ORIGINAL ARTICLE

Profile of sexually transmitted infections among attendees

of special clinics (Suraksha) at an apex regional sexually
transmitted disease centre in North India – a five-year study
Perfil de infecções sexualmente transmissíveis entre participantes de clínicas especiais (Suraksha) em um centro
regional de doenças sexualmente transmissíveis Apex no norte da Índia – um estudo de cinco anos

Sumathi Muralidhar1 , Prashant Gupta1 , Abhishek Lachyan1 ,

Soni Singh1 , Ratan Singh Rana1 , Niti Khunger2

ABSTRACT
Introduction: Sexually transmitted infections (STIs) present significant global and national health challenges, particularly in India. Objective: To estimate
the prevalence and characteristics of STIs among attendees at the Suraksha Clinic in the Apex Regional STD Centre, Safdarjung Hospital. Methods:
Retrospective data from January 2018 to December 2022 were statistically analyzed using Excel and SPSS. The study included the examination for
diagnosis of various STIs, such as syphilis, human immunodeficiency virus (HIV), gonorrhoea, chlamydiasis, trichomoniasis, candidiasis, bacterial
vaginosis, chancroid, and genital herpes. Gender distribution and syndromic diagnoses, including vaginal/cervical discharge and genital ulcers, were
also considered. Referrals to Integrated Counseling and Testing Centres for HIV testing were analyzed. Results: The outcomes reveal a substantial
burden of STIs, with 3.06% showing reactivity to syphilis, 1.74% testing positive for HIV, 3.36% for gonorrhoea, 11.78% for chlamydiasis, 1.05% for
trichomoniasis, 26.24% for candidiasis, 9.97% for bacterial vaginosis, 7.80% for chancroid, 11.64% for herpes genitalis, and 4.01% for other non-STIs.
Attendees’ interactions included 34.36% of referrals to Integrated Counseling and Testing Centres for HIV testing. The gender distribution showed 58.92%
male and 40.94% female attendees. Conclusion: Syndromic diagnoses, including vaginal/cervical discharge (21.22%) and genital warts (8.00%), highlight
prevalent conditions, necessitating routine screening, early detection, and targeted interventions for effective disease control and prevention. These findings
underscore the significance of integrated screening, patient education, and proactive strategies to safeguard public health in the face of rising STI rates.
Keywords: Condom usage. Disease control. Epidemiology. HIV. High-risk population. Patient education. Screening. Sexually transmitted infections.
Syphilis. Vulnerable population.

RESUMO
Introdução: As infecções sexualmente transmissíveis (IST) apresentam desafios de saúde globais e nacionais significativos, particularmente na Índia.
Objetivo: Estimar a prevalência e as características das IST entre os pacientes atendidos na Clínica Suraksha do Centro Regional de doenças sexualmente
transmissíveis (DST) Apex, Hospital Safdarjung. Métodos: Dados retrospectivos de janeiro de 2018 a dezembro de 2022 foram analisados estatisticamente
utilizando Excel e Statistical Package for the Social Sciences (SPSS). O estudo inclui o exame para diagnóstico de diversas IST, como sífilis, HIV,
gonorreia, clamídia, tricomoníase, candidíase, vaginose bacteriana, cancroide e herpes genital. A distribuição por gênero e os diagnósticos sindrômicos,
incluindo corrimento vaginal/cervical e úlceras genitais, também foram considerados. Foram analisados encaminhamentos para Centros Integrados de
Aconselhamento e Testagem para testagem de HIV. Resultados: Os resultados revelam uma carga substancial de IST, com 3,06% apresentando reatividade
à sífilis, 1,74% testando positivo para HIV, 3,36% para gonorreia, 11,78% para clamídia, 1,05% para tricomoníase, 26,24% para candidíase, 9,97% para
vaginose bacteriana, 7,80% para cancroide, 11,64% para herpes genital e 4,01% para outras infecções não IST. As interações dos participantes incluíram
34,36% de encaminhamentos para Centros Integrados de Aconselhamento e Testagem para testes de HIV. A distribuição por gênero mostrou 58,92% de
participantes do sexo masculino e 40,94% do sexo feminino. Conclusão: Os diagnósticos sindrômicos, incluindo corrimento vaginal/cervical (21,22%) e
verrugas genitais (8,00%), destacam condições prevalentes, necessitando de exames de rotina, detecção precoce e intervenções direcionadas para controle
e prevenção eficazes de doenças. Estas conclusões sublinham a importância do rastreio integrado, da educação dos pacientes e de estratégias proativas para
salvaguardar a saúde pública diante do aumento das taxas de IST.
Palavras-chave: Uso de preservativo. Controle de doenças. Epidemiologia. HIV. População de alto risco. Educação do paciente. Triagem. Infecções
sexualmente transmissíveis. Sífilis. População vulnerável.

