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
July-December 2020
Volume 41 | Issue 2
Page Nos. 143-227

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ORIGINAL ARTICLES  

Papanicolaou smear: A diagnostic aid in sexually transmitted infections Highly accessed article p. 143
Sabeena Jayapalan, RS Bindu
DOI:10.4103/ijstd.IJSTD_114_16  
Background: Sexually transmitted infections (STIs) are a major public health problem in developing countries, and treatment with the right medicine at the right time is necessary to reduce transmission and improve sexual and reproductive health. Laboratory diagnosis has undergone changes in the recent years. The new generation tests are not cost-effective in resource-poor settings. Papanicolaou smear (Pap smear) of the cervix is a simple, quick, and inexpensive screening procedure for cervical cancer that can also give a clue to the presence of STIs. Methods: A hospital-based cross-sectional design with fifty patients was conducted studied. The initial diagnosis based on clinical findings and routine laboratory results was compared with the final diagnosis incorporating Pap smear results. Results: The Pap smear was abnormal in 96%, and the abnormalities were koilocytosis (30%), endocervicitis (24%), Trichomonas vaginalis (16%), multinucleated giant cells (10%), low-grade squamous intraepithelial lesion (10%), and clue cells (8%). Pap smear could diagnose an infection in 64%, of which 38% were asymptomatic. Clinical and Pap smear correlation was found only in 26% of the patients. Conclusion: Along with the conventional methods, Pap smear can be a valuable tool in diagnosing STIs. This can detect asymptomatic infections, not detected by conventional methods, thus preventing complications and further spread in the community. Asymptomatic human papillomavirus (HPV) infection and trichomoniasis are the two STIs that can be easily detected by Pap smear. By detecting asymptomatic cervical HPV infection, the patients at risk for carcinoma of the cervix can be identified and referred to gynecology department for further management.
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Assessment of clinical and behavioral profile of clients attending integrated counseling and testing centers of a tertiary care institute in Eastern India: A secondary data analysis p. 149
Debjyoti Mohapatra, Vikas Bhatia, Arvind Kumar Singh
DOI:10.4103/ijstd.IJSTD_40_19  
Introduction: Integrated counseling and testing center (ICTC) forms the major forum under the National AIDS Control Organization (NACO) for counseling and testing of HIV-suspected patients. ICTC setup in a tertiary care institute also provides a chance for opportunistic screening of large number of individuals. Aims: The study was done to assess and to profile the ICTC clients with respect to their seropositivity rate, their biological and behavioral risk factors, and seroconcordance rate. Methodology: We did a secondary analysis of routine health data collected in the ICTC in the formats prescribed by the NACO. Statistical Data Analysis: The data were entered into MS Excel and analyzed using SPSS version 22. Results: Majority of the clients of ICTC were in the age group of 35–49 years. Seropositivity among client-initiated group (11.9%) was much higher compared to provider-initiated group (0.3%). None of the pregnant women were found to be positive. Heterosexual route was most common form of transmission in both provider-initiated and client-initiated groups. Seroconcordance rate was 43.4% in our study. Conclusion: The ICTC of a tertiary care center attracted a huge number of patients. The seropositivity in our study was greater than those generated by sentinel surveillance system. A well-functioning ICTC can help in detecting a large number of cases and also provide a forum for counseling and education about risk factors of HIV.
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Profile of hematological abnormalities and its correlation with absolute CD4 count and human immunodeficiency virus viral load in human immunodeficiency virus-infected patients in a tertiary care hospital p. 156
S Suja, T Saravanan, S Karthikeyan
DOI:10.4103/ijstd.IJSTD_56_19  
Background: A variety of hematological manifestations are seen at every stage of human immunodeficiency virus (HIV) infection, and they often pose a great challenge in the comprehensive management of acquired immunodeficiency syndrome. Anemia is the most common hematological abnormality associated with HIV infection. The severity and the incidence of cytopenia are usually correlated with the stage of the disease and underlying immune status if interpreted cautiously, especially if the patient is on regular follow-up. The primary objective of the present study was to understand the spectrum of hematological abnormalities in HIV-infected patients, whereas the secondary objective was to evaluate the correlation of hematological abnormalities with absolute CD4 count and HIV viral load. Materials and Methods: The present cross-sectional descriptive study was conducted on 100 patients, aged 18 years and above, diagnosed with HIV infection and confirmed by Western blot or ELISA method. Both inpatients and outpatients at our tertiary care hospital were included in the study. Results: Individuals with high viral load and low CD4 count had a higher prevalence of anemia. There was a statistically significant and directly proportionate decrease in the absolute CD4 count as the hemoglobin levels decreased (P = 0.004). In the present study, normocytic normochromic blood picture and anemia of chronic disease blood picture were more prevalent among the study participants. Individuals with high viral load and CD4 count <200 cells/mm3 had a higher rate of occurrence of coinfections. The correlation of absolute neutrophil count and thrombocytopenia with absolute CD4 count and HIV viral load was not statistically significant. Conclusions: Complete blood counts and peripheral smear observations were significantly correlated with high HIV viral load and lower absolute CD4 cell counts and therefore can be suggested as economical alternatives for the evaluation of the status of HIV disease stage and its progression.
