexual partners and practice of unprotected sex. The young girls are victims due to the blind belief that cure of STIs is possible on having intercourse with virgin girls. These cases are usually under reported either due to social stigma or due to threats from assailants. Many of these children do not even understand the nature of crime. The prevalence of STIs worldwide varies from 0.8% to 16% [3,4]. Hence it is very vital to teach parents, teachers, and social workers regarding the recognition of these crimes. In the recent period, sexual activity among older children and adolescents have increased. They are vulnerable due to their limited abstract thinking and belief of invulnerability and uniqueness. Adolescents particularly girls are biologically vulnerable to acquire STI due to cervical ectopy, and smaller introitus. The adolescents indulge in unprotected sex due to less access to barrier contraceptives. In the United States, 50% of STIs are seen in age group of 15-24 yrs [5]. The common agents of infection include fungal (Candida), bacterial (chlamydia, gonorrhoea, and syphilis), parasitic (trichomoniasis), and viral (Herpes Simplex Virus (HSV), Human Immunodeiciency Virus (HIV), Hepatitis, and Human Pappiloma Virus (HPV). In an Indian study conducted at GTB Hospital, New Delhi, there were 58 (16%) cases of STD under 14 yrs out of total 362 patients found in 18 months study period. Two-third of them were males. All of them belonged to low socio-economic strata and 36 were slum dwellers around Delhi-Uttar Pradesh border. All of them had contact with prostitutes and infections they acquire were syphilis, gonorrhoea, and chancroid [3]. Clinical features The clinical features are classiied according to the site and nature of lesion. 1) Urethritis: There is inlammation of urethra that presents with dysuria, burning micturition, itching, and meatal discharge. In males, 30% to 50% can be asymptomatic, where diagnosis is made by clinical signs alone. Pus is discharged from the meatus spontaneously or by gentle pressure. Most common causes are Chlamydia and N. gonorrhoeae [6,7]. Uncommon causes include T. vaginalis, HSV1 & 2, and Epstein Barr Virus (EBV). 2) Epididymitis: This condition results from the inlammation of epididymis and presents with ipsilateral scrotal swelling and pain. There is tender palpable epididymis, associated hydrocele, and history of urethral discharge [6,7]. The common causative pathogens are Chlamydia trachomatis and N. gonorrhoeae. 3) Vaginitis: There is inlammation of supericial vaginal mucosa, with or without extension to vulval region. The presentation varies with the pathogen. Bacterial vaginosis is caused by Gardnerella vaginalis, Ureaplasma, Mycoplasma, and anaerobic bacteria. Pathogenic bacteria replaces peroxide producing commensals. This condition has also been seen with lesbians. Trichomonas vaginalis, a protozoon produces symptoms of vulvar redness, pruritus, and foul smelling June | 2017 Indian Institute of Sexology | Bhubaneswar greenish discharge. Candida albicans produces similar picture with vulval irritation, pruritus, but has characteristic thick curdy vaginal discharge. In severe cases, there is issures and excoriations. These infections occur in isolation or in combinations [8,9]. 4) Cervicitis: The inlammation of cervical wall (endocervix) may be asymptomatic or may present with irregular bleeding. There is characteristic endocervical mucopurulent discharge (swab sign) and/or endocervical bleeding due to friability. The common pathogens are C. trachomatis and N. gonorrhoeae. 5) Pelvic Inlammatory Disease (PID): PID is a severe form of disease involving upper genital tract. The common pathogens are C. trachomatis and N. gonorrhoeae. They can also result from infections due to G. vaginalis, Haemophilus inluenza, anaerobes, Mycoplasma, and cytomegalo virus (CMV). It involves endometrium (endometritis), fallopian tubes (salpingitis), tubes and ovary (tubo-ovarian mass or abscess), or localized/diffuse peritonitis which has adverse long term outcomes like infertility and extrauterine pregnancy. The condition may be asymptomatic during acute stage, and may be recognized later due to fertility issues. The diagnosis in acute stage is made if any of the following signs are present: cervical tenderness on movement, uterine tenderness or adnexal tenderness on internal examination. The extent of involvement can be evaluated by Ultrasound (USG), contrast enhanced computed tomography (CECT), or magnetic resonance imaging (MRI) or laparoscopy. Early diagnosis and treatment always has better outcomes. 6) External Genital lesions: They present as warts caused by HPV (low risk types 6 and 11, or high risk types 16 and 18). Few other lesions include Condylomalata (syphilis) and Molluscum conntagiosum. Ectoparasites like lice and scabies can also be transmitted due to intimate physical contact [10]. 7) Genital ulcers: The causative pathogens are HSV (genital herpes), Treponema pallidum (chancre), Hemophilus ducreyi (chancroid). Ulcer occurs over penis or vulva, but it can also occur in oral mucosa and rectal mucosa due to unusual sexual practices. Genital Herpes is most commonly caused by HSV2, and less commonly by HSV1. They are usually recurrent. HSV1 cases are on rise in men having sex with men (MSM). There are many asymptomatic cases that transmit to others. The lesion starts as a vesicle, which ruptures to a painful, shallow ulcer. There are constitutional symptoms with inguinal adenopathy. The recurrent lesions are less severe, and there is long term subclinical shedding [11]. Chancre is characteristic of primary syphilis. The lesion is solitary and painless. Adenopathy is occasional and less severe. Chancroid presents as painful, multiple unindurated and undermined ulcers with a purulent base. There is unilateral or bilateral painful adenopathy. In severe cases, there is inguinal bubo formation, which can rupture. Lymphogranuloma venerum (LGV) transmitted by L1-L3 serovars is seen in cases of MSM [12]. The other organisms that are transmitted include 37 June | 2017 Indian Institute of Sexology | Bhubaneswar HIV, Hepatitis B virus (HBV), CMV, and many gastrointestinal pathogens that are transmitted due to adolescent sexual practices. Diagnosis As per Centers for Disease Control and Prevention (CDC), there are recommendations for routine screening in sexually active adolescent females and males. They are screened for C. trachomatis, N. gonorrhoeae, syphilis, HIV, HBV, and Hepatitis C virus (HCV). The key for successful screening is a thorough sexual history taking to identify adolescents who need to be further tested for STI [13]. The discussions should be private, and should be individualized to avoid social stigma. Similarly the victims of abuse and sexual assault should receive utmost care and social support during screening and examination. The essential tests include Gram staining of secretions and nucleic acid ampliication test (NAAT) of urine/urethral/cervical/vaginal/anal/ oral secretions to detect C. trachomatis and N. gonorrhoeae. Presence of Gram-negative intracellular diplococci in specimen suggests N. gonorrhoeae infection. In adolescent females with vaginitis, the vaginal discharge specimen is subjected to routine pH test (>4.5 is suggestive of bacterial vaginosis or trichomoniasis) and microcopy studies with dilution in normal saline or 10% Potassium hydroxide (KOH). The saline samples are used to ind motile or dead T. vaginalis or clue cells (clue cells are epithelial cells with obscured borders due to small bacteria), and KOH specimens are used for diagnosing yeast or Candida pseudohyphae. There are many recent Clinical Laboratory Improvement Amendments (CLIA) approved tests that are sensitive, more easily performed and detect multiple organisms 38 like OSOM (Genzyme Diagnostics, Cambridge, Mass), Trichiomonas Rapid test, OSOM BV BLUE test, Afirm VPIII. The Pelvic Inlammatory Disease is diagnosed as a combination of history taking, examination, and laboratory tests. A low threshold is necessary for making the diagnosis. The patient needs to be investigated using transvaginal USG, or laparoscopy (including biopsy) to assess the extent of disease and deciding the treatment. HSV is diagnosed by Tzanck smear (less sensitive and nonspeciic) and NAAT, including PCR assay (more sensitive). Syphilis is diagnosed by VDRL (Venereal Disease Research Laboratory) test or RPR (Rapid plasma reagin), treponemal EIA (enzyme linked immunosorbent assay) or CIA (enzyme or chemiluminescence immunoassay). HIV screening is highly essential at ICTC (integrated counseling and testing centers) [13]. Differential diagnosis Similar symptoms can be seen in number of other infections/conditions. These conditions have to be ruled out for appropriate treatment. The conditions where symptoms can mimic STIs include urinary tract infection, acute appendicitis, colitis, tuberculosis (abdominal and urogenital) tubal pregnancy, Behcet disease, physiological secretions. Treatment The adequacy and completeness of treatment requires easy accessibility and privacy. Complete treatment includes the treatment of the individual and all the sexual contacts within last 60 days or the last contact if more than 60 days. There is delay in seeking medical help by female adolescents due to social stigma and in adults due to inability to differentiate pathological discharges form the June | 2017 Indian Institute of Sexology | Bhubaneswar normal one. Appropriate treatment of the disease is essential to decrease the chances of infertility in future. The patient also needs to be tested for pregnancy. Repeat testing is required after 3 months [13]. The treatment of partner is ideal after physical assessment, however in cases where direct examination is not possible, one partner is given the prescription/medication for the other partner. This is called expedited partner therapy (EPT) or patient delivered partner therapy (PDPT) [14]. The regimens for the treatment of the STIs have been depicted in table 1. The complicated cases may require referral to higher centers. Along with medical treatment, sexual abuse or assault cases need to be given adequate social support and psychiatric counseling. Table 1: Management of uncomplicated STI Infection Treatment N. gonorrhoeae Inj. Ceftriaxone 250mg i.m. stat + 1gm Azithromycin stat (Single Dose) Chlamydia trachomatis Doxycycline 100mg twice daily x 7 days Or Azithromycin 1g stat (Single Dose) Chlamydia trachomatis (L1,2,3) LGV Doxycycline 100mg twice daily x 21 days Primary and secondary syphilis Inj. Benzathine Penicillin G 2.4 million unit i.m. stat (Doxycycline 100 mg BD x 14 days if allergy to penicillin). Late syphilis Inj. Benzathine Penicillin G 2.4 million unit i.m. weekly for 3 weeks (Doxycycline 100 mg BD x 28 days if allergy to penicillin). H. ducreyi Azithromycin 1gm oral single dose or inj. Ceftriaxone 250 mg i.m. single dose T. vaginalis Tab. Metronidazole 2gm single dose. Scabies 5% Permethrin or Tab. Ivermectin 200µg/kg oral 2 doses 2 weeks apart. Pubic lice 1% Permethrin local application.Rinse after 10 min. Herpes simplex virus Acyclovir 400 mg TDS x 7-10 days (1st episode) Acyclovir 400 mg TDS x 5 days (recurrence) HPV (uro-ano-genital warts) Podoilox 0.5% (for external genitalia only) or cryotherapy or Trichloroacetic acid application (all types) 39 June | 2017 Indian Institute of Sexology | Bhubaneswar Prevention STIs can be prevented by avoiding close sexual contacts. Prevention strategies include abstinence, single sexual partner, and effective use of barrier contraceptives. Sex education particularly to adolescents can go a long way in preventing STIs. The HPV infection can be prevented by HPV vaccination in the adolescents [15,16]. Conclusion Estimating the true incidence/prevalence of STIs is very dificult due to the asymptomatic nature of many infections, and social stigma as that would reveal the individual sexual history and preference. On the other hand, the cases are on a rise due to poverty, migration, child labor, and illiteracy. With changes in lifestyles and independency, cases are also being reported among afluent classes with drug-addiction. This menace needs to be addressed by appropriate sex education of adolescents and periodical assessment by questionnaires to ind out issues like drug addiction, depression, and child abuse. Timely and appropriate treatment can cure some of the conditions and preserve the fertility in females. References 1. 2. 3. 4. 5. 6. 7. ACOG Committee on Adolescent Health Care, 2004. ACOG Committee on Adolescent Health Care : Sexually transmitted diseases in adolescents. Sex Transm Dis Adolesc 2004; 104:891-898. White ST, Loda FA, Ingram DL, et al. Sexually transmitted diseases in sexually abused children. Pediatrics 1983, 72: 16-21. Pandhi RK, Khanna N, Sekhri R. Sexually transmitted diseases in children. Indian Pediatrics 1995. Jan; 32 (1); 27-30. Ingram DL, Everett VD, Lyna PR, White ST, Rockwell LA. Epidemiology of adult sexually transmitted disease agents in children being evaluated for sexual abuse. Pediatr Infect Dis J. 1992 Nov;11(11):945-50. Mosher WD, Chandra A, Jones J. Sexual behavior and selected health measures: men and women 1544 years of age, United States, 2002. