Indian J Sex Transm Dis Indian J Sex Transm Dis
Official Publication of the Indian Association for the Study of Sexually Transmitted Diseases
Indian J Sex Transm Dis
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   Table of Contents - Current issue
Coverpage
January-June 2018
Volume 39 | Issue 1
Page Nos. 1-68

Online since Thursday, June 21, 2018

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REVIEW ARTICLE  

A meta-analysis on efficacy and tolerability of sildenafil for erectile dysfunction in patients with diabetes mellitus p. 1
PC Shah, Niyati A Trivedi
DOI:10.4103/ijstd.IJSTD_99_17  
Erectile dysfunction (ED) is a common complication in patients with diabetes mellitus (DM). Sildenafil, a phosphodiesterase-5 inhibitor, is commonly used in patients with ED. This meta-analysis was planned to determine the strength of evidence to assess the efficacy and tolerability of sildenafil in patients with DM-associated ED. Electronic searches were carried out to identify randomized controlled trials (RCTs) which reported clinical efficacy of sildenafil in patients with DM-associated ED. Data were extracted and methodological quality was assessed. Relative Risk (RR) with 95% confidence intervals (CIs) was estimated for the dichotomous outcomes, and the mean difference with 95% CI was estimated for continuous data. Eight randomized controlled trials (RCTs) involving 1172 patients met with our inclusion criteria. In comparison to placebo, sildenafil significantly improved the overall sexual performance in patients of ED associated with DM with relative risk (RR) of answering “yes” to global efficiency question being 3.99 (95% CI: 2.58–6.18) compared to placebo. The rate of discontinuation due to treatment-related adverse reactions was 2.4% in sildenafil arm with RR of 2.67 (95% CI: 0.74–9.62). Sildenafil is an effective and safe medication for the treatment of ED associated with DM.
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ORIGINAL ARTICLES Top

Epidemiological, clinical, and immunological profile of cases at the time of HIV testing (a clinic-based observational cross-sectional study) p. 7
Yogesh S Marfatia, Ruchi Jayeshbhai Shah, Reema Rajesh Baxi, Ashma Surani
DOI:10.4103/ijstd.IJSTD_20_18  
Introduction: With the availability of free antiretroviral therapy (ART), HIV/AIDS has become a chronic manageable disease, but its transmission still continues. Early testing, though desirable, is still a far-fetched goal. Materials and Methods: Forty-six newly detected HIV cases attending skin and sexually transmitted disease (STD) outpatient department (OPD) were studied. Careful inquiry was made to know the reason for HIV testing, marital status, concordance rate in married couples, and CD4 count at the time of presentation. Results: Of the 46 cases, 27 (59%) cases were in the age range of 20–40 years with 41% females and 59% males. Forty-one cases were married and cohabiting, out of which 19 were seroconcordant. Condom was used by 5/19 cases in seroconcordant group and 3/22 cases in serodiscordant group. Fourteen (30.4%) cases were tested for an epidemiologic reason (the most common being spouse positivity and antenatal care testing). Of the remaining 32 cases, the reason for testing was mucocutaneous manifestations in 16 cases, STD in 10 cases, and systemic illnesses (fever of unknown origin and weight loss) in 6 cases. Mean CD4 count was 336/cumm, with 17 cases having CD4 count <250/cumm. Conclusion: Except one, all cases were tested either because they were symptomatic or were referred by health-care provider for epidemiologic reasons. The presence of mucocutaneous manifestations including STD and systemic illnesses as the reason for testing as well as low CD4 count at the time of testing suggest less and late testing. Low condom use and high STD rate in married couple imply continued intramarital transmission. Although HIV seropositivity offers an entry point into continuum of comprehensive care package which includes free ART, it appears that HIV testing is still less and late.