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Sexually transmitted infections and human immunodeficiency virus coinfection: Scenario in Western India p. 162
Santoshdev P Rathod, Bela Padhiar, Bela Shah
DOI:10.4103/ijstd.IJSTD_87_18  
Context: Sexually transmitted infections (STIs) have a well-established synergistic relationship with human immunodeficiency virus (HIV) infection. Coinfection with HIV and STI can increase the probability of HIV transmission to an uninfected partner by increasing HIV concentrations in genital lesions, genital secretions, or both. Concurrent HIV infection alters the natural history of the classic STIs. Aims: The aim was to study the current scenario of STIs with HIV co-infection, and to recognize different manifestations of STIs than the classical presentation in people living with HIV/AIDS (PLHIV). Settings and Design: It was an open, cross-sectional, descriptive study carried out in the setting of state government hospital with attached antiretroviral therapy referral center. Subjects and Methods: The sample size of the study was duration based (30 months). Inclusion Criteria: All PLHIV presenting to the department of dermatology with STIs were included in the study. Exclusion Criteria: Non-STI causes of genital ulceration were excluded in the study. Results: The study includes total (n = 484) patients living with HIV/AIDS, prevalence of different STIs was in the following order, herpes simplex virus infections 24.17%, human papillomavirus infections 8.88%, molluscum contagiosum 7.43%, secondary syphilis 4.33%, gonorrhea 1.85%, chancroid 1.44%, and granuloma inguinale 0.41%. Of all the patients with herpes simplex virus infections, 45.6% (n = 57) had multiple recurrences (>6/year). The incidence of mixed STI was 17.29% in the present study. Conclusions: The study represents decreasing trends in bacterial STIs and the rise of viral STIs. Atypical presentations of classic STIs were more frequent than non-HIV-infected individuals.
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Should we start looking at the elderly for human immunodeficiency virus infections? A study of trends of human immunodeficiency virus, hepatitis B virus, and hepatitis C virus in Mumbai, Maharashtra, India p. 169
Ram Malkani, Harish Ahuja, Aditya Tare, Maninder Singh Setia
DOI:10.4103/ijstd.IJSTD_60_19  
Background: There is limited information on the trends of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) co-infections in India – particularly from private health-care settings. We designed the present research to estimate the prevalence of HIV, HBV, and HCV over a period of 7 years and study the factors associated with them. Materials and Methods: The present study is a secondary data analysis of data from the laboratory records of 24,086 individuals who were tested over a period of 7 years (2009–2015). We estimated the proportion and 95% confidence intervals (CIs) for HIV, hepatitis B surface antigen (HBsAg), and HCV antibodies. Results: The overall seroprevalence of HIV was 0.35% (95% CI: 0.27%, 0.44%), HBsAg was 1.65% (95% CI: 1.48%, 1.82%), and HCV was 1.73% (95% CI: 1.56%, 1.90%). The prevalence of HIV among those who were more than 70 years of age was 0.14% (95% CI: 0.04%, 0.32%). The prevalence of HBsAg was highest in those aged 30–39 years (2.27%, 95% CI: 1.74%, 2.92%) (P = 0.008). The prevalence of HIV/HBsAg co-infection was 0.019% (95% CI: 0.005%, 0.050%), HIV/HCV co-infection was 0.005% (95% CI: 0.000, 0.027%), and HBsAg/HCV co-infection was 0.059% (95% CI: 0.030%, 0.102%). We did not encounter even a single case of all the three infections. Conclusions: HIV infection is relatively high in those who were aged 50 years of more; thus, they need to be included in the National AIDS Control Programme. HIV/HBV/HCV co-infections should be regularly monitored in surveillance programs, and antiretroviral therapy officers and counselors should be trained on the management of HIV in those who are co-infected.