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2005 Sep 15. Richens J. Main presentations of sexually transmitted infections in men. BMJ. 2004 May 22; 328 (7450): 1251-3. Peipert JF. Genital chlamydial infections. N Engl J Med 2003; 349:2424-2430. 40 8. 9. 10. 11. 12. 13. 14. 15. 16. Marrazzo J. Vulvovaginal candidiasis. Br Med J 2003; 326:993-994. Mitchell H. Vaginal discharge-causes, diagnosis, and treatment. BMJ: British Medical Journal. 2004 May 27;328(7451):1306. Schiffman M, Castle PE. When to test women for human papillomavirus. Br Med J 2006; 332:61-62. Cherpes TL, Meyn LA, Hillier SL. Cunnilingus and vaginal intercourse are risk factors for herpes simplex virus type 1 acquisition in women. Sex TransmDis 2005; 32:84-89. Collins L, White JA, Bradbeer C. Lymphogranuloma venereum. Br Med J 2006; 332:66-67. Centers for Disease Control and Prevention : Sexually transmitted diseases treatment guidelines, 2006. MMWR 2006; 55:1-94. Golden MR, Whittington WLH, Handsield HH. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med 2005; 352:676-684. Steinbrook R. The potential of human papillomavirus vaccines. N Engl J Med 2006; 354:1109-1112. Gbesso S, Decosas J, Gnahoui-David B, et al: Adolescent sexual health? Let us get real ! Lancet 2006; 367:1221-1222. June | 2017 Indian Institute of Sexology | Bhubaneswar Neurosyphilis : Current understandings Dr. Ravi uniyal | Dr. Nidhi Tejan Dr. Ravindra Kumar Garg | Dr. Vimal K Paliwal Abstract Neurosyphilis is neurological complication of syphilis, a sexually transmitted disease caused by infection of Treponema pallidum. In pre-antibiotic era, it was considered almost incurable condition. After the introduction of penicillin for treatment, survival dramatically improved. Recently, upsurge is seen in neurosyphilis especially in Human Immunodeiciency Virus (HIV) infected patients and homosexual population. In current scenario, concurrent HIV and syphilis infections poses a major challenge as both conditions have similar modes of transmission and risk factors. Development of neurosyphilis is more common in HIV infected syphilis patients than non-HIV infected patients and presence of syphilis poses a negative impact on viral load (increases viral load) in HIV infected patients which further enhances the transmission of HIV. Introduction Neurosyphilis is neurological complication of syphilis, a sexually transmitted disease caused by infection of Treponema pallidum. Most of the neurological complications are thought to occur late after primary syphilitic infection. But, neurosyphilis can occur early as well as late in the syphilis. There are evidences which suggest that involvement of nervous system by disease process occurs early in the syphilis (within days to weeks). In pre-antibiotic era, neurosyphilis was considered almost incurable condition. People used to think that it was sent from the God as a punishment to the mankind [1]. Before the advent 41 June | 2017 Indian Institute of Sexology | Bhubaneswar of penicillin, a number of therapies (some of them were very bizarre) were used for the management of this condition including mercury, arsenicals with bismuth, fever therapy (fever induced by malaria) and suspension therapy (suspending patients by their necks in an apparatus) [2,3]. After the introduction of penicillin, treatment and survival dramatically improved. Recently resurgence in incidence of neurosyphilis is seen particularly in HIV patients which compels us to review this condition in changing scenario. Pathophysiology of neurosyphilis After primary infection of Treponema pallidum, partial immunity develops which is insuficient to eradicate the bacteria from the human body. This results in persistent latent infection in some patients. There are evidences which suggest that invasion of nervous system occurs very early. In around 25% of untreated patients, the bacteria can be seen in cerebrospinal luid (CSF) in the early syphilis [4]. After the initial invasion, course may vary in individual patients depending upon the host factors and the virulence of strain. In some patients, spontaneous resolution occurs without any inlammatory reaction. In others, transient meningitis may develop which may resolve spontaneously. In some others, persistent meningitis may develop if organism was not cleared from the CSF. These patients may have asymptomatic meningitis. It has been demonstrated that higher the abnormality seen in the CSF in asymptomatic meningitis, higher the chances of developing symptomatic neurosyphilis later. in about one third of patients. At that time, one third used to have asymptomatic neurosyphilis and another one third used to have tabes dorsalis [5]. Around 10% used to have general paresis and in about the same proportion, meningovascular syphilis was seen. Other forms of neurosyphilis were less common and was seen in remaining proportions. In current era, due to wide use of antibiotics, late complications of syphilis including neurosyphilis are uncommon. Tabes dorsalis, once the most common form of neurosyphilis, is now rarely seen. Now-a-days, neurosyphilis is seen mostly in homosexual men, most of them are also having concurrent human immunodeiciency virus (HIV) infection [6]. It has also been shown that HIV patients with lower CD4 lymphocyte counts are more likely to develop symptomatic neurosyphilis. Clinical presentations of neurosyphilis Neurosyphilis can affect the meninges, parenchyma of brain and spinal cord and vessels. On the basis of duration between neurological presentation following the primary infection, neurosyphilis can be categorized as early and late neurosyphilis. Early complications include asymptomatic meningitis, symptomatic meningitis and meningovascular syphilis. Late neurosyphilis includes general paresis of insane and tabes dorsalis. Ocular syphilis (posterior uveitis and panuvieitis) and otitic syphilis (hearing loss with or without tinnitus) can occur early as well as late. Asymptomatic meningitis: Patient does not have Changing epidemiology In pre-antibiotic era, neurological complications of syphilis were very common and used to be seen 42 any symptom or sign suggestive of neurological involvement but CSF examination is abnormal. It occurs within weeks to months after the primary June | 2017 Indian Institute of Sexology | Bhubaneswar infection. It is rare after two years of initial infection. Sometimes patient may have symptoms and signs suggestive of simultaneous primary or secondary syphilis. The diagnosis is primarily based on abnormal CSF indings which include CSF lymphocytes> 5 cells/microlitre, CSF protein >45 mg/dl and reactive CSF-VDRL (Veneral Disease Research Laboratory) in different combinations. Most of these patients have milder abnormalities i.e. CSF-cells<100 cells/microlitre, protein <100 mg/dl. In HIV negative patients if asymptomatic meningitis is clinically suspected, abnormal CSF indings are considered consistent with the diagnosis even if CSF-VDRL is nonreactive. In HIV positive patients, if CSF-VDRL is non reactive, the diagnosis of asymptomatic meningitis is dificult to substantiate because mild CSF abnormality can also occur due to HIV infection itself. Symptomatic meningitis: It usually occurs within a year of initial infection but can also occur later. Patient usually presents with headache, nausea, vomiting, confusion and neck stiffness. Fever is uncommon. Cranial nerves involvement is quite common. Common cranial nerves affected are 7th, 8th, 6th and 2nd cranial nerves. Focal meningeal inlammation may turn into diffuse meningitis or it may form syphilitic gummas (focal inlammatory mass lesions adjoining leptomeninges). Sometimes meningitis may resolve spontaneously. Most of the times, these untreated meningitis patients develop more severe forms of neurosyphilis later. Syphilitic meningitis sometimes may also involve spinal cord and lead to meningomyelitis and present with back pain, weakness, sensory loss and incontinence. In symptomatic meningitis, CSF abnormality is more severe in comparison to asymptomatic meningitis. In these patients, CSF-VDRL is almost always reactive. CSF-cells are in range of 200-400 cells/ microl and protein is found in range of 100-200 mg/dl. Cranial or spinal Magnetic Resonance Imaging (MRI) usually shows enhancement of meninges. Cerebral gummas are enhancing lesions contiguous to meninges with associated surrounding oedema [7]. Meningovascular syphilis: Syphilitic meningitis can cause infectious arteritis of any vessel surrounding the brain or spinal cord which may lead to thrombosis and infarction. This can present as an ischemic stroke, especially in young people. Stroke may develop at any time from the initial few months to few years after the primary infection. In the pre-antibiotic era, the mean duration between primary infection and stroke was seven years [5]. Middle cerebral artery is most commonly involved. Rarely, anterior spinal artery may also get involved and patient may develop spinal cord infarction. Some patients develop headache, dizziness, change in behaviour (due to concurrent meningitis) prior to the onset of ischemic stroke. CSF abnormality found in meningovascular syphilis is less severe in comparison to acute meningitis. CSF-cells range from 10-100 cells/microlitre and protein ranges from 100-200 mg/dl. CSF-VDRL is usually reactive but not necessarily in all cases. Vascular abnormalities in form of focal segmental narrowing, focal narrowing and dilatation, or complete occlusion can be visualized on CT/MR/ digital subtraction angiography. The indings are non-speciic and can be seen in any infectious or non-infectious vasculitis. 43 June | 2017 Indian Institute of Sexology | Bhubaneswar General paresis of insane: It is a form of tertiary syphilis and usually occurs 10-25 years after the primary infection but can also occur early occasionally. It is also known as paretic neurosyphilis or dementia paralytica. In preantibiotic era, it usually led to death within few years with a mean of 2.5 years. Initially, these patients develop forgetfulness and personality change. Gradually as disease progresses, the severity of symptoms increases and they develop severe dementia. Occasionally patients also develop predominant psychiatric symptoms in form of depression, psychosis or mania. Neurological examination reveals dysarthria, tone abnormality and relex abnormality. Argyll-Robertson pupil may also be seen. Pupillary abnormality is more consistent with tabes dorsalis. CSF is always abnormal in this condition [8]. Tabes dorsalis: In pre-antibiotic era, this was the most common presentation of neurosyphilis which is now very rare. It usually occurs after 20 years of primary infection but can also occur as early as after three years of primary infection. In this, posterior column of spinal cord and dorsal roots are affected. Clinically patients present with sensory ataxia and lancinating pains. Sensory ataxia causes dificulty in walking especially when eyes are closed. It may lead to frequent falls especially in the dark. The pain occurs in the form of sudden, severe episodes of stabbing pain. It may affect limbs or back and may last for minutes to days. Sometimes patient may develop recurrent attacks of epigastric pain, nausea and vomiting. Bladder dysfunction in the form of urinary retention or overlow incontinence can occur early in the course. Other important clinical features include pupillary irregularities, absent 44 lower limb relexes, impaired vibratory and joint position sense in feet, optic atrophy. One very important pupillary sign seen in tabes dorsalis, is the Argyll Robertson pupil which is observed in around half of the patients. Argyll Robertson pupil is characterized by small sized pupil which does not respond to light but contracts normally to accommodation and convergence. It also does not dilate in response to painful stimuli and dilates poorly to mydriatics. In tabes dorsalis, CSF examination may be entirely normal or it may show mild lymphocytic pleocytosis (10-50 cells/ microl) and mildly raised protein (45-75 mg/dl). In around one fourth of patients, CSFVDRL test may be nonreactive. Atypical forms of neurosyphilis: Some authors proposed the entity of ‘atypical neurosyphilis’ for those patients who do not fulill the clinical criteria for one of the classically described forms neurosyhilis i.e. symptomatic meningitis, meningovascular syphilis, general paresis, and tabes dorsalis. They hypothesized that widespread use of antibiotics for unrelated infection in an undiagnosed syphilis patient may lead to incomplete treatment which further may produce atypical forms or forme fruste of typical syndromes. They reported milder forms and mono-symptomatic clinical presentations e.g. relex abnormality, sensory abnormality, seizure or pupillary abnormality [9]. There is another school of thought which says that such milder forms were always existed [5] and their proportion has not increased in recent reports. HIV and neurosyphilis: There are evidences