INTRODUCTION million annual cases of curable STIs occur in developing countries,

underscoring the gravity of this widespread issue(1). The repercus-
Sexually transmitted infections (STIs) pose a significant and
sions extend beyond individual suffering, encompassing substantial
intricate health concern globally, with particular emphasis in the
economic losses due to the burden of ill health.
context of India. Notably, about three-fourths of the estimated 340
In India, the impact is profound, with approximately 6.00% of
the adult population grappling with the effects of STIs(2). The dis-
eases transmitted through sexual contact include, notably, syphilis,
1
Safdarjung Hospital, Apex Regional STD Centre – New Delhi, India. E- gonorrhoea, chlamydiasis, and trichomoniasis. The STIs stand out as
mails: sumu3579@yahoo.com, dprashant.gupta@gmail.com, drabhilachy-
particularly pervasive, causing systemic manifestations and severe
an@gmail.com, soni.chauhan1410@gmail.com, rattansingh00@gmail.com
2
Safdarjung Hospital, Department of Dermatology & STD and Apex consequences. While sexual contact is the primary mode of trans-
Regional STD Centre, Head of Department – New Delhi, India. E-mail: mission, other routes such as needle-stick injuries or blood transfu-
drniti@rediffmail.com sions can also introduce these infections into the body(2).
https://doi.org/10.5327/DST-2177-8264-2024361400 DST - J bras Doenças Sex Transm 2024;36:e24361400 - ISSN on-line: 2177-8264
2 MURALIDHAR et al.

The cumulative burden is immense, with approximately 6 saponin-lysed blood agar with supplements to diagnose Neisseria
million new cases of syphilis reported annually. The gravity of gonorrhoeae (Ng). The identification of trichomoniasis involved a
each infection is compounded when they co-infect individuals, direct wet mount examination and culture on Kupferberg media.
exacerbating the disease’s progression and increasing morbid- Vulvovaginal candidiasis (VVC) investigation utilized direct Gram-
ity and mortality(3). stained smear examination and culture on Sabouraud dextrose agar,
In response to this health crisis, an imperative need for a holistic confirmed by the germ tube test, sugar assimilation/fermentation
approach to early diagnosis and treatment arises. Recognizing the tests, and morphological identification on corn meal agar (CMA).
significance of STIs in public health, Suraksha clinics, established Bacterial vaginosis diagnosis included physiological tests, presence
across the Indian subcontinent, routinely screen attendees for syphi- of clue cells, and vaginal Gram-stained smear interpretation follow-
lis, other STIs, and human immunodeficiency virus (HIV). However, ing Nugent’s scoring. Chlamydial infections causing non-gonococcal
there is a crucial need to comprehensively evaluate the incidence of urethritis (NGU) were recognized by Chlamydia trachomatis anti-
all STIs, considering the potential for co-infections. gen detection, the enzyme-linked immunosorbent assay (ELISA)
Suraksha Clinic is a chain of STI/RTI clinics established by the or direct fluorescent antibody (DFA) tests, or by antibody detec-
National AIDS Control Organization (NACO) to provide enhanced tion ELISA tests.
sexual health services and prevent HIV/Acquired Immunodeficiency Diagnosis of other genital ulcer diseases (GUD) included
Syndrome (AIDS) in India. Tzanck smear and ELISA tests for herpes genitalis, Gram-
stained smears for chancroid, and Giemsa-stained crushed tis-
sue smears for donovanosis. Additionally, the presence of HIV 1
OBJECTIVE and 2 antibodies was determined using the HIV testing Strategy-
This study aimed to estimate the prevalence of STIs among III established by NACO, employing ELISA/Rapid tests with
Suraksha clinic attendees at the Apex Regional STD Centre, situ- NACO-approved kits.
ated in one of the largest tertiary care hospitals in North India. By
doing so, we seek to enhance our understanding and contribute to
Statistical analysis
more effective prevention and intervention strategies for these crit-
ical public health issues(4). Excel and Statistical Package for Social Sciences (SPSS) were
used for statistical analysis, recognized software tools in epidemi-
ological and public health research. These facilitated thorough data
METHODS analysis, assisting in result interpretation and identifying significant
patterns and trends within the collected data. This analytical process
was a fundamental element of our research, enabling the formulation
Study design and data collection
of conclusions grounded in robust statistical principles.
A retrospective study was conducted at the Apex Regional STD
Centre, affiliated with Safdarjung Hospital, New Delhi, India.
Data covering five years from January 2018 to December 2022
RESULTS
were retrieved from hospital records. The study included attendees In this study, we sought to estimate the prevalence of STIs among
both with diagnosed STI complaints and those without a diagno- Suraksha clinic attendees at the Apex Regional STD Centre, Safdarjung
sis, during this timeframe. Comprehensive clinical data were col- Hospital, during the period from January 2018 to December 2022.
lected from these attendees before inclusion in the study. To ensure Our findings provide important insights into the epidemiology of
the data primarily reflected the experiences of first-time attendees these infections in this population.
during the specified period, repeat Suraksha clinic attendees were Table 1 delineates the gender-wise distribution of attendees at
excluded from the analysis. the Suraksha Clinic. Notably, nearly 59% were identified as male,
indicating a substantial representation of men seeking services.
Additionally, approximately 41% of attendees were female, also
Microbiological testing
underlining the significant presence of women in the clinic popu-
Microbiological testing procedures followed guidelines estab- lation. A minimal proportion constituting only 0.13% was identi-
lished by NACO. For the diagnosis of syphilis, a genital ulcer-caus- fied as ‘Others.’
ing disease, a standardized protocol was adhered to. Symptomatic Table 2 presents a detailed breakdown of the characteristics of
attendees initially underwent the venereal disease research labora- attendees at the Suraksha Clinic, shedding light on their interac-
tory (VDRL) test. Reactive VDRL specimens were further tested by tions and availing of various services. Notably, 19.14% engaged in
a quantitative VDRL test, involving successive two-fold dilutions Partner Notification services, indicating an active effort in notifying
of serum in 0.9% saline. Samples reactive or weakly reactive in the
VDRL test were further confirmed by the specific Treponema pal- Table 1. Gender-wise distribution (n=12,978).
lidum hemagglutination assay (TPHA) test, chosen for reliability Gender-wise distribution among Suraksha Clinic attendees
and accuracy in identifying syphilis. Sr No. Gender Total No. Percentage (%)
STIs causing genital discharge were diagnosed using standard 1. Male 7,647 58.92
laboratory procedures. Direct urethral/cervical specimens were 2. Female 5,314 40.94
tested by Gram-stained smears, and culture on chocolate agar and 3. Others 17 0.13