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Correlation between venereal diseases research laboratory titers and CD4 T-lymphocyte count determined by flow cytometry in HIV-infected adults: A 5-year study p. 13
Prabhav Aggarwal, Sonali Bhattar, Preena Bhalla, Swati Sharma
DOI:10.4103/ijstd.IJSTD_137_15  
Introduction: Venereal Diseases Research Laboratory (VDRL) is one of the key tests for the diagnosis of syphilis; however in HIV-positive individuals, it has been reported to give inappropriate results at times. Thus, this study was conducted to determine if the VDRL test titers vary with the severity of immunosuppression as determined by CD4 cell count. Materials and Methods: A total of 2630 samples from HIV-positive adults were tested by qualitative and quantitative VDRL test and if reactive, by Treponema pallidum hemagglutination (TPHA) test. CD4 cell counts were determined at the same time by flow cytometry (BD FACSCount™ system). Correlation between CD4 T-lymphocyte cell count and VDRL titers was sought for. Results: Nearly 6.7% (176/2631) of individuals were VDRL reactive, males more than females (7.6% vs. 5.1%, P = 0.014). Four of the VDRL-reactive patients were found negative by TPHA test and were excluded from further study. VDRL titers ranged from weakly reactive to being reactive at 1:128 (median = 1:2). The CD4 cell count ranged from 23 cells/μl to 883 cells/μl (median = 276 cells/μl, mean = 323.9 ± 200.9). Pearson's coefficient of correlation (R) between CD4 cell count and VDRL titers was calculated to be 0.0559; coefficient of determination (R2) was 0.0031. Conclusions: Although the correlation coefficient shows a positive correlation, the association was very weak. Therefore, CD4 cell count cannot be expected to influence VDRL titers in HIV-positive adults significantly.
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A study of behavioral and disease patterns among transgenders in a tertiary care center p. 18
Bhanu Priya Tamilselvan, Najuk Mehta, Srikanth Shanmugam, Krishnan Subramanian
DOI:10.4103/2589-0557.229941  
Introduction: Transgenders are a group whose sexual identity, orientation, and practices differ from majority of the society. Aim: The aim of the study is to highlight the presence of infectious and noninfectious dermatological and venereal diseases among transgender population. Materials and Methods: A retrospective study was conducted on 120 transgender patients who attended DVL OPD from January 2011 to April 2015. The demographic profile, behavioral patterns, and prevalence of infectious and noninfectious dermatological and venereal diseases were studied. Results: All transgenders were male to females. Almost 46.6% (56) of transgenders belonged to age group 21-30, 25% (30) to 11-20 and 30-40, and 3.4% to >40 years. Nearly 61.3% (74) completed high school, 14.7% (18) graduation, 12% (14) primary school, 9% (10) higher secondary, and 1.3% (2) were illiterate and postgraduates each. All had multiple sex partners at certain point of time, of which 25% (31) are now committed to a single partner and 15% (19) involved in commercial sex. The safe sexual practice was followed by 68% (84). Among sexual practices, oral contributed 97.3% (117), anal 92% (110.4), finger 9% (11), thigh 6% (7), and vaginal 24% (28.8). Of 120 patients, 63.3% (76) had infectious diseases, 42.5% (51) had noninfectious diseases, and 5.9% (7) had both. Nearly 76.3% (58) had infectious dermatological diseases 76.3 (58) and 23.7% (18) had venereal infections. Noninfectious dermatological diseases accounted for 96.1% (49) and venereal diseases for 4% (2). Conclusion: There was relatively lower prevalence of infectious venereal diseases among transgender population, attributable to the good level of awareness among them.
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Cardiac complications in people living with human immunodeficiency virus/acquired immunodeficiency syndrome and their association with CD4+ T-cell count – A cross sectional study p. 23
Shailesh Singh, Deepankar Vatsa, Shobhit Tomar, GK Aneja, TV S. Arya
DOI:10.4103/ijstd.IJSTD_18_16  
Introduction: Cardiac complications of HIV infection tend to occur late in the disease or are associated with related therapies and are therefore becoming more prevalent as therapy and longevity improve. Materials and Methods: The study was undertaken to study the common cardiovascular complications in Indian HIV patients and to their association with the CD4+ T-cell count. Observations and Conclusion: Prevalence of cardiac abnormality in our study was 24%. The abnormalities included LVDD (22%), pulmonary hypertension (12%), DCMP (12%), pericardial effusion (7%), left ventricular systolic dysfunction (5%), and right ventricular dysfunction (1%).