that suggest that HIV infection modulates the clinical presentation of syphilis in form of greater organ involvement, atypical and lorid skin rashes. June | 2017 Indian Institute of Sexology | Bhubaneswar It may also lead to more rapid progression to neurosyphilis [10]. Status of HIV infection may also affect the results of serologic tests for syphilis. Apart from that, there are also evidences which suggest that simultaneous syphilis infection may lead to increased HIV viral load. The risk factors for developing neurosyphilis in HIV infected patients include CD4 count of <350 cells/microl, RPR (rapid plasma reagin) titer >1:128, and male gender [11]. Diagnosis of Neurosyphilis Diagnosis of neurosyphilis is established using CSF examination indings and clinical criteria. Cell count (WBCs either polymorphs and/or lymphocytes) of >5/ml, proteins >0.45g/l in CSF or IgG index of >0.6 are indicators of the disease. The indings are nonspeciic and have a low sensitivity. These parameters should be carefully interpreted in patients with HIV as the rise in cell count and proteins may be present without the disease. A single test cannot be used to conirm the diagnosis. Ruling in the diagnosis, relies upon the detection of intrathecal antibodies which can either come via blood brain barrier through circulation or may be produced from plasma cells intrathecally. There are two types of test which can be used for diagnosing neurosyphilis. The non-treponemal tests detect the antiphospholipid antibodies which can be nonspeciic while treponemal tests detect the anti-treponemal antibodies. Non-treponemal tests include venereal disease research laboratory (VDRL) and rapid plasma reagin (RPR). Treponemal tests include luorescent treponemal antibody absorption (FTAABS), treponema pallidum particle agglutination assay (TPPA) and syphilis enzyme immunoassays (EIAs). Neurosyphilis is conirmed when serum treponemal tests are reactive along with CSFVDRL [12]. In neurosyphilis especially in tabes dorsalis, the nontreponemal tests may be nonreactive. If there is clinical suspicion of late neurosyphilis, serum treponemal tests i.e. FTAABS, TPPA, or syphilis EIA should always be conducted. In patients with syphilis, these tests usually remain reactive, irrespective of previous treatment. If these tests are reactive, it suggests that the patient had syphilis any point of time in his or her life and there is a risk of neurosyphilis in these patients. The diagnostic criteria of neurosyphilis are as follows: Deinite neurosyphilis 1. Positive blood treponemal serology and 2. Positive CSF VDRL Probable neurosyphilis 1. CSF mononuclear pleocytosis, 2. Neurological signs and symptoms compatible with neurosyphilis, 3. Positive blood treponemal serology and 4. Negative CSF VDRL Possible neurosyphilis 1. CSF mononuclear pleocytosis, 2. Absent neurological signs and symptoms compatible with neurosyphilis, 3. Positive blood treponemal serology and 4. Negative CSF VDRL Treatment of neurosyphilis Centers for Disease Control and Prevention (CDC) has provided guidelines for the treatment of neurosyphilis [13]. 1. Aqueous crystalline penicillin G, 18 to 24 million units per day, administered as 3 to 4 million 45 June | 2017 Indian Institute of Sexology | Bhubaneswar units intravenous (I/V) every four hours, or 24 million units daily as a continuous infusion for 10 to 14 days, or Procaine penicillin G, 2.4 million units intramuscular (IM) once daily plus probenecid 500 mg orally four times a day, both for 10 to 14 days. 2. An alternative treatment for patients who have a mild penicillin allergy is ceftriaxone 2 g IV or IM daily for 10 to 14 days, with careful observation for crossreactivity [14]. High dose doxycycline 200 mg orally twice a day for 21 to 28 days may also be used as an alternative (still not recommended by the CDC or European guidelines) option [15]. Conclusion After the introduction of penicillin, there is marked reduction in neurosyphilis. Recently, upsurge is seen in neurosyphilis especially in HIV infected patients and homosexual population [16,17]. In current scenario, concurrent HIV and syphilis infections poses a major challenge as both conditions have similar modes of transmission and risk factors [18]. Apart from that, infection with one condition may enhance the transmission of the other [19,20]. It is very important to keep the possibility of neurosyphilis in patients with HIV and/or homosexual behaviour presenting with neurological problems. Apart from this, now a days, short course antibiotic use is common for various infective indications. This may lead to incomplete treatment in an undiagnosed syphilis patient which may lead to milder atypical forms or forme fruste of typical syndromes. This further complicates the issue and demands high clinical suspicion in relevant clinical scenario. References 1. 2. 3. 4. 5. 6. 7. McGough LJ. Demons, nature, or God? Witchcraft accusations and the French disease in early modern Venice. Bull Hist Med. 2006 Summer. 80(2):21946. [Medline]. WagnerJauregg J. The history of the malaria treatment of general paralysis. 1946. Am J Psychiatry. 1994 Jun. 151(6 Suppl):2315. [Medline]. Lanska DJ. The suspension apparatus for tabes dorsalis. Neurology. 1999 Apr 12. 52(6):1295. [Medline]. Lukehart SA, Hook EW 3rd, BakerZander SA, et al. Invasion of the central nervous system by Treponema pallidum: implications for diagnosis and treatment. Ann Intern Med 1988; 109:855. Merritt HH, Adams RD, Solomon HC. Neurosyphilis, Oxford University Press, New York 1946. Wong W, Chaw JK, Kent CK, Klausner JD. Risk factors for early syphilis among gay and bisexual men seen in an STD clinic: San Francisco, 20022003. Sex Transm Dis 2005; 32:458. Fargen KM, Alvernia JE, Lin CS, Melgar M. Cerebral syphilitic gummata: a case presentation and analysis of 156 reported cases. Neurosurgery 2009; 64:568. 46 8. 9. 10. 11. 12. 13. 14. Zheng D, Zhou D, Zhao Z, et al. The clinical presentation and imaging manifestation of psychosis and dementia in general paresis: a retrospective study of 116 cases. J Neuropsychiatry Clin Neurosci 2011; 23:300. Hooshmand H, Escobar MR, Kopf SW. Neurosyphilis. A study of 241 patients. JAMA 1972; 219:726. Flood JM, Weinstock HS, Guroy ME, et al. Neurosyphilis during the AIDS epidemic, San Francisco, 19851992. J Infect Dis 1998; 177:931. Ghanem KG, Moore RD, Rompalo AM, et al. Neurosyphilis in a clinical cohort of HIV1infected patients. AIDS 2008; 22:1145. Harding AS, Ghanem KG. The performance of cerebrospinal luid treponemalspeciic antibody tests in neurosyphilis: a systematic review. Sex Transm Dis 2012; 39:291. Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64 (RR3) :1-137. Marra CM, Boutin P, McArthur JC, et al. A pilot study evaluating ceftriaxone and penicillin G June | 2017 Indian Institute of Sexology | Bhubaneswar as treatment agents for neurosyphilis in human immunodeficiency virus infected individuals. Clin Infect Dis 2000; 30:540. 15. Yim CW, Flynn NM, Fitzgerald FT. Penetration of oral doxycycline into the cerebrospinal luid of patients with latent or neurosyphilis. Antimicrob Agents Chemother 1985; 28:347. 16. Tomberlin MG, Holtom PD, Owens JL, Larsen RA. Evaluation of neurosyphilis in human immunodeiciency virus–infected individuals. Clin Infect Dis 1994; 18:288–94. 17. Centers for Disease Control and Prevention (CDC). Symptomatic early neurosyphilis among HIVpositive men who have sex with menfour cities, United States, January 2002June 2004. MMWR Morb Mortal Wkly Rep 2007; 56:625. 18. Ganesan A, Fieberg A, Agan BK, et al. Results of a 25year longitudinal analysis of the serologic incidence of syphilis in a cohort of HIVinfected patients with unrestricted access to care. Sex Transm Dis 2012; 39:440. 19. Solomon MM, Mayer KH, Glidden DV, et al. Syphilis predicts HIV incidence among men and transgender women who have sex with men in a preexposure prophylaxis trial. Clin Infect Dis 2014; 59:1020. 20. Wasserheit JN. Epidemiological synergy. Interrelationships between human immunodeiciency virus infection and other sexually transmitted diseases. Sex Transm Dis 1992; 19:61. With Best Compliments From Zydus Alidac Fortiza THE MAKERS OF Sustanon 100/250 ( TESTOSTERONE PROPIONATE IP 30MG, TESTOTERONE PHENYL PROPIONATE 60MG, TESTOSTRONE DECANOATE BP 100MG ) Zydalis 10/20 (TADALAFIL 10MG & 20MG) Penegra – 50mg & 100mg ( SILDENAFIL CITRATE TAB ) Udzire 100 ( UDENAFIL 100MG ) Registered Ofice : “ ZYDUS TOWER” Satellite Cross Road Sarkhej-Gandhi Nagar Highway Ahmedabad – 380 015 47 June | 2017 Indian Institute of Sexology | Bhubaneswar Sexually Transmitted Disease and Mental Illnesses : understandings and Implications Ms. Deblina Roy | Dr. Sujit Kumar Kar Abstract Both sexually transmitted diseases (STDs) and mental illnesses are important public health concerns. Both mental illnesses and STDs have high burden of care and they produce signiicant impairment in life. When these entities exist together, morbidity and consequently the cost of care multiply several times. Mental illness increases the risk of STD. Patients with STDs also have higher risks to develop mental illnesses. Considering the public health signiicance, it is important to understand the association of STDs and mental illness, so that appropriate preventive as well as remedial measures can be taken. Introduction Sexually transmitted diseases (STDs) are one of the major public health concerns worldwide. Having a mental illness, may pose risk to develop STDs in an individual. Studies have reported that the risk for the sexually transmitted diseases are 10-20 fold higher in the psychiatric patients, compared to the general population and the factors that have been found responsible for that are, impaired autonomy, increased impulsivity, increased susceptibility to persuaded or threatened sexual activity, poor living conditions, medical and environmental conditions [1]. The major factor for the increased sexually transmitted infections (STI) was found to be the prominent psychiatric conditions which impair the person’s decision making and thought process. Failure of the standard STI prevention interventions in such vulnerable population demands the need for the newer and innovative methods for the prevention of STI [1]. 48 June | 2017 Indian Institute of Sexology | Bhubaneswar A study from Brazil, revealed that nearly one fourth of patients with mental illness have lifetime history of STDs [2]. Similarly a study from United States revealed that the prevalence of HIV, Hepatitis B and C virus infection in patients with severe mental illnesses are several folds higher than their prevalence in general population [3]. Evidences suggest that women having sex with women (WSW) attending STD clinics, had disproportionately higher incidences of mental health issues (anxiety, depression, suicidal behavior) including substance use disorders [4]. A large scale study with a sample size of 289604, was conducted among the privately insured clients of America who used mental health facilities to ind out the prevalence of sexually transmitted infections. The results showed that among the mentally ill females there was 3% chance of incurring STIs and in case of male the chance for being diagnosed with STI was about 1.2% [5]. The study recommended that among the united states privately insure population the strategies like screening for mental illness and STIs should be adopted to reduce the cost of health care [5]. The relationship between sexually transmitted diseases (STDs) and mental illness is bidirectional. Presence of STDs increases the risk of mental illness and vice versa. There may be exceptions to this relationship. For example, victims of sexual abuse are at risk of acquiring sexual transmitted diseases and psychological dificulties. Here, both the effects (STD and mental illness) are related more due to sexual abuse. Kawsar et al., in their study found the prevalence of sexually transmitted infections (STIs) in children and adolescents with sexual abuse to be 26% and psychological issues in this population to be 81% [6]. Mood changes, attempts of self-harm and sleep disturbances were the common issues in this population [6]. STDs in patients with Mental Illness Sexuality is a very important aspect of any human being whether ill or healthy, but the sexual practices among the patients with mental illnesses, have been studied quite less. Research shows that they have negative self-esteem, low conidence level and they are also unhappy with their sexual life [7]. There are various factors that make the patients with mental illness vulnerable to acquire STDs. Patients with severe mental illnesses and those in intoxicated state with substance often have lack of judgement, which make them vulnerable to indulge in unsafe sexual practices and acquire STDs [8]. When severe mental illness and illicit substance use co-exist, high risk sexual behavior increases, further making the individual more vulnerable for STDs [9]. Evidences suggest that young individuals with schizophrenia spectrum disorders, mania, substance use disorder and antisocial personality carry higher risk to indulge in risky