DST - J bras Doenças Sex Transm 2024;36:e24361400

Trends in STI prevalence: a five-year analysis of Suraksha Clinic attendees in North India 3

partners about potential risks. Additionally, 10.40% were managed Table 4 is a valuable resource for understanding the various syn-
through Partner Managed services. A significant proportion (34.36%) dromic diagnoses encountered in the Suraksha Clinic, which supports
of individuals were referred to Integrated Counselling and Testing the development of appropriate treatment strategies and healthcare
Centres (ICTC) for HIV counselling and testing. Another 14.05% interventions. The comprehensive data in the table encompasses a
were referred to other services. The “Other” (Condom Provided, TI wide range of conditions, providing healthcare professionals with
[Targeted Intervention] Services) category encompassed 22.03% insights that can inform targeted and effective care for the diverse
of attendees. patient population.
As per guidelines established by NACO, syndromic approach Table 5 provides a comprehensive overview of positivity rates
has been adopted for the management of STIs. for various STIs over five years, from January 2018 to December
Table 3 provides a detailed breakdown of the syndromic diagnoses 2022. The data table includes laboratory tests performed, with the test
among attendees at the Suraksha Clinic, offering valuable insights results and the percentage of positivity for each STI, including HIV.
into prevalent conditions and the diversity of cases encountered. Syphilis positivity rates ranged from 2.23% to 4.44% across the
The most commonly observed syndromes include vaginal cervical five years, with an average positivity of 3.16%. Gonorrhoea showed
discharge (VCD), constituting 21.22% of cases, and genital warts varying positivity rates from 2.08% to 5.04%, averaging at 3.36%.
(GW) with 8.00%. Cases of genital ulcer disease (GUD), indicating Chlamydiasis exhibited a wide range of positivity rates from 2.17%
genital ulcers potentially linked to herpes, made up 6.96% of diag- to 29.09%, with an average of 11.78%. Trichomoniasis displayed
noses. Additionally, syphilis and HIV cases were notable, compris- relatively low positivity rates ranging from 0.30% to 2.73%, with
ing 3.23% and 0.60% of the total, respectively. The category “Not an average of 1.05%. Candidiasis revealed positivity rates fluctuat-
Diagnosed STI” stood out, with 42.23% of cases. ing from 21.87% to 29.98%, averaging at 26.24%.

Table 2. Characteristics of Suraksha Clinic attendees (n=12,978).

Sr No. Characteristics of Suraksha Clinic attendees Total No. Percentage (%)
1. Partner notification 2,484 19.14
2. Partner managed 1,350 10.40
3. Referred from Suraksha Clinic to ICTC 4,460 34.36
4. Referred to other departments /services (e.g., Tuberculosis clinic) 1,824 14.05
5. Others (Condom Provided, TI Services) 2,860 22.03

Table 3. Sexually transmitted infections syndromic diagnosis (n=12,978).