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Changing trends of sexually transmitted infections and estimation of partner notification at a tertiary care center in North India p. 176
Seema Goel, Dimple Chopra, Vivek Choudhary, Amandeep Riyat, Siddharth Chopra
DOI:10.4103/ijstd.IJSTD_10_19  
Background: Sexually transmitted infections (STIs) are dynamic and show a variable prevalence in different parts of the country. Moreover, the prevalence changes with time in the same geographical area. It is important to have the knowledge of current trend of STIs and partner notification (PN) rate in a particular area for the effective implementation of preventive and control measures. Aims: This study aimed to assess the changing demographic and clinical trends of STIs in the patients attending a tertiary care center in North India. Materials and Methods: This study was conducted at STI clinic located at a tertiary care center in North India. All the patients visiting STI clinic over a 5-year period from January 1, 2013, to December 31, 2017, were included in our study. Diseases were diagnosed on the basis of detailed history, clinical examination, and relevant investigations, and PN was done using the patient-oriented notification method. Results: The most common STI affected age group was 25–44 years (45.11%), and the most common STI noted was candidal balanoposthitis in males (19.49%) and candidal vaginal discharge in females (20.54%), followed by herpes genitalis (15.04%) and condylomata acuminata (14.66%) in both the genders. Bacterial STIs such as syphilis (1.58%), lymphogranuloma venereum (0.45%), and chancroid (0.39%) were less common. The average PN rate was 42.48%. Conclusion: In the present study, fungal and viral STIs showed an upward trend, whereas bacterial STIs such as syphilis and chancroid demonstrated a declining trend. The measures to improve PN are urgently required for both cure and the prevention of STIs.
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Factors affecting adherence to treatment in children living with HIV p. 181
Deepshikha Verma, Damodar Bachani, Anita Shankar Acharya, Anju Seth, Alok Hemal
DOI:10.4103/ijstd.IJSTD_43_18  
Background: With the successful introduction of ART, the life expectancy of children living with HIV (CLHIV) is substantially increased. However, strict compliance is a necessary step to begin with as noncompliance is again associated with its own demerits of incomplete suppression and decreasing the overall survival of the patients. Aims: The aim of this study was to measure factors associated with adherence to ART among CLHIV. Materials and Methods: This is a 1-year follow-up study conducted from November 2012 to December 2013. A total of 171 children between 18 months and 15 years living with HIV and on ART attending the two ART centers of Delhi were enrolled in the study. Adherence and factors affecting adherence were obtained from the study participants using a semi-structured interview schedule. Statistical Analysis Used: Collected data were transformed into variables and analyzed into SPSS. All observations were in terms of mean, median, standard deviations, percentages, and proportions. Tests of significance such as Chi-square test and t-test were applied wherever required. Results: In nearly 89% of the study participants, adherence to ART was ≥95% at the end of the study. The most common reason for nonadherence was forgetfulness (59%), and 57% of the parents/caretakers were facing monetary problems. Long distance, greater duration to reach center, and unavailability of the parents/caretakers were also quoted as problems. Conclusion: Adherence is genesis to successful treatment outcome and is strongly associated with availability of support by their parents/caretakers. Professional help along with guidance and encouragement is required not only at the caretaker level but also to the family as a whole.
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Viewing the resurgence of early syphilis in light of increasing male homosexuality and childhood sexual abuse p. 188
Seena Palakkal, K Anila, K Sobhanakumari, Machiyanikal Issac Celine, Mary Vineetha
DOI:10.4103/ijstd.IJSTD_104_16  
Back Ground and Objectives: A rising trend of syphilis has been documented worldwide recently. After decriminalization of homosexuality in India more and more males having sex with males (MSMs) have come out to seek medical advice. Aim: We evaluated sexual behavior of patients with syphilis attending our sexually transmitted infections (STIs) clinic focusing on the factors associated with the increasing MSM practices and rising trend of syphilis among MSM. Materials and Methods: This is a 10-year (2006–2015) descriptive study from among STI patients attending the dermatology outpatient department in a tertiary care center. Recognizing the rising homosexuality, from 2011 onward, we had given a questionnaire to assess their sexual behavior and sexual practices. Results: Analysis of data from 560 cases diagnosed as having STI revealed a rising trend of all STIs including syphilis from 2011 onward. The MSM cases reporting to our STI clinic showed a sustained rise from 2011 onward. The most common STI in MSM was syphilis that too early acquired. More than half of the MSM indulged in bisexual activities and the predominant mode was anoreceptive. Nearly 70% had unprotected contact and most had early sexual debut (<20 years). Thirty-six percent gave a history of childhood sexual abuse (CSA) by a close male acquaintance. Conclusions: After 2011, we have observed a resurgence of early acquired syphilis which coincided with an increase in promiscuous homosexuality. Many of the MSMs were bisexuals and homosexuality was an acquired behavior. An alarming increase in the incidence of CSA was observed in MSMs.