sexual practice and are at higher risk of acquiring STDs [10]. Even patients with depression can indulge in high risk sexual activities, which counters the myth that the depressed patients have no sexual desire at all [11]. The lack of insight and lack of self-concern in the patients with the major psychiatric illnesses also makes them more vulnerable for STI and decreases their chances of the adherence to the treatment leading to complications. It has also been observed in the studies that the people affected with STIs often irst show affective symptoms, most commonly depression and diagnosis of STI follows [12]. Substance use has 49 June | 2017 Indian Institute of Sexology | Bhubaneswar been very strongly linked with the high risk sexual behaviour and studies also show that the use of alcohol and other stimulants have increased high risk sexual behaviour and consequently higher incidences of sexually transmitted diseases among heterosexuals [13]. Hypersexual behavior, novelty seeking behavior and poor impulse control in various psychiatric disorders lead to indulgence in unsafe sexual practice and development of STDs. The igure 1 below describes the various factors that attribute to development of STDs in patients with mental illness. Figure 1: Explanatory model of Sexually Transmitted Disease in Mental Illness If sexually transmitted disease is present in patients with mental illnesses, then the risk of transmission in the community increases due to their high risk sexual behavior and unsafe sexual practices. Mental illnesses in patients with STDs Patients suffering from STDs go through enormous shame, guilt, fear and anger. This affects their mental health adversely. These psychological reactions are secondary to acquiring STDs. Similarly, STDs may cause 50 signiicant impairment and disability, which may develop mental illnesses. Stigma has a close association with STDs. Stigma causes isolation, unemployment and loss of self-repute, which may in turn cause psychological distress. A study suggests that there is high prevalence of the neurocognitive disorders in the HIV infected individuals and the highly active anti-retroviral treatment is also not that effective to stop the neuro psychiatric complications of HIV [14]. The igure 2, below explains the causes of mental illness in patients with STDs. June | 2017 Indian Institute of Sexology | Bhubaneswar Figure 2: Explanatory model of Mental Illness in Sexually Transmitted Disease Other than the above mentioned speciic causes, the patients with STDs may also develop mental illnesses due to other risk factors like positive family history, substance use, past history of psychiatric illness, maladaptive personality and poor coping skills etc which put general population at risk also. STD prevention strategies among the mentally ill The best quality evidences gathered over the past few decades suggest that the strategies for the behavioural change in the mentally ill to prevent the STIs are better if the interventions are targeted towards awareness, attitude and behavior of the individual. The strategies that caused fear among the patients regarding HIV were least effective [15]. Research evidences also show that only providing education to the mentally ill people is not enough to ensure the prevention of the STI among them. There is a requirement of the behaviourally focused interventions like promotion of the barrier methods among both men and women irrespective of their serological status and training to effectively use them, and continuous reinforcement for maintenance of these behaviours. Peer interventions also have been found signiicantly effective in these groups [16]. Mentally ill people have been disproportionately affected by the spread of HIV. There are various factors like social stigma, clinic waiting time, no prior testing, lack of knowledge and poor attitude for the serological testing which contribute for increased susceptibility for the STI. Interventions like use of rapid HIV testing kits and education at the psychiatric setting can be an effective method for secondary prevention of the STIs [17]. 51 June | 2017 Indian Institute of Sexology | Bhubaneswar Studies also suggest that the assertiveness training in the woman with the severe mental illness may help in the reduction of the HIV transmission and as well as the other sexually transmitted infections [18]. There are various types of interventions that are tried effectively in prevention of STIs in patients with mental illnesses • Informational motivational behaviour model (IMB) model [8]. This model can be used as a conceptual framework for the construction of the preventive intervention among the severely mentally ill. Figure 3: Informational motivational behaviour (IMB) model • • • Introduction of the periodic and routine testing for STIs including HIV among the severely mentally ill, alcohol and other drug abusers. The best intervention for these groups could be long term relapse prevention maintenance strategies which could reduce the high risk behaviour among these groups of patients. Maintenance of the anti-psychotic therapy along with the motivational counselling for prevention of the substance abuse. Enhanced cognitive behavioural skill building intervention with health promotion. The essential components of this intervention 52 are use of condoms , attitudinal changes for regarding safer sex , perceived susceptibility to HIV and behavioural skills regarding the perceived personal eficacy and objective ability to use the protective methods [19]. A systematic review of the interventions for the prevention of the STI among the severely mentally ill population suggested that the more structured and the culturally appropriate interventions may be put into the practice [20]. Abuse, Neglect and Violence with relation to STI In people suffering with STI, a retrospective June | 2017 Indian Institute of Sexology | Bhubaneswar evaluation of childhood history revealed that most people had adverse childhood experiences. The numbers of adverse childhood experiences are directly proportional to STI in adults [21]. Evidences also suggest that people with STIs are at higher risk to be abused [22]. Abuse and violence may increase the risk of mental illness in them. A study among the low income African-American women was done regarding coerced sexual activity and it was found that the women who reported about increased coercion had abused substances like alcohol, marijuana, crack and cocaine. They perceived that persuading the partner regarding the use of condoms will lead to violence. They also reported about being subjected to violence by the domestic partners and being involved in unwanted sexual activity as their partners threatened them for forceful sexual acts. These indings suggests that women face both psychological and social issues which make them highly vulnerable for HIV and other sexually transmitted disorders [23]. Figure 4: The factors in association with mental illness and STDs. Pharmacological considerations : Mental Illness and Sexually Transmitted Infections Various studies show that there are clinically signiicant drug to drug interactions between the antibiotics used for the treatment of STIs and the 2nd generation of the antipsychotics, which also open up chances for more research to ind the best suited therapies for them. Certain antibiotics have been found to lower the plasma levels of the 2nd generation antipsychotics [24]. Macrolides and Fluoroquinolones have been found to cause prolongation of the QT intervals and increase the concentration of the potassium leading to arrhythmias when used together with the antipsychotics. Antiretroviral drugs and 53 June | 2017 Indian Institute of Sexology | Bhubaneswar second generation antipsychotic agents inluence metabolism of one another through the CYP 450 enzyme system, hence the clinician need to consider appropriate medications to avoid this [14, 24]. Conclusion Prevalence of sexually transmitted disease is higher in patients with mental illnesses and vice versa. The clinicians need to screen for sexually transmitted diseases in individuals with mental illnesses if initial evaluation of the patient gives a lead in this regards. Similarly patients with sexually transmitted diseases need to be screened for mental illnesses. A collaborative and multidisciplinary approach to these groups of patients may be more useful than the conventional approach. Identifying the risk factors of STDs in patients with mental illnesses and risk factors of mental illness in patients with STDs will help in prevention of both these disorders. References 1. 2. 3. 4. 5. 6. 7. 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Ramrakha S, Caspi A, Dickson N, Mofitt TE, Paul C. Psychiatric disorders and risky sexual behaviour in young adulthood: cross sectional study in birth cohort. Bmj. 2000;321(7256):263-6. Mehta CM, Walls C, Blood EA, Shrier LA. Associations between affect, context, and sexual desire in depressed young women. The Journal of Sex Research. 2014;51(5):577-85. Shrier LA, Harris SK, Beardslee WR. Temporal associations between depressive symptoms and self-reported sexually transmitted disease among adolescents. Archives of Pediatrics & Adolescent Medicine. 2002;156(6):599-606. Raj A, Reed E, Santana MC, Walley AY, Welles SL, Horsburgh CR, et al. The associations of binge alcohol use with HIV/STI risk and diagnosis among heterosexual African American men. Drug and Alcohol Dependence. 2009;101(1):101-6. Heaton R, Clifford D, Franklin D, Woods S, Ake C, Vaida F, et al. HIV-associated neurocognitive disorders persist in the era of potent antiretroviral therapy CHARTER Study. Neurology. 2010;75(23):2087-96. Albarracín D, Gillette JC, Earl AN, Glasman LR, June | 2017 Indian Institute of Sexology | Bhubaneswar 16. 17. 18. 19. Durantini MR, Ho M-H. A test of major assumptions about behavior change: a comprehensive look at the effects of passive and active HIV-prevention interventions since the beginning of the epidemic. American Psychological Association; 2005. Collins PY, Geller PA, Miller S, Toro P, Susser ES. Ourselves, our bodies, our realities: an HIV prevention intervention for women with severe mental illness. Journal of Urban Health. 2001;78(1):162-75. Hobkirk AL, Towe SL, Lion R, Meade CS. Primary and Secondary HIV Prevention Among Persons with Severe Mental Illness: Recent Findings. Current HIV/AIDS Reports. 2015;12(4):406-12. Weinhardt LS, Carey MP, Carey KB, Verdecias RN. Increasing assertiveness skills to reduce HIV risk among women living with a severe and persistent mental illness. Journal of Consulting and Clinical Psychology. 1998;66(4):680. Malow RM, McMahon RC, Dévieux J, Rosenberg R, Frankel A, Bryant V, et al. Cognitive behavioral HIV risk reduction in those receiving psychiatric treatment: a clinical trial. AIDS and Behavior. 2012;16(5):1192-202. 20. Kaltenthaler E, Pandor A, Wong R. The effectiveness of sexual health interventions for people with severe mental illness: a systematic review. Health Technology Assessment. 2014;18(1):1-74. 21. Hillis SD, Anda RF, Felitti VJ, Nordenberg D, Marchbanks PA. Adverse childhood experiences and sexually transmitted diseases in men and women: a retrospective study. Pediatrics. 2000;106(1):e11-e. 22. El-Bassel N, Witte SS, Wada T, Gilbert L, Wallace J. Correlates of partner violence among female streetbased sex workers: substance abuse, history of childhood abuse, and HIV risks. AIDS patient care and STDs. 2001;15(1):41-51. 23. Kalichman SC, Williams EA, Cherry C, Belcher L, Nachimson D. Sexual coercion, domestic violence, and negotiating condom use among low-income African American women. Journal of Women’s Health. 1998;7(3):371-8. 24. Kennedy WK, Jann MW, Kutscher EC. Clinically signiicant drug interactions with atypical antipsychotics. CNS drugs. 2013;27(12):1021- 48. SonoviSion [3D/4D COLOUR DOPPLER) PC PNDT Regd. No. BLS/35/2016 Clinical Est. Regd. No. - 1894/16 DR. DHIRESH KUMAR SARANGI MD ( O & G ) RAIPUR, SORO, BALASORE M : 8456929501 55 June | 2017 Indian Institute of Sexology | Bhubaneswar Prevention of Sexually Transmitted Diseases Dr. Neelam Gautam Abstract Sexually transmitted diseases (STDs) are global public health problems because of their health, social and economic consequences. Problems of STDs is like an iceberg, loating tip represents only a small portion of the clinical cases whereas a major portion of disease is submerged hidden where prevention can play the most important role in managing these infections. Elimination of reservoirs, breaking the channel of transmission and protection of susceptible can prevent the transmission of STDs. Reservoirs can be eliminated by case detection and complete treatment. Cases can be detected either by screening of high risk groups, contact tracing or cluster testing. Complete treatment of cases is necessary. Susceptible can be protected by having ‘safe sex’ practices, prophylaxis vaccination, sexual awareness and other measures. Introduction Sexually Transmitted Diseases (STDs) are usually transmitted by sexual contacts and are caused by wide range of bacteria, virus, protozoa, fungi and ectoparasites. Some of the STDs are treatable while some such as HIV infection are not curable and can be fatal. Despite various attempts by health care providers to reduce the prevalence and incidence of sexually transmitted diseases, more than 1 million people acquire an STD every day. Each year, an estimated 500 million people acquire one of the four STDs i.e. chlamydia, gonorrhea, syphilis and trichomoniasis [1]. STDs can have serious consequences beyond 56 June | 2017 Indian Institute of Sexology | Bhubaneswar the immediate impact of the infection itself. Therefore, prevention has an important role in managing these infections. Primary prevention focusing on the transmission of infection and secondary prevention focusing on minimizing the adverse health effects of infection (STDs) or usually a combination of the two is necessary [2]. The various intervention measures required for preventing the spread of STDs depend on several sociocultural factors such as age, gender, employment status, level of education, religion, culture etc. These factors can inluence sexual conduct and therefore spread of the infections. The prevention and control of STDs are based on the following ive major strategies [3]. 