Sr No. Syndromic diagnosis among Suraksha Clinic attendees Total No. Percentage (%)
1. Vaginal cervical discharge (VCD) 2755 21.22
2. Genital ulcer-non-herpetic (GUD-NH) 74 0.57
3. Genital ulcer-herpetic (GUD-H) 904 6.96
4. Lower abdominal pain (LAP) 90 0.69
5. Urethral discharge (UD) 277 2.13
6. Inguinal bubo (IB) 31 0.23
7. Painful scrotal swelling (SS), anorectal discharge (ARD) 59 0.45
Others
1. Genital warts (GW) 1039 8.00
2 Other infections 1399 10.77
3. Not diagnosed as sexually transmitted infections 5481 42.23

Table 4. Sexually transmitted infections syndromic diagnoses at Suraksha Clinic.

Syndromic diagnosis Description
Refers to individuals diagnosed with genital ulcer disease caused by the herpes simplex virus (HSV). This condi-
GUD-herpetic
tion is characterized by the presence of painful sores in the genital area, attributed to the herpes infection.
This diagnosis is assigned to patients with genital ulcer disease caused by agents other than the herpes simplex
GUD-non herpetic virus. Possible diseases include syphilis, chancroid, lymphogranuloma venereum or granuloma inguinale, leading
to non-herpetic ulcers.
Patients with this diagnosis present with swelling in the scrotal region. The cause of scrotal swelling can vary and
Scrotal swelling
may be associated with various conditions, including infections or inflammation.
This diagnosis indicates that patients have been diagnosed with an inguinal bubo, which refers to an enlarged and
Inguinal bubo
swollen lymph node in the inguinal (groin) area. Such swelling may signal the presence of an underlying infection.
This diagnosis is assigned to patients with abnormal discharge from the anal or rectal area, which may be indica-
Anorectal discharge
tive of various infections or inflammatory conditions.
Individuals with this diagnosis experience abnormal discharge from the vaginal or cervical area. The presence of
Vaginal/cervical discharge
such discharge may be associated with various gynecological or infectious conditions.
Those diagnosed with lower abdominal pain may experience discomfort in the lower abdominal area, which can
Lower abdominal pain
have various causes, including infections, reproductive health issues, or other medical conditions.

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4 MURALIDHAR et al.

Bacterial Vaginosis has positivity rates ranging from 6.90% not detected positive throughout the five years. HIV exhib-
to 12.41%, with an average of 9.97%. Chancroid showed vary- ited positivity rates ranging from 1.21% to 2.10%, with an
ing positivity rates from 0% to 16.66%, averaging at 7.80%. average of 1.74%.
Herpes Genitalis and HSV 1& 2 Ab displayed positivity Table 6 includes medications prescribed to treat specific
rates fluctuating from 5.88% to 22.72%, with an average of infections or conditions diagnosed in patients, and plays a cru-
11.64%. Donovanosis and lymphogranuloma venereum were cial role in managing and curing STIs in clinics.

Table 5. Consolidated laboratory data of five years.

(2018–2022)
SR No. STIs Laboratory Test 2018 Positivity 2019 Positivity 2020 Positivity 2021 Positivity 2022 Positivity
Average %
Dark field micros-
copy
VDRL
RPR
1. Syphilis
TPHA
TP ELISA(IgG/
IgM)
FTA-Abs 1,573/3,5379=4.44% 996/27,788=3.58% 483/19,117=2.52% 620/27,725=2.23% 970/31,623=3.06% 3.16%
Direct smear male
(Gram stain)
Direct smear fe-
male (Gram stain)
2. Gonorrhoea
Culture male
Culture female
Anti-microbial
70/2,445= 2.86% 39/1,521=2.56% 14/673=2.08% 56/1,310=4.27 % 76/1,506=5.04% 3.36%
sensitivity testing
Chlamydia ELISA
antigen
Chlamydia anti-
body IgG
3. Chlamydiasis
Chlamydia anti-
body IgM
DFA
PCR 41/1,881=2.17% 31/861=3.60% 32/110=29.09% 68/598=11.37% 106/836=12.67% 11.78%
Direct wet mount
Trichomo-
4. Culture
niasis
PCR 8/1,928=0.41% 45/1,648=2.73% 2/666=0.30% 5/1,128=0.44% 18/1,276=1.41% 1.05%
KOH wet mount
Gram stain
5. Candidiasis Culture
Anti-fungal sensi-
687/2,644=29.98% 647/2,958=21.87% 268/1,096=24.45% 548/1,928=28.42% 628/2,371=26.48% 26.24%
tivity testing
Bacterial Amsel’s criteria
6.
Vaginosis Nugent’s score 228/1,928=11.82% 142/1,470=9.65% 46/666= 6.90% 140/1,128=12.41% 144/1,580=9.11% 9.97%
Gram stain
7. Chancroid
Culture 6/94=6.38% 0 0 4/25=16.00% 1/6=16.66% 7.8%
Giemsa stain for
Herpes MNGC
8.
Genitalis HSV 1& 2 Ag
HSV 1& 2 Ab 16/118=13.55% 25/110=22.72% 5/61=8.19% 10/170=5.88% 10/127=7.87% 11.64%
9. Donovanosis Giemsa stain 0/2=0 0/0=0 0/1=0 0/4=0 0/0=0 no positive
Giemsa stain
Lymphogran-
DFA
10. uloma ve-
ELISA Ag
nereum
ELISA Ab 0/0=0 0/0=0 NA NA NA no positive
11. HIV HIV 496/2,3561=2.10% 324/19,157=1.69% 289/14,619=1.98% 387/22,028=1.75% 319/26,220=1.21% 1.74%
Others non
12. Pyogenic culture NA NA 29/363=7.98% 35/674=6.09 % 39/649=6.00 % 4.01%
STIs
VDRL: venereal disease research laboratory; RPR: rapid plasma reagin; TPHA: Treponema pallidum hemagglutination assay; TP ELISA: enzyme-
linked immunosorbent assay for Treponema pallidum; IgG/IgM: immunoglobulin G/M; FTA-Abs: fluorescent treponemal antibody-absorption; DFA:
direct fluorescent antibody; PCR: polymerase chain reaction; KOH: potassium hydroxide; MNGC: Multinucleated Giant Cell; HSV: Herpes Simplex
Virus; HIV: human immunodeficiency virus; NA: not available; STIs: sexually transmitted infections.