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CASE REPORTS Top

Clinical features of a large chronic ulcer on the genital and perianal region in HIV-infected patients can be a strong clinical clue for the diagnosis of herpes simplex infection p. 192
Chandra Sekhar Sirka
DOI:10.4103/ijstd.IJSTD_140_15  
Herpes simplex infection presents as a large, chronic, genital, and perianal ulcer in immunosuppressed HIV-positive patients. However, the characteristic morphological feature for clinical diagnosis is unclear. This case series illustrates the morphological characteristics of large, chronic, herpes simplex ulcers at the genital and perianal region in four HIV-positive patients. The diagnosis of herpes simplex infection was confirmed by laboratory test and/or rapid response to acyclovir therapy. All four of our patients had consistent morphological features such as uniform depth, punched out edge and arcuate border on the genital and perianal ulcers, along with positive IgM and IgG antibodies to herpes simplex virus and/or rapid response to acyclovir. Such findings suggest that these morphological features may be the characteristic feature of large and chronic herpes simplex ulcer in HIV/ADS positive patients.
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A rare case of early congenital syphilis with patent ductus arteriosus: The continuing curse for generations p. 195
Vukkadala Nivedita Devi, Boina Kinnera, Vinnakoti Anitha, Bonthu Indira
DOI:10.4103/ijstd.IJSTD_19_19  
A 19-year-old female with untreated syphilis (venereal disease research laboratory test reactive) delivered a female child at 34 weeks with low birth weight, intrauterine growth retardation, respiratory distress, and bilateral pedal edema. One week later, the baby was found to be having pansystolic murmur confirmed by ECHO as patent ductus arteriosus. At 2 weeks, the baby developed maculopapular rash; hepatomegaly; and swelling of the shoulder, knee, ankle, wrist, and medial end of the clavicle. Both parents and baby were rapid plasma reagin test. X-ray showed Wimberger's sign at the upper end of the tibia. A diagnosis of congenital syphilis was made. The baby became asymptomatic after giving injection benzylpenicillin for 10 days.
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Behcet disease - A nonvenereal cause of genital ulceration p. 198
Yogesh S Marfatia, Hiral K Patel, Rashmi Mahajan, Kishan Ninama
DOI:10.4103/ijstd.IJSTD_24_20  
Behcet's disease (BD) is a chronic, relapsing, inflammatory vascular disease with no diagnostic or pathognomonic test. Here, we present a case of 26-year-old male with a complaint of recurrent oral, genital, and cutaneous lesions. The diagnosis of BD was confirmed on the basis of revised the International Criteria for BD. The case was treated satisfactorily with systemic corticosteroid in the tapering dose and oral Dapsone.
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A double whammy in an immunocompromised patient p. 201
Archana Baburao, Amandeep Singh, Huliraj Narayanswamy, Bhavya Shivalingaiah
DOI:10.4103/ijstd.IJSTD_70_18  
Pneumocystis jirovecii pneumonia (PCP) is a common opportunistic infection in immunocompromised patients, especially those with human immunodeficiency virus (HIV) infection. Cytomegalovirus (CMV) pneumonia most often occurs as a coinfection with another opportunistic pathogen especially in patients with severe immunosuppression. We present a case of PCP-CMV coinfection in a newly diagnosed HIV patient who was treated with the recommended therapy for both diseases and had a favorable outcome. The presence of CMV in the context of another opportunistic respiratory tract infection is often to be not treated, due to conflicting evidence of its therapeutic benefit. Our report highlights the importance of CMV treatment to achieve clinical stability and recovery in newly diagnosed patients with HIV and severely immuno-compromised status.
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The management of vulvovaginal warts using intralesional Bacillus Calmette–Guérin immunotherapy p. 204
Sunil Kumar Gupta
DOI:10.4103/ijstd.IJSTD_62_19  
Genital warts/condyloma acuminata is the most common mucosal human papillomavirus (HPV) infection encountered by the dermatologists. They can be asymptomatic or symptomatic. They can present as discrete lesions or confluent masses. Depending on the HPV strains, lesions can either be benign or may turn malignant. The treatment modalities for genital warts range from topical, systemic, intralesional immunotherapy, and surgical interventions (intralesional immunotherapy has shown promising results in the treatment of viral and genital warts). However, there are very few reports that have used Bacillus Calmette–Guérin (BCG) as immunotherapy in genital warts. Here, we report, in author's opinion, the first case of female vulvovaginal warts successfully treated with intralesional BCG immunotherapy, leading to complete resolution of injected warts as well as near-distant warts.