1. Accurate risk assessment and education. 2. Pre-exposure vaccination for vaccinepreventable STDs. 3. Identiication of infected persons whether asymptomatic or symptomatic. 4. Effective diagnosis, treatment, counseling, and follow up of infected persons. 5. Evaluation, treatment, and counseling of sex partners of persons who are infected with an STD. Primary prevention is to change sexual behaviors that increase the risk of contracting STDs i.e. ‘practicing safe sex’. This can be achieved by following measures: 1. Health education: Health education is the irst important step in reducing the number of persons who engage in risky sexual behavior. The aim of educational intervention is to help individual to alter their behavior in an effort to avoid STDs, that is, to minimize disease acquisition and transmission. Information on STD prevention should be individualized on the basis of the patient’s stage of development and understanding of sexual issues. The target groups may include the general public, patients, priority groups, community leaders etc. [2]. 2. Abstinence: One of the best ways to prevent transmission of STDs is to avoid casual sexual contact with other individuals (i.e., anal, vaginal or oral) which may be impractical but not impossible. 3. Mutual monogamy: Mutual monogamy (only having sex with one partner) is another way to limit exposure to sexually transmitted infections (STIs). If neither partner has ever had sexual contact of any kind with another person, there is no risk of STIs. If either person has ever had sex with anyone else, they may get tested and, if necessary, treated for STIs at the beginning of each relationship. Many STIs can be ‘silent’ causing no noticeable symptom. Some STIs may not be detectable through testing ranging anywhere from a few weeks to a few months. 4. Sexual health check-ups: Attending a sexual health screening before engaging in sexual contact with a partner helps to prevent new cases of infection. Before resuming sexual relations one must always check if a partner has engaged in sexual activity with someone else. This may not always be a full proof method since many infections may go undetected for certain periods of time. 5. Avoid alcohol and recreational drug use: Avoiding alcohol and recreational drug use reduces the risk of contracting an STD/STI, having an unwanted pregnancy, or being coerced to have sex. Alcohol and drug use can reduce one’s ability 57 June | 2017 Indian Institute of Sexology | Bhubaneswar to make good decisions and make it less likely to actually implement the safer sex decision. It increases the vulnerability of one to be coerced into participating in an activity without being able to give full and informed consent. 6. STD/HIV Prevention Counselling : Prevention counselling is most effective if provided in a nonjudgmental and empathetic manner appropriate to the patient’s culture, language, gender, sexual orientation, age, and developmental level. Prevention counselling for STD/HIV should be offered to all sexually active adolescents and to all adults who are diagnosed with an STD,have had an STD in the past year, or have multiple sexual partners [3]. Personal prophylaxis a. Contraceptives: Mechanical barrier (e.g. condoms and diaphragms) provide a barrier against the contraction of STDs from an infected individual. Male Condoms, however, need to be used correctly to prevent transmission. Used condoms must be removed and disposed of appropriately to prevent spread. These barrier methods especially when used with spermicides will minimize the risk of acquiring STD infections. However, their use is limited by lack of motivation, acceptability and convenience. The exposed parts should be washed after contact with soap and water as soon as possible [4]. It is observed that consistent use of male condom in heterosexual HIV serodiscordant relationships (i.e. one infected and one uninfected partner) decreases the chances of HIV-negative partners to be infected with HIV less likely by 80% compared with persons in similar relationships in which condoms were not used. Moreover, studies demonstrate 58 that consistent condom use reduces the risk for other STDs, including chlamydia, gonorrhea, and trichomoniasis [5]. Female condoms like male condoms are also available but are costly compared with male condoms, however they offer the advantage of being a female-controlled STD/HIV prevention method. b. Pre-exposure vaccination: Pre-exposure vaccination is one of the most effective methods for preventing transmission of human papillomavirus (HPV) and Hepatitis B Virus (HBV). HPV vaccination is recommended routinely for boys and girls aged 11 to12 years. All unvaccinated and uninfected persons being evaluated or treated for an STD should be immunised withHepatitis B vaccine. In addition, hepatitis B vaccines are recommended for Men having Sex with Men (MSM), Injectable-drug users (IDUs), persons with chronic liver disease, and persons living with HIV infection who have not yet been infected with hepatitis virus [3]. Identiication of asymptomatically infected persons and persons with STD symptoms Early case detection is of supreme importance. The usual methods for early detection are: a. Screening: Screening tests are done on the apparently healthy volunteers from the general population. As STDs are not brought to notice easily in community, high priority is given to special groups- pregnant women, blood donors, industrial workers, army, police, refugees, prostitutes, convicts, restaurant and hotel staffs, truck drivers, migrants, construction site workers etc. [2]. b. Contact Tracing: Contact tracing is a technique by which the sexual partners of diagnosed patients are identiied, located, investigated and treated. June | 2017 Indian Institute of Sexology | Bhubaneswar This is one of the best methods of controlling the spread of infection. Patients are interviewed for their sexual contact by trained staff. The key to success in this technique is patient himself who must disclose all sex contacts voluntarily. By using telephone, telegram and other rapid means of communication contacts are sought and then persuaded to attend an STD clinic for examination and treatment [6]. c. Cluster Testing: In this technique patients are asked to name other persons of either sex who move in the same socio-sexual environment. These persons are then screened and pathological tests are done. This technique has been succeeded in inding almost double the number of cases [7]. Effective diagnosis, treatment, counseling, and follow up of infected persons a. Case holding and treatment: Adequate treatment of patients and their contacts is the mainstay of STD control. There is a tendency on the part of patients suffering from STDs to disappear or drop out before treatment is complete. Therefore every effort should be made to ensure complete and adequate treatment [2]. b. Epidemiological treatment (contact treatment): It consists of administration of full therapeutic dose of treatment to persons recently exposed to STD while awaiting the results of laboratory tests.Its effects are not lasting unless it is combined with a venereological examination and the tracing of contacts revealed by that examination [8]. c. STD Clinic: Establishing STD clinics where all consultation, investigation and treatment, contact tracing and all other relevant services are available is an essential part of prevention and control of STDs. Because of the stigma attached to the STD clinics, many patients seek alternative sources of medical care including self-medication. It is now being considered to integrate STD clinic service into the primary health care services. This service should be free, easily accessible and available. There should be suitable arrangements for treating female patient separately and maintain the patient’s desired anonymity. In India there is a National STD Control Programme where ‘syndromic approach’ is adapted for prevention and control of sexually transmitted diseases [2]. d. Laboratory services: Adequate laboratory facilities and trained staff are essential for proper patient management. It provides a basis for correct aetiological diagnosis and treatment decision, for contact tracing, surveillance of morbidity and detection of antimicrobial resistance [9]. e. Primary health care: As STD control activities are integrated into primary health care system, it imply the inclusion of primary health care workers (eg. village health guides, multi purpose workers) in the STD ‘health team’. Then only it will be possible to provide effective treatment to the greatest number of cases in the community [2]. f. Information system: The basis of an effective control of any communicable disease is an existence of a robust information system. Three types of data requirement are relevant in the control of STDs: clinical notiication, laboratory notiication and sentinel and adhoc surveillance. National notiication system at best includes only the classical venereal diseases where existing reporting systems suffer from under notiication, inaccurate diagnosis and concealment of cases owing to social stigma. Without a notiication system, it is not possible to assess the magnitude of the problem, to allocate resources and to evaluate the impact of control measures. There is an urgent need to develop an effective and 59 June | 2017 Indian Institute of Sexology | Bhubaneswar detailed reporting system of STDs in countries where it does not exist [9]. g. Legislation: Many countries are still far away in enacting suitable legislation for the control of STDs [10]. The purpose of legislation should be to encourage patients to seek early treatment and name their sexual contacts, to screen high risk groups to improve notiication by general practitioners, health education of the public etc. The Immoral Trafic (Prevention) Act,1986 covers all persons whether male or female who are exploited sexually for commercial purposes. It makes punishment for the offences under the Act more stringent than the previous Act [2]. Social Welfare Measures STDs are social problems with medical repercussions. It implies there should be ‘social therapy’ which would prevent or control the conditions leading to promiscuity and STDs. The various social measures include: 1. Rehabilitation of commercial sex workers 2. Provision of recreation facilities in the community 3. Provision of decent living conditions (home discipline, parents should understand that their own sex behavior inluences the children). 4. Marriage counseling 5. Sex education in school and colleges 6. Prohibiting the sale of sexually stimulating literature, pornographic books, photographs and ilms etc. [2]. Conclusion Appropriate treatment at the irst point of contact with the health system is an important measure to prevent further transmission and development of complications. Health providers from both private sector and public system should be given frequent periodic training regarding syndromic management of STIs and the training should stress on the need for risk reduction and condom promotion messages along with medical management. Program planners should take necessary steps to ensure adequate and continuous supply of free drugs and tackle issues of conidentiality and privacy. Without promotion of health and sex education, STDs cannot be prevented. References 1. 2. 3. 4. WHO. Fact sheet; No.110.Nov, 2013. http://www.who. int/mediacentre/factsheets/fs110/en/ [Last accessed on 11-04-2017]. Park K. Park’s Textbook of Preventive and Social Medicine. 23rd edition. M/s Banarsidas Bhanot Publications, New Delhi. 2015 : 339-340. Centres for Disease Control and Prevention. Morbidity and mortality weekly report, Recommendations and reports. 2015.vol.64, No.3:pp.2. https://www.cdc.gov/ mmwr/inde x 2015.html [Last accessed on 12-042017]. World Health Organisation (WHO). Tech Rep Ser 1986; 736.S. 60 5. Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database System, Rev 2002;1: CD003255. 6. World Health Organization (WHO) Tech Rep Ser 1982; 674. 7. World Health Organization (WHO) Tech Rep Ser 1963; 262. 8. World Health Organization (WHO) Tech Rep Ser 1978; 616. 9. WHO. Control of Sexually Transmitted Diseases, WHO, Geneva.1985. 10. World Health Organization, Venereal Disease Control: A Survey of Recent Legislation. Geneva: WHO, 1975. June | 2017 Indian Institute of Sexology | Bhubaneswar STI/RTI Prevention and Control Programme in India Dr. S.K. Singh | Dr. Abhishek Gupta | Dr. uday Mohan Abstract Diseases that are transmitted by sexual contact are known as STDs. It includes infections and clinical diseases like syphilis, gonorrhea, chancroid, donovanosis, nongonococcal urethritis, genital warts, herpes genitalis and diseases or infections that may not cause clinical disease of genitals, but are transmitted by sexual interaction e.g., all STDs and hepatitis B, Human Immunodeiciency Virus (HIV), Human T-cell Lymphotrophic Virus type-1 (HTLV-1) etc. National STD Control Programme has been in operation since the mid-1950s which is now a part of National AIDS Control Programme (NACP). Objectives of STI/RTI control and prevention program are: Reduce STD cases and there by control HIV transmission by minimizing the risk factor and Prevent the short term as well as long term morbidity and mortality due to STD. The STI/RTI Prevention and Control Programme is providing effective control of sexually transmitted infections including Reproductive Tract Infections for general population through continued support to the designated STI/RTI clinics (Suraksha Clinics) in public sector and for high risk population through Targeted Interventions (TI) programme. Introduction Diseases that are transmitted by sexual contact are known as STDs. Sexual transmission requires the agent to be present in one partner, the other partner to be susceptible to infection 61 June | 2017 Indian Institute of Sexology | Bhubaneswar with that agent and that the sex partners engage in sexual practices, which can transmit the pathogen. Sexually Transmitted Infections (STIs) differ from Sexually Transmitted Diseases (STDs) in that STDs conventionally includes infections resulting in clinical diseases that may involve the genitalia and other parts of the body participating in sexual contact 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 STDs and hepatitis B, human immunodeiciency virus (HIV), Human T-cell lymphotrophic virus type-1 (HTLV-1) etc. Nowadays, the term STI is preferred, since it covers all the diseases that can be transmitted by sexual contact. However, for all practical purposes, both STI and STD are used synonymously [1, 2]. Sexually Transmitted Infections (STI) increases chance of acquiring and transmitting HIV infection by 4 to 8 times, so control and prevention of STI is a key prevention strategy for HIV. Syndromic Case Management (SCM), with minimal laboratory tests is the cornerstone of STI/RTI management in India [3]. National STD Control Programme has been in operation since the mid-1950s which is now a part of National AIDS Control Programme (NACP)[4]. Phase I of NACP was started in 1992 followed by NACP II in 1999, NACP III in 2007 and latest NACP IV in 2014 which aims to provide universal, comprehensive, standardized and quality STI/RTI services to all population with special emphasis on High Risk Group (HRG) population and vulnerable groups, including women and adolescents [4]. The STI/RTI Prevention and Control Programme 62 aims for providing effective control of sexually transmitted infections including RTIs for general population through continued support to the designated STI/RTI clinics (Suraksha Clinics) in public sector and for high risk population through Targeted Interventions (TI) programme [5]. Targeted Intervention (TI) programme is one of the most important prevention strategies under NACP [6]. TIs comprise of preventive interventions working with focused client populations in a deined geographic area where there is a concentration of one or more High Risk Groups (HRGs) [6]. The key high risk groups covered through Targeted Intervention (TI) programme include Core High Risk Groups (HRGs) such as Female Sex Workers (FSW), Men who have Sex with Men (MSM), Transgender/Hijras (TGs), Injecting Drug Users (IDU) and Bridge Populations such as Migrants and Long Distance Truckers [6]. Relation between these groups with general population and transmission of STI/RTI is shown in igure 1. TI projects provide a package of prevention, support and linkage services to HRGs through outreachbased services delivery model which includes screening for and treatment of STI, free condom and lubricant distribution among core groups, social marketing of condoms, Behaviour Change Communication (BCC), creating an enabling environment with community involvement and participation, linkages to integrated counselling and testing centres for HIV testing, linkages with care and support services for HIV positive HRGs, community mobilization and ownership building and speciically for IDUs, distribution of clean needles and syringes, abscess prevention and management, Opioid Substitution Therapy (OST) and linkages with detoxiication/ rehabilitation services [6]. June | 2017 Indian Institute of Sexology | Bhubaneswar Figure 1: Transmission of STI/RTI from Core HRGs to General Population The vision of STI/RTI control and prevention program during NACP IV is to provide quality standardized STI/RTI services at all levels of health system through convergence with National Health Mission (NHM) and private sector, especially focusing on women, adolescent and marginalized population [4]. Objectives of STI/RTI control and prevention program are: a) Reduce STD cases and there by control HIV transmission by minimizing the risk factor. b) Prevent the short term as well as long term morbidity and mortality due to STD. The speciic strategies are as follows : Provision of standardized STI/RTI management to general and vulnerable population at all government health facilities in convergence with National Rural Health Mission NRHM [4]. Scaling up by partnering with organized public and private sector to enhance reach and coverage of the program [4]. Provision of quality STI/RTI services to high risk group population through lexible approach of service delivery [4]. Provision of laboratory support for etiologic diagnosis and surveillance of STI/RTI. Strengthening capacity building and mentoring needs to achieve quality STI/RTI service delivery through all facilities [4]. 63 June | 2017 Indian Institute of Sexology | Bhubaneswar Current Status During 2014-15, against the physical target of treating 70 lakh episodes of STI/RTI, 75.46 lakh episodes of STI/RTI were treated [5]. A study published in 2015 showed that prevalence of STI among the female sex workers as per syndromic diagnosis was 35.8% in a city of north India [7]. NACO target was to manage 80 lakh episodes of STI/RTI in 2015-16, out of which the programme has achieved 48.48 (60.6%) lakhs till October, 2015 [3]. A total of 18,72,391 rapid plasma reagin (RPR) tests were conducted among attendees of DSRCs of which only 0.4% were reactive [3]. Among the pregnant women attending antenatal care, 18,08,120 lakhs were screened for syphilis of which 2738 (0.15%) were found reactive for syphilis and were provided treatment [3]. The sero-prevalence of Syphilis is observed to be declining steadily among patientswith STI/RTI, pregnant women and high risk groups [3]. Figure 2: STI clinic visits during 2015-16 (Up to Sept 2015) [6] Sl. No. Indicator 2013-14 2014-15 2015-16 1 Total number of cases managed 71.6 lakh 79.6 lakh 89.2 lakh 2 % STI attendees Tested for Syphilis 34% 22% 40% 3 % Sero Positive for Syphilis M=0.83%, F=0.5% M=0.97%, F=0.37% M=0.64%, F=0.23% 4 % STI attendees Tested for HIV 37% 19% 36% 5 % Sero Positive for HIV M=0.95%, F=0.6% M=1%, F=0.41% M=0.57%, F=0.35% Table 1: Status of Syphilis and HIV [4] 64 June | 2017 Indian Institute of Sexology | Bhubaneswar Progress & Expansion of STI/RTI Services in Government Health Facilities The Network of STI Laboratories comprise of 01 Apex Laboratory, 09 Regional STI Training, Research and Reference Laboratories, 45 State Reference Centres (SRC), Integrated Counselling & Testing Centre(ICTC) / Hospital laboratories linked to Designated STI/RTI clinics (DSRC)[4] that provide validation of syndromic case management by doing etiologic testing, antibiotic susceptibility testing for Gonococci, External Quality Assurance Services (EQAS) for syphilis [4]. Designation STI/RTI Clinics are located at Medical Colleges, District Hospitals and in some area hospitals (sub-divisional and /rural hospitals). The program offers free treatment using standardized STI colour coded treatment kits to treat common STIs/RTIs syndromes [4]. Program has branded the DSRCs as ‘Suraksha Clinics’ which has improved the footfalls [4]. The four implementation structures of the STI/RTI Programme are as follows: 1) Designated STI/RTI Clinics 2) Targeted Interventions 3) NHM facilities 4) Regional STI Training Referral, Research Laboratories & State Reference centres Provision of STI/RTI Services in High Risk Group Population There are 1677 (till October 2015) Targeted Intervention Projects where STI services are being provided to the High Risk Group for free [4]. Services are also available for truckers and migrants at subsidized rate. Partnerships with the private sector have seen more than 3400 private providers (project provides maximum consultation fee of @Rs75/- per consultation, free drugs and free HIV and Syphilis testing) [4]. Preferred private provider approach has been rolled out to scale up STI/RTI services to HRG population under TI Projects. These providers are selected by the community members through group consultation [3]. This mechanism saw tremendous increase in the access to services of HRGs from 0.23 million in 2007-08 to 4.67 million in 2015-16 (>20 fold increase) [4]. Partnering with Organized Public Sector, Public Sector undertaking and Professional Organization The major proportion of patients with STI/RTI seek services from network of private healthcare delivery systems ranging from freelance private practitioners to large public hospitals [3]. Also, many are accessing services from public healthcare systems under other sectors like railways, ESI, armed forces, CGHS, port hospitals as well as health facilities of public sector undertakings like Coal India Ltd, SAIL etc. [3]. It has been felt that reaching out to maximum numbers of people suffering from STI/RT is not possible without partnership with private sector and organized public sectors. NACO has initiated partnership with organized public sectors and private sectors through professional associations to support the delivery of STI/RTI services with the objective to reach the populations presently not covered by the public healthcare delivery system [3]. In addition program is in active engagement with professional bodies like IMA and FOGSI etc. [4]. Functional integration with the RMNCH+A Programme of the National Health Mission has helped both programmes mutually [4]. Joint STI/RTI operational guidelines have been developed which is standard for implementing 65 June | 2017 Indian Institute of Sexology | Bhubaneswar STI/RTI control and prevention program across different health care Institutions right from primary health centres (PHCs) up to the Medical Colleges [4]. New Initiative under STI/RTI Programme Under Elimination of Parent to Child Transmission (EPTCT) Programme of Syphilis, NACO and Maternal Health Division are aiming for early registration, early screening for both Syphilis and HIV and treat those found reactive, promote institutional delivery and follow up the new born up to 18 months of age [3]. The latest directives [3,4,9] issued provide for universal screening for Syphilis and HIV; task shifting of testing to Auxiliary Nurse Midwifery (ANMs) using Point of Care (POC) test kits for both infections and their management once detected positive at Primary Health Centre (PHC) and above health facilities including promoting institutional delivery and tracking the Mother-Baby pair till the child attains 24 months of age. Ministry of Health and Family Welfare, Govt. of India has included indicators for capturing data on screening tests done by ANMs for HIV and Syphilis using POC tests as well as indicators for conirmatory tests done at PHC/CHCs (Community Health Centres) of rapid plasma reagin (RPR) and HIV Rapid Antibody Tests, in the Health Management Information System (HMIS) formats [4]. A booklet ‘Shaping our Lives: (Version -2)’ a training/ knowledge booklet for ANMs/ASHA workers/ Anganwadi Workers and members of SHGs with recent updates on the PPTCT Programmes of HIV and Syphilis has been developed [4]. The goal is to eliminate of Parent to Child Transmission of HIV & Syphilis by 2020 [4]. 