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Metabolic syndrome and cardiovascular disease risk assessment among human immunodeficiency virus-infected individuals on antiretroviral therapy p. 28
Jyothi Idiculla, N Swaroop, Suresh Shastri, Nisha George, BB Rewari, Anita Shet
DOI:10.4103/ijstd.IJSTD_89_16  
Background: The association of cardiovascular risk with first-line antiretroviral therapy (ART) in Indians has been a matter of concern with the background of a high risk in South Asians. Aims: This study aimed to compare metabolic syndrome and its components, dyslipidemia, insulin resistance, and cardiovascular risk among patients on first-line ART (Group 1) with age-matched, ART-naïve human immunodeficiency virus (HIV)-infected patients (Group 2) and normal controls (Group 3). Methods: Patients attending a tertiary care center in Mysore were enrolled in the study after obtaining informed consent and controls were chosen from relatives of patients. Results: The total number of patients enrolled in the study was 217 (males 111; females 106), and the mean age of these patients was 34.1 ± 7.4 years. The number of patients in Group 1 (HIV+, ART experienced) was 76; in Group 2 (HIV+, ART naïve) was 71, and in Group 3 (HIV−) was 70. There was no statistically significant difference in the prevalence of metabolic syndrome between the three groups. On comparing the components of metabolic syndrome, serum triglycerides (mg/dl) were significantly higher in the ART group (Group 1: 149.5 [interquartile range (IQR): 84–187], Group 2: 108 [IQR: 74–152], and Group 3: 141.5 [IQR: 89–192]; P = 0.014) and serum high-density lipoprotein cholesterol was higher in HIV-uninfected individuals (Group 1: 37.5 ± 11.83, Group 2: 31.5 ± 12.23, and Group 3: 40.1 ± 12.09; P = 0.0002). There was no association between metabolic syndrome, duration of HIV, and type of first-line ART. Total and low-density lipoprotein (LDL) cholesterol were significantly higher in the ART group. Homeostatic model assessment and Framingham scores did not reveal any significant difference across the three groups. Conclusion: HIV-infected individuals on ART had higher levels of triglycerides, LDL, and total cholesterol, but no increased cardiovascular risk compared to other groups.
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Sexual behaviors reported by a sample of human immunodeficiency virus-positive men who have sex with men: A descriptive study in Khon Kaen, Thailand p. 34
Jiratha Budkaew, Bandit Chumworathayi, Chamsai Peintong, Tipaya Ekalaksananan
DOI:10.4103/ijstd.IJSTD_5_17  
Context: In Thailand, men who have sex with men (MSM) have a far higher rate of human immunodeficiency virus (HIV) infections. If these persons do not modify their behavior to safer lifestyles, they may increase the spread of HIV infection. Aims: This study aims to identify the behavior of HIV-positive MSM in comparison to their prediagnostic behaviors. Settings and Design: We conducted a cross-sectional study involving antiretroviral clinic (ARV) in Khon Kaen hospital to explore the sexual behaviors of HIV-positive MSM after the diagnosis of HIV infection. Subjects and Methods: HIV-positive MSM aged ≥18 years were asked to enroll in the study. The questionnaire was administered to 114 MSM at least 3 months after HIV diagnosis. Statistical Analysis Used: Descriptive statistics was used including means, frequencies, and percentage. Results: Forty percent of HIV-positive MSM had not have sex with a man during the 12 months. Nineteen participants reported unprotected sex, 4.31% and 12.28% reported engaging in unprotected anal and oral intercourse, respectively. About 16.6% reported that they had practiced at-risk sexual behavior. The mean of number of partners in the past 3 months was 1.8. In total, 32.46% (n = 37) reported that they had relationships with a stable partner, while 22.80% (n = 26) indicated they continued relationships with casual partners. Conclusions: Our sample of HIV-positive MSM, though aware of being infected, engage in sexual behaviors that could sustain transmission of HIV and other sexually transmitted infections. This highlights the need for a national prevention programs for persons living with HIV.