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Chronic actinic dermatitis: An only presenting manifestation of human immunodeficiency virus in a young Indian male p. 207
Manoj Pawar, Vijay Zawar
DOI:10.4103/ijstd.IJSTD_8_19  
Skin diseases often provide the first clue to diagnose human immunodeficiency virus (HIV) infection and may serve as a clinical indicator of the underlying immune status of the patient. Photodermatitis in HIV patients presents with a protean of clinical manifestations, and it usually develops after the diagnosis or during the course of HIV, especially in patients with low CD4 counts. We present the case of a young, healthy Indian male with chronic actinic dermatitis (CAD), who was later confirmed to have HIV seropositivity with CD4 count of 180/μl, without any systemic illness or evidence of acquired immunodeficiency syndrome (AIDS)-defining illnesses. CAD as an initial presentation of HIV is a rare finding, especially in the absence of other AIDS-defining illnesses.
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An unusual secondary extramammary Paget's disease of vulva p. 210
Alvish Noel, Ramesh M Bhat, Sujaya V Rao, Shannon Fernandes
DOI:10.4103/ijstd.IJSTD_69_19  
Extramammary Paget's disease (EMPD) of the vulva is a rare disease that occurs mainly in postmenopausal women. It can be primary or secondary. Prognosis of primary EMPD is good, but when secondary, we need to find the underlying malignancy as the prognosis depends on it. Very few cases of secondary EMPD of the vulva have been reported till now. We hereby report a case of a 65-year-old postmenopausal woman with EMPD secondary to invasive adenocarcinoma with neuroendocrine features in the dermis and she was treated surgically followed by radiotherapy.
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LETTERS TO EDITOR Top

Progression of CD4 count among human immunodeficiency virus-seropositive patients in a tertiary care hospital of Tripura, North East India p. 213
Tapan Majumdar, Niladri Sekhar Das, Ayan Modak
DOI:10.4103/ijstd.IJSTD_85_16  
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Genital ulcer in an adolescent girl p. 214
Taru Garg, Anuja Yadav, Ram Chander, Kiran Aggarwal
DOI:10.4103/ijstd.IJSTD_11_19  
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Granuloma inguinale in a mentally retarded girl p. 215
Murugan Sankaranantham
DOI:10.4103/ijstd.IJSTD_47_18  
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Pseudoepitheliomatous, keratotic, and micaceous balanitis with Koilocytes p. 218
C Chandrakala, Parimalam Kumar, J Nilavu, D Shanthi
DOI:10.4103/ijstd.IJSTD_113_15  
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Partner age difference and sociodemographic correlates of herpes simplex virus type 2 seropositivity: A community-based study in South India p. 219
Makella S Coudray, Abraham Degarege, Anisa Khan, Kavitha Ravi, Vijaya Srinivas, Jeffery D Klausner, Purnima Madhivanan, Caitlyn D Placek
DOI:10.4103/ijstd.IJSTD_90_18  
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Revisiting blood agar for the isolation of Neisseria gonorrhoeae p. 221
Sunil Sethi, Shreya Singh, Surinder Singh Banga, Neha Jain, Swati Gupta, Nandita Sharma, Hemant Chaudhry, Sakshi Malhotra, Tarun Narang
DOI:10.4103/ijstd.IJSTD_51_18  
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Self-stigma among women living with human immunodeficiency virus in South India p. 222
Vedapurieswaran Shanmugam, Pitchaimani Govindharaj, Chithradevi Velumani
DOI:10.4103/ijstd.IJSTD_68_18  
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A rare syndromic presentation of HIV infection p. 224
Abhishek Juneja, Kuljeet Singh Anand, Brijlal Choudhary
DOI:10.4103/ijstd.IJSTD_95_19  
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OBITUARY Top

Dr. B. S. Verma p. 226
Yogesh S Marfatia
DOI:10.4103/ijstd.ijstd_111_20  
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Dr. D. K. Gupta (1932-2020) p. 227
Somesh Gupta
DOI:10.4103/ijstd.ijstd_117_20  
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