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Sexually transmitted infections (STI) are an important public health problem due both to their morbidity and their complications and sequelae in the absence of early diagnosis and treatment. Sexually transmitted infections (STIs) have been recognized as a major public health problem for a number of years in Pakistan. Sexually transmitted infections (STIs) are among the most common causes of illness in the Pakistan and have far reaching health, social and economic consequences. In addition to their sheer magnitude, STIs are a major public health problem for two additional reasons: their serious sequelae, and the fact that they facilitate transmission of HIV.According to the World Health Report 1999, STIs excluding HIV accounted for 1.2% disability adjusted life years (DALYs) during 1998; 0.8% among males and 1.7% among females3.Because STIs and their sequelae have a widespread effect on men, women, youth and newborns, the problem of curable STIs is costly to individuals and the health care system. The World Bank has estimated that STIs collectively rank second in importance among diseases for which intervention is possible and those four curable STIs, gonorrhoea, Chlamydia infection, syphilis and cancroids rank among the top 25 causes of healthy days of life lost in sub-Saharan Africa. Epidemiological studies from sub-Saharan Africa, Europe and North America have suggested that there is approximately four times greater risk of becoming HIV-infected in the presence of a genital ulcer such as caused by syphilis and/or cancroids; and a significantly, increased risk in the presence of STIs such as gonorrhoea, Chlamydia infection and trichomoniasis, which cause local accumulations of lymphocytes and macrophages5.In order to evolve effective prevention strategies as well as efficient and cost-effective means for treating sexually transmitted infections, it is important to have a better understanding of what STIs the men are most likely to encounter, what are the most common modes of transmission and where the men are most likely to get treatment for such diseases. The aim of this present study was to generate similar data for Pakistan covering the afore-said parameters.Epidemiological informationThere has been some HIV testing among antenatal clinic attendees in Pakistan since 1992. In 1995, no evidence of HIV infection was found among antenatal clinic attendees in Faisalabad or Karachi. In Lahore, 0.6 percent of women tested were HIV positive. There was no evidence of HIV infection among the women tested outside the major urban areas between 1992 and 1999, except in 1997 with 0.2 percent of antenatal clinic attendees tested were HIV positive.Among sex workers, 1.2 percent of women tested in a no specified area were HIV positive in 1993, 0.7 percent in 1995 and no evidence of HIV infection was found in 1995.In 1995, 0.2 percent of STD clinic patients tested in Karachi and 4 percent tested in Lahore were HIV positive. Outside of the major urban areas in a no specified area, HIV prevalence among STD patients tested ranged from 4.2 percent in 1992, 6.1 percent in 1994, to no evidence of infection in patients tested in 1998 and 1999.In 1996, 1 percent of IV drug users tested in Karachi were HIV positive. From 1994 to 1998, no evidence of HIV infection was found among IV drug users tested in a no specified area except in 1995, when 5.4 percent of users tested were HIV positive.HIV testing of truck drivers in Karachi in 1995 found no evidence of HIV infection.Mechanisms of transmission and control of STI’s in PakistanThe predominant mode of transmission of both HIV and other STIs is sexual intercourse. Measures for preventing sexual transmission of HIV and STI are the same, as are the target audiences for interventions. In addition, strong evidence supports several biological mechanisms through which STI facilitate HIV transmission by increasing both HIV infectiousness and HIV susceptibility. Significant also is the observation of a sharp decline in the concentration of HIV in the genital secretions when the infection is treated. Monitoring trends in STI can provide valuable information on the sexual transmission of HIV as well as the impact of behavioural interventions, such as promotion of condom use.
Incidence and Prevalence of STI’s – Situation in PakistanWomen with vaginal discharge had higher incidence of STI (84%) than without it (38%) (OR with vaginal discharge = 5.31; OR without discharge = 0.61; OR 8.7). Out of total 500 women recruited, 221 were symptomatic, therefore incidence rate of STI was 3952/100,000 per 6 months and period prevalence of 3.95%. STI in refugees (156 P<0.001) and women with grand multiparity (164 P<0.01) make them high risk group for targeted testing. The commonest infections in this study were vaginitis (74 cases 33.48% ), bacterial vaginosis (68 cases 30.7%), candidiasis (22 cases 10%), trichomoniasis (16 cases 7.2%), gonorrhea (3 cases 1.35%), lymphogranuloma venereum (1 case 0.45%), chancroid (1 case 0.45%), hepatitis B (3 cases 1.35%); but no cases of HIV/AIDS, syphilis or genital herpes were detected. Awareness about STI and high risk behaviour(regarding multiple sexual partners and intravenous drug abuse)determined from history (questionnaire), was maximum in the patients living within 5 km of hospital as compared to those living more than 5 km away (P<0.02) (Table 1). Risk factors related to STITable 1. Knowledge on STI related to distance of residence from hospital.
Distance Knowledge of STI None Total
<5Km 58 76 1345-10 Km or more 23 64 87
Total 81 140 221
P<0.02Table 2. Risk factors for STI.
Risk factors STI Cases % P Value
1 Occupation of Husband(labourer or jobless) 146 70 <0.0012 Smoking in Women (bothpast and current) 186 84.16 <0.0013 Vaginal douching 106 48 <0.0014 Contraceptive practice 71 32 <0.505 Ethnicity: Pashtoon 124 56 <0.0016 Multiple sex partners orhistory of extramarital sexual encounter 0 0 -* 1 STI in women with spouse/husband being jobless/labourer class (p<0.001).* 2 STI in refugees (Pashtoons and Persians/Balochs) versus local population (p<0.001).
Prevalence in this study were low socioeconomic status that is laborer/jobless class and smoking (Table 2). HVS with gram staining as screening test for STI with vaginal discharge showed sensitivity of 64% and specificity of 83%.STI’s and ImmigrationClinical services offering STI care are an important access point for people at high risk for both AIDS and STI, not only for diagnosis and treatment but also for information and education. Therefore, control and prevention of STI have been recognized as a major strategy in the prevention of HIV infection and ultimately AIDS. One of the cornerstones of STI control is adequate management of patients with symptomatic STIs. This includes diagnosis, treatment and individual health education and counselling on disease prevention and partner notification. Consequently, monitoring different components of STI control can also provide information on HIV prevention within a country.