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Trends in STI prevalence: a five-year analysis of Suraksha Clinic attendees in North India 5

Table 6. Drugs used in sexually transmitted infections treatment.

Drug Name Description
Acyclovir is an antiviral medication commonly used to treat infections caused by herpes viruses, including genital
Acyclovir 400 mg
herpes (herpes simplex virus) and shingles (herpes zoster).
Amoxicillin is an antibiotic used to treat a wide range of bacterial infections, including those affecting the genital and
Amoxicillin 500 mg
urinary tract.
Azithromycin 1 gm Azithromycin is an antibiotic used to treat various bacterial infections, including chlamydiasis and gonorrhoea.
Benzyl Penicillin 2.4MU Benzylpenicillin, also known as penicillin G, is an antibiotic used to treat syphilis.
Cefixime 400 mg Cefixime is an antibiotic used to treat bacterial infections, including some STIs such as gonorrhoea.
Ceftriaxone is an antibiotic used to treat a wide range of bacterial infections, including gonorrhoea. The dosage
Ceftriaxone 250 mg & 1 gm
may vary based on the specific infection.
Ciprofloxacin 500 mg Ciprofloxacin is an antibiotic used to treat various bacterial infections, including those of the urinary and genital tract.
Clotrimazole 500 mg Clotrimazole is an antifungal medication used to treat fungal infections, including yeast infections in the genital area.
Doxycycline 100 mg Doxycycline is an antibiotic used to treat bacterial infections, including some STIs such as chlamydiasis and syphilis.
Erythromycin 500 mg Erythromycin is an antibiotic used to treat various bacterial infections, including genital infections.
Fluconazole 150 mg Fluconazole is an antifungal medication used to treat fungal infections, including yeast infections in the genital area.
Metronidazole 400 mg Metronidazole is an antibiotic and antiprotozoal medication used to treat trichomoniasis.
Secnidazole 500 mg Secnidazole is an antibiotic used to treat parasitic infections, including some STIs, like trichomoniasis.