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Clinico-epidemiological profile and high-risk sexual behavior among clients attending sexually transmitted infection clinic at a tertiary care hospital in North India p. 38
Swastika Suvirya, Mukesh Shukla, Sucheta Pathania, AK Singhal, Jyotsana Agarwal
DOI:10.4103/ijstd.IJSTD_21_17  
Context: Sexually transmitted infections (STIs) are one of the most catastrophic events of health causing huge psychosocial and economic morbidity consequences. Aim: The study aims to study the clinico-epidemiological profile and high-risk sexual behavior among clients attending STI clinic at tertiary care hospital in North India. Materials and Methods: The present study was conducted at STI clinic, King George's Medical University, Lucknow, Uttar Pradesh. Data from 1283 clients attending STI clinic between August 2015 and July 2016 were compiled using master client register and STI/reproductive tract infection patient-wise register, and a final completed data set of these patients was analyzed according to the aims and objectives. Results: On analyzing the various factors associated with high-risk sexual behavior among clients attending STI clinic marital status, sexual preference and employment status were found to be significantly associated with high-risk sexual behavior (P < 0.05). On multivariate analysis, unmarried/divorced/widow/separated marital status (odds ratio [OR]: 14.72; 95% confidence interval [CI]: 1.89–114.17; P = 0.00) and unemployed status (OR: 6.10; 95% CI: 2.00–18.60; P = 0.02) were found to be independent predictors of high-risk sexual behavior (unprotected sex). Conclusions: Based on findings of study, it is highly recommended to provide periodic screening to these STI patients for assessment of their sexual behavior along with specific counseling session.
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A study of clinicopathological correlation of pruritic papular eruptions in HIV patients p. 44
Dimple Chopra, Sarvjit Kumari, Ramesh Kumar Kundal, Rakesh Kumar Bahl, Shivali Aggarwal, Harpal Singh, Shalini Bansal
DOI:10.4103/ijstd.IJSTD_10_17  
Context: Pruritic papular eruption (PPE) is a chronic eruption of papular and pruritic lesions of unknown etiology, symmetrically distributed over trunk and extremities. These are common cutaneous manifestations in HIV patients. It is an important cause of HIV-related morbidity. PPE can be the first marker of HIV. Their etiology, histopathological findings, and associated factors vary from region to region. There are no clear data available on the etiology, exact spectrum of the condition, histopathological findings, or treatment of PPE. Aims: The study is aimed at documenting the etiology, CD4 count, and its histopathological correlation in HIV-infected patients. Settings and Design: An observational study conducted in Government Medical College, Patiala. Subjects and Methods: Two-year data regarding history, HIV status, cluster of differentiation 4 (CD4) cell count, and skin biopsy of clinically suspected PPE patients with known HIV status were analyzed. Statistical Analysis Used: All the results were then statistically analyzed. Categorical data were analyzed by Chi-square test, and one-way Spearman's rho test was used for multiple group comparison. Results: Data of 50 eligible patients were analyzed. The majority of the patients were female (between 21 and 50 years of age). The most common histopathological patterns were of papular urticaria, scabies, and drug reaction, and the others less common PPE were polymorphic light eruption and eosinophilic folliculitis. Patients with papular urticaria (32%) had significantly lower mean CD4 counts (157 cells/mm3), while in scabies, the mean CD4 count (376 cells/mm3) was higher. Conclusions: We conclude that histopathology helps in specifying the pattern of PPE and its etiology. It can be a marker of advanced HIV infection. Thus, correlation between the histopathology, clinical diagnosis, and CD4 counts helps to know the disease process.