66 Key Issues and Challenges Following are the key issues and challenges in implementing STI/RTI programme in India. • A recent study in Lucknow showed that knowledge about the role of condom in prevention of STI and the STI-HIV link was signiicantly less among home-based FSWs (Female Sex Workers) than those who are street-based. There is a great lack in the awareness among FSWs regarding STI and their prevention [8]. • Saturation of Syphilis testing of pregnant women and non-availability of Benzathine Penicillin in hospitals and decreased preference among health providers to recommend Penicillin are the key bottle necks [4]. • Lack of recent data on burden of STIs amongst general population and HRG ; But high prevalence of Syphilis amongst STI Clinic attendees in many states of India [4]. • Inadequate spouse/ partner testing. • Lack of training and skill building in the ield due to limited resources. Participation of Private sector and organised sector in STI programme is still very less. Private sector adherence to standard STI treatment guidelines & reporting requirements is low [4]. Conclusion STI/RTI Prevention and Control Programme in India is providing continued support for effective control of STI/RTI, treatment of general population through designated STI/RTI clinics (Surakasha Clinics) and high risk population through Targeted Intervention (TI) programmes. Designated STI/ RTI Clinics which are service delivery terminals are located at Medical Colleges, District Hospitals and in area hospitals (Sub-divisional hospitals / June | 2017 Indian Institute of Sexology | Bhubaneswar Rural Hospitals/ CHCs/PHCs). The program offers free treatment using standardized STI colour coded treatment kits to treat common STI/RTI syndromes. The program also reaches employees of organized sectors under public undertakings (Railways, Employees State Insurance Corporation, Port Trust, Defence and Professional Associations), and private sectors by developing partnerships. New Initiative under STI/ RTI Programme aims to eliminate parent to child transmission (EPTCT) of syphilis. 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Available from: http://www.naco.gov.in/nacoevents/mid-term-appraisalmta-nacp-iv-aug-2016 [Last accessed on 20.04. 2017]. Press Information Bureau, Government of India, Ministry of Health and Family Welfare: Declining Trend of HIV/ AIDS [updated 18-Dec 2015]. Available from: http:// 6. 7. 8. 9. pib.nic.in/newsite/AdvSearch.aspx [Last accessed on 20.04. 2017]. National Aids Control Organization (NACO), annual report 2015-2016, chapter 24, page 338-339. Department of health & family welfare ministry of health & family welfare government of India. Available from: http://www.naco.gov.in/sites/default/files/annual%20 report%202015-16_naco.pdf [Last accessed on 20.04.2017]. Shukla P, Masood J, Singh JV, Singh VK, Gupta A, Krishna A. Predictors of Sexually Transmitted Infections among Female Sex Workers (FSWs) in a City of Northern India. Indian J Community Med 2015; 40:121-6. Shukla P, Masood J, Singh JV, Singh VK, Gupta A, Asuri K. Perception of sex workers of Lucknow City, Uttar Pradesh, India towards sexually transmitted infections. Indian J Public Health 2015;59:318-22. Mid-Term Appraisal of National AIDS Control Programme. Phase IV. Technical report Page 8. August 2016. National AIDS Control Organisation Ministry of Health & Family Welfare Government of IndiaAvailable from:http://www.naco.gov.in/nacoevents/mid-termappraisal-mta-nacp-iv-aug-2016 [Last accessed on 20.04.2017]. The contents and views relected in the articles are of the respective authors. IISB is not responsible for any controversy or any intellectual property right infringement. IISB is also not responsible for the content of any advertisement published. Inclusion of any advertisement in no way implies approval or recommendation of IISB. 67 June | 2017 Indian Institute of Sexology | Bhubaneswar Sexually Transmitted Diseases in Ayurveda Dr. Swapnil Saxena Abstract Sexually transmitted diseases (STD) have been reported since the ancient times with their description dating back to the time of Sushruta and Charaka. Though there has been a description of various diseases in Charaka Samhita with similar symptoms to the infection of Trichomonas and Chlamydia, but a clear reference to their sexual mode of transmission is not available. The diagnosis in Ayurvedic texts is made clinically, based on the symptoms. Despite of the vivid description of sexually transmitted diseases in the ancient Ayurvedic texts, it is dificult to identify their exact modern counterparts on the basis of these texts. The two most commonly talked about STD in various ayurvedic texts are irang and updansha. This article provides an overview on the evolution of STDs, their nomenclature in different eras and Ayurvedic treatment as an alternative system of medicine. Introduction : STD include the diseases which are transmitted through sexual contacts when body luids are exchanged. The sexual transmission depends on the susceptibility of partner to the pathogen and indulgence in sexual practice with the infected partner [1]. The concept of transmission of diseases through unsafe sexual practices was known since the time of Acharaya Sushruta (1000-1500BC). He mentioned about the spread of kustha, updansha, pooymeha through sexual contact of the infected man with a woman and vice versa. This has been discussed in reference to the aoupsargik rogas (contagious diseases) and their spread [2]. The description of sexually transmitted diseases was also seen in the Charaka 68 June | 2017 Indian Institute of Sexology | Bhubaneswar Samhita (2nd century AD). The Bhavaprakash Samhita also has a vivid description of STDs (updansha & irang) and it was written around 16th century AD. Epidemiology According to a study conducted in United States, adolescents and young adults (15-24yr) make up only 25% of sexually active population but contribute 50% to the total share for newly diagnosed STDs [3]. The incidence of major viral and bacterial STDs worldwide is estimated to be more than 125 million cases yearly [4]. According to study conducted at JIPMER in India by Thapa et al (2007) genital herpes was the commonest infection followed by syphilis and condyloma acuminate. Upto 10% of patients have mixed lesions [1]. No study has been conducted, to the best knowledge of author, to know the prevalence or distribution of sexually transmitted disease based on criterias and lesions described in Ayurveda. Description of STD in Sushruta Samhita The classical explanation of various types of Updansha, a sexually transmitted disease and its causative factors as mentioned by Sushruta, are dusta yoni viyonivanaarimatyarthamupsevmaanasya (excessive coitus with an infected woman) hasta abhighata (abrasion due to hand while masturbation), aprakshalana dibhimedhra (not cleaning the genitalia), chatushpadi gamanaad (beastility/ unethical sexual indulgence). These factors cause local lesions and inlammation of the genitalia. This leads to vitiation of doshas in the injured genitalia [5]. Updansha can further be classiied into ive types as per the symptoms that develop in the due course of time. These are vataja updansha, pittaja updansha, kaphaja updansha, sannipataja updansha, raktaja updansh [6]. In vataja updansha the symptoms encountered are parushya (dryness), twakpariputanam (cracks on the genitalia), parushshophatavividhaschvatavedana (pain and swelling with sensory loss). In pittaja updansha jwara (fever) and shvayathu (swelling) teevradaha (excessive burning sensation), kshiprapaka (rapid suppuration). The symptom of kaphaj aupdansha apart from swelling is, severe itching. The symptoms of raktaja updansha are krishnasphota atyarthama srik privratti (blister formation and discharge of blood). The symptoms of sannipataja updansha include mixed symptoms as described in each of the above types of updansha along with avdaranam cha shefasah (longitudinal cracks on penis) and krimipradurbhaavo maranam (infestation with worms and inally death) [7]. Apart from these, Sushruta has mentioned about lingaarsh and yonyaarsh (genital warts). Though the explanation for their spread through sexual contact is not mentioned but there is explanation of features similar to what we ind today in context of genital warts. Sushruta said that due to vitiation of maansa and rakta there develops itching in the penis of male which later on gives rise to warts over the area. There occurs picchil rudhirasraava (sticky blood mixed discharge) from the penis. In a similar way due to vitiation of rakta and maansa there is development of warts in women, produce a sticky and bad odoured discharge [8]. Description of STD in Bhavaprakash Samhita In a similar way updansha has been mentioned along with its ive types by Acharya Bhavaprakash. 69 June | 2017 Indian Institute of Sexology | Bhubaneswar He also mentioned about its transmission through sexual contact [9]. Another sexually transmitted disease irst talked in Bhavprakash Samhita is irang. He mentioned about its transmission through sexual contact with a woman of iranga desh (some foreign country). It is also an example of aaguntaja sankramaka roga (highly contagious disease). There is clear indication of its spread through unsafe sexual indulgence {sansargaat / prasangaat (sexual intercourse)} [10]. Firang was known to Indian subcontinent since the time of Bhava Misra (16th century) and was called Portuguese disease, which soon became widespread [11]. Firang has been classiied as baahya and aabhyantar. The symptoms of baahya irang are sphota (blisters on genitalia) and alparuja (mild pain). The aabhyantar irang has symptoms which manifest in joints and cause inlammation. The upadarava (complications) ofirang include kaarshya (weakness), balakshaya (weight loss), agnimandhya (anorexia), asthishosha (destruction of bones), nasabhang (loss of nasal cartilage) [12]. genitalia) is redness, inlammation and pain, purulent discharge and blisters on penis. There also occurs whitish or red yellow discharge from penis. Along with these symptoms there occurs fever, weight loss and severe burning sensation [13]. Description of STD by Charaka For treatment of updansha, Sushruta has mentioned about rakta mokshana (blood letting), and ubhay marg nirharan {vaman (emesis)/ virechan (purgation) therapy)} [15]. Acharya Bhava Misra also mentioned of raktamokshan and vaman, virechan and niroohvasti (procedure in which a herbal decoction mixed with salt, honey, oil etc. is administered through anal route) [16]. Apart from this Bhava Misra has mentioned the lepan dravyas (drugs for local application) for all types of updansha according to their symptoms. For the symptoms of vatajaupdansha, kalk (paste) of mulethi (Glycyrrhiz aglabra), agar (Aquilaria Yet another STD described in Charaka Samhita, which has symptoms resembling updansha is dhwajbhang. While describing kleevta (impotency) Aacharya Charaka has mentioned that it can be due to four reasons. Among those four, one is due to Dhwaja bhanga. Among other factors, Dhwaja bhang results from ayonigaman (beastility), deergha rogini (coitus with woman suffering from disease since long), dushta yoni parisrutaam (intercourse with women suffering from such infection and infected vaginal discharge). The symptoms of dhwaja bhang (destruction of 70 Comparison of various STDs described in ayurveda and modern literature It is dificult to identify their exact modern disease entities on the basis of signs and symptoms described in ancient ayurvedic texts [14]. However symptoms of irang are comparable to what we know as syphilis today as initial symptoms of blisters on genitalia with mild pain followed by complications ranging from joint pain, anorexia, destruction of bone and nasal cartilage matches with that of description of syphilis in current literature. Comparison can also be drawn between description of updansha with symptoms (dryness, pain and cracks on genitalia) with that of chancroid. Treatment and prognosis of STDs in Ayurveda June | 2017 Indian Institute of Sexology | Bhubaneswar agallocha), raasna (Plucheal anceolata), elaichi (Elettaria cardamomum) is to be applied locally and the kwath (decoction) be used for parishek (pouring of warm decoction). For pittaja updansha kalkaofnishoth (Operculina turpethum), khas (Vetiveria zizanioides), chandan (Santalum album) kamal (Nelumbo nucifera) to be applied locally. For kaphaja updansha bark of sal tree (Shorea robusta) mixed with oil is best for local application. In raktaja updansha for local application kalk and kwathparishek by neem (Azadirachta indica),arjun (Terminalia arjuna), peepal (Ficus religiosa), jamun (Syzygium cumini), bargad (Ficus bengalensis), gular (Ficus racemosa) helps relieve the symptoms. Sannipataj aupdansha has been described to be non curable, washing the genitals with triphala (haritaki/Terminalia chebula , bibhitaki/ Terminalia belerica, amalki/Emblica oficinalis) kwatha (decoction) and bhringaraj (Eclipta alba) swaras (juice) and symptomatic treatment can be given [17]. For the treatment of irang, ras karpoor, saptashaali vati have been advised as the drug of choice [18]. For yonyaarsh and lingarsh, Sushruta has mentioned the use of either of the four procedures, namely aoushadh, kshaar, agni and shastra. Aoushadh is the medicinal treatment, kshaar treatment involves the use of kshara sutra (medicated caustic thread) or direct application of kshara on the infected area, agni (thermal cautery) and shastra (surgical excision) [19]. Bhava Misra mentions that newly diagnosed, bahaya type iranga without the development of complications as mentioned above is curable [20]. Where as updansha with development of necrosis of genitalia, vitiation of all three doshas (vata, pitta, kapha) is not curable [21]. Conclusion Ancient ayurvedic texts describe various sexually transmitted disease and their associated lesions, complications and their treatment. However because of lack of studies based on these texts it is dificult to comment prevalence and incidence of STDs based on these criterias. It is also dificult to draw comparison between lesions described in ayurvedic literature and current nomenclature used in venerology, except for few diseases. Further studies are needed to explore the sexually transmitted diseases based on ayurveda and to establish the eficacy of ayurvedic treatment in their management. References 1. 