DISCUSSION to the consistent efforts of NACO in this regard. HIV is a signifi-

cant public health concern worldwide, and early detection is crucial
Sexually transmitted infections pose a substantial public health
for initiating antiretroviral therapy and preventing further transmis-
challenge, not only on a global scale but also within the specific con-
sion. The prevalence of HIV among attendees at this STI clinic was
text of India. As observed in this study, the burden of these infections
higher than in the general population, emphasizing the importance
is significant, and its implications extend far beyond the immediate
of integrated screening for HIV in this setting.
concerns of individuals’ health. We will now delve into a detailed
discussion of the key findings and their implications.
Other STIs prevalence
Prevalence of STIs The rising trend in gonorrhoea positivity rates, ranging from
Our study revealed an STI prevalence of 9.38% and HIV of 2.08% to 5.04%, calls attention to the need for intensified preven-
1.74% among attendees of the Suraksha Clinic at Apex Regional tive measures. Our results are still lower than those reported by
STD Centre, Safdarjung Hospital, during the five years from January Choudhary et al.(2), which is far higher at 19.3%, and Passos et al.
2018 to December 2022. Among the patients, we found a large pro-
(5)
who presented 13.06%. Garland et al.(6) had a gonorrhoea preva-
portion of males (58.92%), which corroborates a study by Agrawal lence of 4.54%, which is close to our study.
et al.(1) with 58.10%, most of them new patients. These findings are The use of diverse diagnostic methods provided a comprehen-
indicative of a high-risk population seeking care at this facility, con- sive evaluation, emphasizing the importance of early detection and
sistent with the notion that STI clinics primarily serve individuals intervention strategies. According to the World Health Organization
with a higher likelihood of infection. (WHO), drug resistance in gonorrhea is exhibiting an increasing
trend, thus requiring strengthening of the STI program for the man-
agement of the disease. Antimicrobial resistance increases this burden
Syphilis prevalence by prolonging the infection in more people and raising the number
Syphilis demonstrated a consistent average positivity of 3.16% of patients with long-term complications of gonococcal infections.
over the five years. Passos et al.(5) reported an average of 9.55%, The prevalence of chlamydiasis exhibited significant fluctuations,
higher than our result, probably due to the longer duration of time peaking at 29.09% in 2020 with an overall 11.78% in five years. This
study (13 years). The utilization of multiple laboratory tests allowed is comparable to the slightly higher percentage of 16.30% reported
for a thorough assessment, highlighting the need for ongoing sur- by Choudhry et al.(2) On the other hand, Garland et al.(6) reported
veillance to monitor any potential changes in syphilis dynamics. only 5.45% in their study, which is lower than the present study. This
All 3.16% of attendees had a reactive VDRL test suggesting active variability underscores the complex nature of chlamydial infections
syphilis infection. It is important to note that this disease can have and suggests the necessity for targeted interventions during periods
severe health consequences if left untreated, making early detection of elevated prevalence. Further research into the factors influencing
and treatment vital. these fluctuations could provide valuable insights.
Consistent and low positivity rates in trichomoniasis (0.30 to
2.73%) were seen in five years, overall 1.05%, suggesting a com-
HIV prevalence paratively lower prevalence. Here again, the study by Choudhry
The study also highlighted that 1.74% of attendees were HIV- et al.(2) was higher at 4.70%. Two other studies by Garland et al.(6)
positive, a much lower result than that obtained by Choudhry et al.(2) (3.63%) and Passos et al.(5) (3.86%), also recorded higher preva-
who reported 10.30%. In India, HIV prevalence is still low, thanks lence than our study.
DST - J bras Doenças Sex Transm 2024;36:e24361400
6 MURALIDHAR et al.

Chancroid displayed sporadic peaks, reaching 16.66% in 2022, in this study, can have a positive impact on reducing the transmission of
and overall, in five years it was 7.80%. Choudhry et al.(2) related STIs, including HIV. This finding highlights the need to emphasize and
19.30%, which is far higher than our study. The infrequent detec- further develop patient education strategies within Suraksha clinics(9,10).
tion of cases emphasizes the importance of heightened vigilance and The observation of a potential decrease in the number of patients pre-
targeted awareness campaigns, particularly for less common STIs. senting with sexual tract infections (STIs) during the years 2020–2021,
Herpes genitalis exhibited a fluctuating but generally moderate juxtaposed with the global COVID-19 pandemic and associated lock-
prevalence. The inclusion of multiple diagnostic methods ensures a downs, sparks a compelling discussion on the interplay between infec-
comprehensive understanding of herpes genitalis cases, supporting tious diseases and healthcare-seeking behavior(11,12). The pronounced
ongoing efforts in prevention and management. restrictions imposed during the lockdown periods may have inadver-
The absence of positive cases in donovanosis and lymphogran- tently influenced the patterns of attendance at Suraksha Clinic, lead-
uloma venereum suggests a low prevalence or potential underre- ing to a noteworthy decline in reported cases. Factors such as reduced
porting. The comprehensive diagnostic methods employed provide social interactions, fear of contagion, and limited accessibility to health-
confidence in the findings, emphasizing the need for sustained sur- care facilities might have contributed to a scenario where individuals
veillance and awareness. with STIs were less inclined to seek medical attention. This nuanced
Vaginal candidiasis maintained a persistent presence with an aver- intersection between the COVID-19 pandemic and the management
age positivity of 26.24%. Our results were much higher when com- of STIs prompts further exploration into the dynamics of public health
pared to those of Choudhry et al.(2), which were only 2%. This could responses, healthcare utilization, and the broader implications for sexual
reflect a geographical variation across the country and the presence health initiatives in the context of unprecedented global health crises(13,14).
of fungal species in several locations. It is important to identify the
diverse species of candida causing vulvovaginal candidiasis to insti-
Strengths
tute appropriate treatment as some species are inherently resistant to
routinely used antifungal agents (e.g., Candida krusei).
Bacterial vaginosis showed fluctuating but generally moderate
Comprehensive analysis
positivity rates. The variations underscore the need for continued
research to elucidate the factors influencing the disease dynamics The study provides a thorough and comprehensive analysis of the
and to inform strategies for prevention and management. prevalence and characteristics of various STIs over a five-year period,
In addressing the non-STIs, the fluctuating positivity rates and offering valuable insights into the epidemiology of these infections.
an average of 4.01% highlighted the diversity of these infections.
Further exploration of the infections included in this category and
Diverse diagnostic methods
their contributing factors could assist in targeted interventions.
The utilization of diverse diagnostic methods for different STIs
ensures a nuanced understanding of their prevalence, contributing
Implications for public health
to the accuracy and reliability of the findings.
The findings of this study have several important implications for
public health. First and foremost, the significant prevalence of STIs
Integration of syndromic approach
and HIV in this clinic population underscores the vulnerability of
individuals seeking care at Suraksha Clinic. Routine screening and The inclusion of syndromic diagnoses provides a holistic view
testing for syphilis, other STIs, and HIV is essential to ensure early of prevalent conditions, aiding in the identification of diverse cases
diagnosis and timely treatment. This not only benefits the affected and informing targeted interventions.
individuals but also aligns with broader public health objectives
related to disease control and prevention(7).
Longitudinal data
The study covers a substantial time frame (January 2018 to
Integration of screening and treatment
December 2022), allowing for the observation of trends and fluctu-
To address the public health challenge of STIs effectively, it is imper- ations in STI prevalence over time.
ative to integrate targeted screening for STIs and HIV within existing
STI prevention and treatment services. This approach can help create a
Emphasis on patient education
more robust and proactive strategy for identifying and managing these
infections, thereby contributing to the reduction of their prevalence and The study recognizes the importance of patient education, partic-
the mitigation of their adverse consequences(8). The syndromic approach ularly in promoting condom usage, contributing to the development
suggests a need for further investigation or indicates a diverse range of effective prevention strategies.
of conditions that may require more targeted diagnostic approaches.
Experienced laboratory personnel and experts
The role of education
The authenticity of data is assured by highly experienced and
Additionally, our data provides insights into the importance of patient dedicated personnel, devoted primarily to the diagnosis of STIs,
education strategies. Education and promotion of condom usage, as seen from the Apex STD Centre in the country.
DST - J bras Doenças Sex Transm 2024;36:e24361400
Trends in STI prevalence: a five-year analysis of Suraksha Clinic attendees in North India 7