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Deploying machine learning to find out the reasons for not using condom in a questionnaire-based study of 120 patients p. 50
Balaji Govindan, Karunakaran Maduravasagam
DOI:10.4103/ijstd.IJSTD_64_17  
Context: Even though condom offers more than 90% protection against human immunodeficiency viral infections (human immunodeficiency virus) and few sexually transmitted infections (STIs), the overall use of condom in India is low. Many studies revealed that the significant barriers for not using condom were lack of privacy in stores, cultural differences, etc. Aims: We intended to find out the reasons for not using condoms in patients attending the STI clinic, by using questionnaire, and had applied machine learning tool to predict those reasons for not using condoms, from the data collected. Subjects and Methods: A questionnaire was administered on 120 patients of age above 10 years attending the STI clinic in a tertiary hospital. From the dataset obtained, we intended to understand if the demographic profile of the candidate could predict the reasons for the avoidance of condoms during sexual activity, by using machine learning algorithm called Support Vector Machine. Statistical Analysis Used: MS Excel worksheet to enter the data and Support Vector Machine algorithm were used for statistical analysis. Results: Respondents were 53% male, 45% female, and 2% transgender. Despite the knowledge of the condoms, 68% of the patients in the study did not use condom. The majority of the patients (41%) stated that condoms were not necessary when they have sexual activity with a known and consistent partner. With machine learning, we found that the prediction accuracy was significantly more than chance (73.47% ±14%) when the feature vectors include only the response to Question 1. Conclusions: Results of the study identify the specific reasons for not using condom and help us in devising specific strategies to promote the condom usage. Our results from machine learning suggest that gender of the respondent is the best predictor in predicting the reason for the nonusage of condom.
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CASE REPORTS Top

AIDS-related progressive multifocal leukoencephalopathy-really rare in India: A case report and review of literature p. 55
Sushma Choudhary, Manoj Kumar Parashar, Namita Parashar, Shailendra Ratre
DOI:10.4103/ijstd.IJSTD_4_15  
Progressive multifocal leukoencephalopathy (PML) is a rare but devastating disease in acquired immuno deficiency syndrome (AIDS) patients. PML in HIV/AIDS is rare in India and literature is limited. We are reporting a case of probable AIDS-related PML from Antiretroviral Therapy (ART) Centre Jabalpur. It was our first case of PML (possible) in 3194 registered HIV patients taking ART since 2006.
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Human immunodeficiency virus neuropathy: A new mimicker of leprous neuropathy p. 59
Ankita Srivastava
DOI:10.4103/ijstd.IJSTD_90_16  
Peripheral neuropathy is usually the domain of the physician or neurologist. Still, many times patients land up in dermatology department with complaints such as sensory loss, paresthesia, and trophic ulcers. Usually, these patients are evaluated for leprosy and then referred to departments of internal medicine or neurology. We report one such patient who was initially seen by a dermatologist but was ultimately found to be suffering from human immunodeficiency virus neuropathy.
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LETTERS TO EDITOR Top

Homosexual and Zika virus infection: Is it a new start of new problem for gay? p. 61
Pathoom Sookaromdee, Viroj Wiwanitkit
DOI:10.4103/ijstd.IJSTD_65_16  
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Emergence of forgotten entities p. 63
Murugan Sankaranantham
DOI:10.4103/ijstd.IJSTD_107_16  
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RESIDENTS PAGE Top

Ebola virus: An emerging sexually transmissible infection pathogen p. 65
Ashma Surani, Yogesh S Marfatia, Ashutosh Pal, Ruchi Shah
DOI:10.4103/ijstd.IJSTD_21_18  
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QUIZ Top

IJSTD quiz based on articles in volume 39 issue 1 p. 68
Ashutosh Pal, Ashma Surani, Yogesh S Marfatia
DOI:10.4103/ijstd.IJSTD_24_18  
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