2. 3. Thappa DM, Kaimal S. Sexually transmitted infections in India: Current status (except human immunodeiciency virus/acquired immunodeiciency syndrome). Indian J Dermatol 2007;52:78-82. Shastri, Kaviraj Ambika Dutta. SushrutaSamhita Volume 1. 1st ed. varanasi: chaukhambasanskritsansthan, 2010. Print.( verse 32 chapter 5 kusthanidana , nidansthana pg.325) Da Ros CT, da Silva Schmitt C. Global Epidemiology Of Sexually Transmitted Diseases. Asian Journal of Andrology. 2008 Jan 1; 10 (1) : 110-4. 4. 5. 6. De Schryver A, Meheus A. Epidemiology of sexually transmitted diseases: the global picture BullWorld Health Organ. 1990;68(5):639-54. Shastri, Kaviraj Ambika Dutta. Sushruta Samhita Volume 1. 1st ed. varanasi: chaukhambasanskritsansthan, 2010. Print (verse 10, chapter 12, vriddhiupdanshashleepadanaamnidana, nidanasthan pg. 360) Shastri, Kaviraj Ambika Dutta. Sushruta Samhita Volume 1. 1st ed. varanasi: chaukhambasanskritsansthan, 2010. Print (verse 11, chapter 12, vriddhiupdanshashleepadanaamnidana, nidanasthan pg. 360) 71 June | 2017 Indian Institute of Sexology | Bhubaneswar 7. 8. 9. 10. 11. 12. 13. 14. Shastri, Kaviraj Ambika Dutta. Sushruta Samhita Volume 1. 1st ed. varanasi: chaukhambasanskritsansthan, 2010. Print (verse 12, chapter 12, vriddhiupdanshashleepadanaamnidana, nidanasthan pg. 360) Shastri, Kaviraj Ambika Dutta. Sushruta Samhita Volume 1. 1st ed. varanasi: Chaukhamba Sanskrit Sansthan, 2010. Print.(verse18, chapter 2, Arshasaamnidana, nidansthana pg.309) Misra, Bhava. Bhavaprakash. 11th ed. Varanasi: chaukhambasanskritbhavan, 2010. Print. (verse 1 chapter 51 updanshadhikaar, madhyakhanda,pg. 507) Misra, Bhava. Bhavaprakash. 11th ed. Varanasi: chaukhambasanskritbhavan, 2010. Print. (verse 1-3 chapter 59 irangarogaadhikaar, madhyakhanda,pg. 561-562) Thappa DM. Evolution of venereology in India. Indian J DermatolVenereolLeprol. 2006;72:187–97. Misra, Bhava. Bhavaprakash. 11th ed. Varanasi: chaukhambasanskritbhavan, 2010. Print. (verse 4-7 chapter 59 irangarogaadhikaar, madhyakhanda,pg. 563) Shastri, Kashinath, and Gorakhnath Chaturvedi. Charaka Samhita Volume 2. 1st ed. varanasi: chaukhambasanskritsansthan, 2010. Print. (verse 154, 164-167 , chapter 30 yonivyaapada pg. 863-864) Thappa DM, Sivaranjini R. Venereology in India. Indian J Dermatol. 2011 Jul-Aug; 56(4): 363–367. 15. Shastri, Kaviraj Ambika Dutta. Sushruta Samhita Volume 1. 1st ed. Varanasi: Chaukhamba Sanskrit Sansthan, 2010. Print (verse 25-26 chapter 19 vriddhiupdanshashleepadachikitsa, Chikitsasthan pg.112) 16. Misra, Bhava. Bhavaprakash. 11th ed. Varanasi: chaukhambasanskritbhavan, 2010. Print.(verse 6-8 chapter 51 updanshadhikaar, madhyakhanda,pg. 509) 17. Misra, Bhava. Bhavaprakash. 11th ed. Varanasi: chaukhambasanskritbhavan, 2010. Print. (verse 9-16 chapter 51 updanshadhikaar, madhyakhanda,pg. 509510) 18. Misra, Bhava. Bhavaprakash. 11th ed. Varanasi: chaukhambasanskritbhavan, 2010. Print. (verse 10 and15 chapter 59 irangarogadhikaar, irangrogasyachikitsa, madhyakhanda,pg. 563-564) 19. Shastri, Kaviraj Ambika Dutta. Sushruta Samhita Volume 1. 1st ed. varanasi: Chaukhamba Sanskrit Sansthan, 2010. Print.(verse 3, chapter 6, Arshachikitsa, chikitsasthana pg.46) 20. Misra, Bhava. Bhavaprakash. 11th ed. Varanasi: chaukhambasanskritbhavan, 2010. Print. (verse 9 chapter 59 irangrogadhikaarchikitsaprakaranam, madhyakhanda,pg. 563) 21. Misra, Bhava. Bhavaprakash. 11th ed. Varanasi: chaukhambasanskritbhavan, 2010. Print. (verse 3-4 chapter 51 updanshadhikaar, madhyakhanda,pg. 508) Visit our website www.iisb.org for updates. 72 June | 2017 Indian Institute of Sexology | Bhubaneswar Fear of Getting HIV Infection : A Case Study from Psychiatric Clinical Practice Dr. Divyesh Vernwal Clinical Presentation A 35 year old, married, truck driver referred to the psychiatric outpatients department for complaints of headache, palpitation, restlessness, lethargy, poor appetite and abdominal pain for more than 6 months. Patient was constantly worried about his symptoms, and their seriousness. History revealed about sexual contact with commercial sex worker with use of condom. Initially he was worried of acquiring Human Immunodeiciency Virus (HIV) for which he had undergone multiple testing. Results were negative. Despite the negative test results, he was very much distressed and not able to convince himself for being healthy. There was no history of cough, sore throat, prolonged feverwith chills or rigors, and evening rise of temperature, burning micturition. Intensity of symptoms luctuate. Patient had undergone various investigations including testing for HIV infection several times from different pathological laboratories, but results were within normal limits. Patient occasionally consumes alcohol. Pre-morbidly the patient was well adjusted to life; however history suggested that during his early adolescence, he used to feel anxious and worry on trivial issues. He would also worry for minor issues related to health. In past whenever he became sick, he would become very apprehensive and undergone various investigations and would be assured with very dificulty even all indings were within normal limits. His academic and work performances were also affected because of this behavior. There is history of depression in his mother and it was treated adequately by a psychiatrist. On mental status examination, patient was found conscious, co-operative, well-oriented to time, place and person. He was having predominantly anxious mood, pessimistic view about future and had preoccupations of having HIV infection. His general physical examination and systemic examinations were within normal limits. 73 June | 2017 Indian Institute of Sexology | Bhubaneswar Clinical investigations The body mass index (BMI) score was 24.5. All routine blood investigations were within normal limits. He was nonreactive for Hepatitis C antigen, HIV 1,2 and was western blot test- negative. After clinical evaluation the patient was diagnosed with ‘Somatisation Disorder’ according to International Classiication of Diseases, 10th edition (ICD-10). Management Both non-pharmacological andpharmacological measures started simultaneously. Patient was irst counselled about his illness and his irrelevant apprehensiveness and worries about symptoms. Hewas explained about safe sexual practices and avoidance of risky behaviours. Psychological interventions had focussed on issues of stress and use of appropriate coping skills to handle it. Patient was given proper rationales and facts to clear his queries and myths. Progressive muscular relaxation exercises sessions were taken. Pharmacological treatment continued with antidepressant (Escitalopram 10 mg at night time) and anxiolytic agent (Clonazepam 0.5 mg/day in divided doses). Outcome After several sessions of relaxation exercises and psychotherapy, feedback was taken from the patient. He reported signiicant improvement in his symptoms and was able to cope with stress. Frequency and intensity of various somatic complaints also decreased. After one month of therapy, there was a noticeable improvement in mood and substantial decrease in other symptoms like headache, palpitation, excessiveworry etc. He was adhered to the treatment till two months follow up. Conclusion In somatoform disorders, the major symptoms of presentation are physical symptoms, but evidences of obvious medical disorder that can explain those symptoms are not there. There are evidencesthat link physical symptoms with psychological factors or conlicts. Patients with somatoform disorder undergo signiicant psychological distress and use maladaptive coping methods to counter their distress. Substance abuse tendency is common in patients with somatoform disorders to get rid of somatic pain [1]. Knowledge about somatoform disorders is now accumulating which shows that it is a treatable condition, particularly in the early stages before its illness-behaviour aspects have become embedded. In Somatoform disorder, cognitive behaviour therapy (CBT) and counselling are two good options to help with treatment [2]. A cadre of well-trained therapists who are knowledgeable in the principles and practice of CBT is required in both family practice and tertiary care settings, where most somatisation disorder patients are found [3]. References 1. 2. Vitiello B, Burnam MA, Bing EG, Beckman R, Shapiro MF. Use of psychotropic medications among HIVinfected patients in the United States. American Journal of Psychiatry. 2003 Mar 1;160(3):547- 54. Kroenke K, Swindle R. Cognitive-behavioral therapy 74 3. for somatization and symptom syndromes: a critical review of controlled clinical trials. Psychotherapy and psychosomatics. 2000 Jun 13;69(4):205 - 15. Mai F. Somatization disorder: a practical review. The Canadian Journal of Psychiatry. 2004 Oct 1;49(10): 652- 62. June | 2017 Indian Institute of Sexology | Bhubaneswar Authors Dr. Abhishek Gupta Assistant Professor, Department of Community Medicine, TSM medical college, Lucknow, UP. E Mail- ab23kgmc@gmail.com Dr. Bhawna Nagel Senior resident, Lok Nayak Jai Prakash Hospital, New Delhi. E Mail- bhawna_nagel@yahoo.co.in Ms. Deblina Roy MSc (Psychiatric nursing), King George’s Medical University, Lucknow, UP. E Mail- kittuzx@gmail.com Dr. Divyesh Vernwal Senior Resident, King George’s Medical University, Lucknow, UP. E Mail- divyesh2k5@gmail.com Dr. Kangana Sengar Senior Resident, Lok Nayak Jai Prakash Hospital, New Delhi. E Mail- drksengar@gmail.com Dr. Kirti Dudeja Department of Dermatology, Venereology and Leprology, Pt. B. D. Sharma PGIMS, Rohtak, Haryana. E Mail- kirtidudeja69@gmail.com Dr. Neelam Gautam Assistant Professor, Department of Community Medicine, Hind Institute of Medical Sciences, Sitapur, UP. E Mail- nlmgautam0@gmail.com Dr. Nidhi Tejan Senior Resident, Department of Microbiology, SGPGIMS, Lucknow, UP. E Mail- getnids@gmail.com Dr. Pritilata Panda Department of Microbiology, P.R.M. Medical College & Hospital, Baripada, Mayurbhanj, Odisha. E Mail- drpreetilata@yahoo.com Dr. Priyadarshini Sahu Assistant Professor,Department of Dermatology, Venereology and Leprology, Pt. B. D. Sharma PGIMS, Rohtak, Haryana. E Mail- priyadarshini.sahu.9@gmail.com Dr. Ravindra Kumar Garg Professor and Head, Department of Neurology, KGMU, Lucknow, UP. E Mail- garg50@yahoo.com Dr. Ravi uniyal Assistant Professor, Department of Neurology, KGMU, Lucknow, UP. E Mail- ravi.sun.uniyal@gmail.com Dr. Sarvodaya Tripathy Department of Microbiology, MKCG Medical College & Hospital, Brahmapur, Ganjam, Odisha. E Mail- sarvo_trip@yahoo.co.in Dr. S.K. Singh Professor, Department of Community Medicine and Public Health, King George’s Medical University, Lucknow, UP. E Mail- shivmymail0522@gmail.com Dr. Shruti Sharma Pt. B. D. Sharma PGIMS, Rohtak, Haryana. E Mail- kaush0211shruti@gmail.com Dr. Sujit Kumar Kar Assistant Professor, Department of Psychiatry, King George’s Medical University, Lucknow, UP. E Mail- drsujita@gmail.com Dr. Surabhi Dayal Department of Dermatology, Venereology and Leprology, Pt. B. D. Sharma PGIMS, Rohtak, Haryana. E Mail- surabhidayal7@gmail.com Dr. Swapnil Saxena Assistant Professor, SRV Ayurvedic Medical College, Chinhat, Lucknow, UP. E Mail- saxenaswapnil26@gmail.com Dr. T.V. Ram Kumar Assistant Professor, Department of Pediatrics, MKCG Medical College, Berhampur, Odisha. E Mail- starringram@gmail.com Dr. uday Mohan Professor & Head , Department of Community Medicine and Public Health, King George’s Medical University, Lucknow, UP. E Mail- drudaymohan@yahoo.co.in Dr. Vimal K Paliwal Additional Professor, Department of Neurology, SGPGIMS, Lucknow, UP. E Mail- getnids@gmail.com 75 June | 2017 Indian Institute of Sexology | Bhubaneswar Indian Institute of Sexology Bhubaneswar Sanjita Maternity Care & Hospital Plot. No.-1, Ekamra Marg, Unit-6 Bhubaneswar- 751001, Odisha, India E-mail : sexualityinfo@gmail.com Web : www.iisb.org Not for sale For free circulation only 76 Design: Srujani, Balasore June | 2017 Indian Institute of Sexology | Bhubaneswar