Limitations Acknowledgment
We want to express our sincere gratitude to all those who con-
tributed to the successful completion of this study. In particular, we
Single-centre study
extend our heartfelt appreciation to Ms. Nandini, Mr. Sahil our ded-
The study is conducted at a specific clinic (Suraksha Clinic in icated data entry operator and MTS, respectively, for their invalu-
the Apex Regional STD Centre, Safdarjung Hospital), limiting the able assistance in managing and organizing the vast amounts of data
generalizability of findings to a broader population. required for this research. We would also like to thank all the indi-
viduals who participated in this study and the medical staff of the
concerned department for their invaluable contributions. Their coop-
Retrospective design
eration and dedication were instrumental in ensuring the reliability
The retrospective design of the study relies on existing data, of our findings. Lastly, we extend our gratitude to our colleagues,
which may be subject to limitations such as incomplete records or mentors, and peers for their guidance and insights throughout this
variations in data quality over the five-year period. paper. Their knowledge and expertise immensely contributed to
shaping this research and its conclusions.
External factors (e.g., COVID-19):
The study acknowledges the potential impact of external factors,
REFERENCES
such as the COVID-19 pandemic, on healthcare-seeking behaviour. 1. Agrawal N, Rana MM, Patel KB, Bapat N. Profile of reproductive tract
However, the complex interplay between infectious diseases and infections among attendees of reproductive tract infection/sexually
transmitted infection clinic in a tertiary care Institute of Ahmedabad,
healthcare utilization requires further exploration. Gujarat. Indian J Community Med. 2019;44(1):62-3. https://doi.
org/10.4103/ijcm.IJCM_32_18
2. Choudhry S, Ramachandran VG, Das S, Bhattacharya SN, Mogha NS.
CONCLUSION Pattern of sexually transmitted infections and performance of syndromic
management against etiological diagnosis in patients attending the sexually
The prevalence of STIs and HIV among Suraksha Clinic attend-
transmitted infection clinic of a tertiary care hospital. Indian J Sex Transm
ees markedly surpasses that of the general population. This under- Dis AIDS. 2010;31(2):104-8. https://doi.org/10.4103/0253-7184.74998
scores the critical importance of implementing routine screening 3. Parashar A, Gupta BP, Bhardwaj AK, Sarin R. Prevalence of RTIs among
for these infections among individuals seeking care at Suraksha women of reproductive age group in Shimla city. Indian J Community
Clinic. Early detection and prompt treatment are not only essential Med. 2006;31:15-7. https://doi.org/10.4103/0970-0218.54924
for the well-being of affected individuals but also for the broader 4. Balamurugan SS, Bendigeri N. Community-based study of reproductive
tract infections among women of the reproductive age group in the urban
public health objectives of controlling the spread of these diseases health training centre area in Hubli, Karnataka. Indian J Community Med.
and preventing associated complications. 2012;37(1):34-8. https://doi.org/10.4103/0970-0218.94020
To address this public health challenge effectively, it is imperative 5. Passos MR, Arze WN, Mauricio C, Barreto NA, Varella RQ, Cavalcanti
to integrate a targeted screening approach for STIs and HIV within SMB, et al. Is there increase of STDs during Carnival? Time series of
existing STI prevention and treatment services. By doing so, we diagnoses in a STD clinic. Rev Assoc Med Bras (1992). 2010;56(4):420-
7. https://doi.org/10.1590/s0104-42302010000400014
can create a more robust and proactive strategy for identifying and 6. Garland SM, Tabrizi SN, Chen S, Byambaa C, Davaajav K. Prevalence
managing these infections, thereby contributing to the reduction of of sexually transmitted infections (Neisseria gonorrhoeae, Chlamydia
their prevalence and the mitigation of their adverse consequences. trachomatis, Trichomonas vaginalis and human papillomavirus) in
This approach aligns with the broader goals of disease prevention female attendees of a sexually transmitted diseases clinic in Ulaanbaatar,
and underscores the necessity of continued efforts to safeguard the Mongolia. Infect Dis Obstet Gynecol. 2001;9(3):143-6. https://doi.
org/10.1155/S1064744901000254
health and well-being of our communities. 7. Murphy PA, Jacobson J, Turok DK. Criterion-based screening for sexually
transmitted infection: Sensitivity, specificity, and predictive values of
commonly used questions. J Midwifery Womens Health. 2012;57(6):622-
Participation of each author 8. https://doi.org/10.1111/j.1542-2011.2012.00228.x.
8. Goyal MK, Witt R, Hayes KL, Zaoutis TE, Gerber JS. Clinician adherence
SM: Conceptualization, Investigation, Methodology, Project
to recommendations for screening of adolescents for sexual activity and
administration, Supervision, Validation. PG: Data curation, Formal sexually transmitted infection/human immunodeficiency virus. J Pediatr.
analysis. AL: Conceptualization, Data curation, Formal analysis, 2014;165(2):343-7. https://doi.org/10.1016/j.jpeds.2014.04.009
Investigation. SS: Resources, Validation. RSR: Resources. NK: 9. Brook G, McSorley J, Shaw A. Retrospective study of the effect of
Resources, Supervision, Validation. enhanced systematic sexually transmitted infection screening, facilitated
by the use of electronic patient records, in an hiv-infected cohort. HIV
Med. 201314(6):347-53. https://doi.org/10.1111/hiv.12020
Funding 10. Bala M, Mullick JB, Muralidhar S, Kumar J, Ramesh V. Gonorrhoea
& its co-infection with other ulcerative, non-ulcerative sexually
The authors declare no financial support. transmitted & HIV infection in a Regional STD Centre. Indian J Med Res.
2011;133(3):346-9. PMID: 21441694.
11. Sonkar SC, Wasnik K, Kumar A, Sharma V, Mittal P, Mishra PK, et al.
Conflict of interest Evaluating the utility of syndromic case management for three sexually
transmitted infections in women visiting hospitals in Delhi, India. Sci
The authors declare no conflicts of interest. Rep. 2017;7(1):1465. https://doi.org/10.1038/s41598-017-01422-y

DST - J bras Doenças Sex Transm 2024;36:e24361400

8 MURALIDHAR et al.

12. Kumarasamy N, Balakrishnan P, Venkatesh KK, Srikrishnan AK, Cecelia AJ, Address for correspondence
Thamburaj E, et al. Prevalence and incidence of sexually transmitted infections SUMATHI MURALIDHAR
among South Indians at increased risk of HIV infection. AIDS Patient Care
Safdarjung Hospital, Ansari Nagar East, near to AIIMS
STDS. 2008;22(8):677-82. https://doi.org/10.1089/apc.2007.0166
13. Choi J, Bahl D, Arora M, Xuan Z. Changes in self-reported sexually Metro Station
transmitted infections and symptoms among married couples in India New Delhi (Delhi), India
from 2006 to 2016: a repeated cross-sectional multivariate analysis from 110029
nationally representative data. BMJ Open. 2021;11(10):e049049. https:// E mail: sumu3579@yahoo.com; drsumathimdhar@vmmc-sjh.nic.
doi.org/10.1136/bmjopen-2021-049049
in; Muralidhar-sumu3579@yahoo.com,
14. Brahme RG, Sahay S, Malhotra-Kohli R, Divekar AD, Gangakhedkar RR,
Parkhe AP, et al. High-risk behaviour in young men attending sexually
transmitted disease clinics in Pune, India. AIDS Care. 2005;17(3):377-85. Received on: 10.01.2024
https://doi.org/10.1080/09540120412331299771 Approved on: 07.02.2024

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