|Year : 2015 | Volume
| Issue : 3 | Page : 410-412
Asymptomatic reproductive tract infections/sexually transmitted infections among HIV positive women
S Bhattar1, P Bhalla1, D Rawat1, R Tripathi2, R Kaur1, K Sardana3
1 Department of Microbiology, Maulana Azad Medical College, Delhi University, New Delhi, India
2 Department of Obstetrics and Gynaecology, Maulana Azad Medical College, Delhi University, New Delhi, India
3 Department of Dermatology and Sexually Transmitted Diseases, Maulana Azad Medical College, Delhi University, New Delhi, India
|Date of Submission||28-May-2014|
|Date of Acceptance||13-Feb-2015|
|Date of Web Publication||12-Jun-2015|
Department of Microbiology, Maulana Azad Medical College, Delhi University, New Delhi
Source of Support: None, Conflict of Interest: None
This study aims to highlight the importance of screening all HIV positive women for various reproductive tract infections/sexually transmitted infections (RTIs/STIs) irrespective of symptoms and to determine its occurrence in asymptomatic HIV positive women. Relevant specimens were collected for diagnosis of various RTIs/STIs. STIs were diagnosed in nearly one-third of the HIV positive asymptomatic patients which is quite high. The national strategy for STIs/RTIs control misses out large number of asymptomatic RTIs/STIs in HIV positive women which is responsible for silently transmitting these infections in the community. So this strategy should be modified to include screening of all HIV positives women irrespective of symptoms of STIs/RTIs.
Keywords: Asymptomatic, Human immunodeficiency virus (HIV), Reproductive tract infections (RTIs), screening, sexually transmitted infections (STIs)
|How to cite this article:|
Bhattar S, Bhalla P, Rawat D, Tripathi R, Kaur R, Sardana K. Asymptomatic reproductive tract infections/sexually transmitted infections among HIV positive women. Indian J Med Microbiol 2015;33:410-2
|How to cite this URL:|
Bhattar S, Bhalla P, Rawat D, Tripathi R, Kaur R, Sardana K. Asymptomatic reproductive tract infections/sexually transmitted infections among HIV positive women. Indian J Med Microbiol [serial online] 2015 [cited 2019 Dec 9];33:410-2. Available from: http://www.ijmm.org/text.asp?2015/33/3/410/158568
| ~ Introduction|| |
Sexually transmitted infections (STIs) are important cofactors that enhance Human immunodeficiency virus (HIV) transmission.  HIV-infected individuals with STI are at greater risk of transmitting HIV than those individuals without STIs.  There is also evidence that improved STI control reduces HIV transmission. 
Under Syndromic case management of reproductive tract infections/sexually transmitted infections (RTIs/STIs), treatment is given only to the symptomatic individuals as it is based on categorization of patients into syndromes on the basis of presenting signs and symptoms.  This implies that this strategy misses out patients who are asymptomatic and as a result do not come to the STI clinic. Asymptomatic STIs may function as a hidden reservoir contributing to the ongoing epidemic of symptomatic STIs including HIV. The primary objective of this study was to highlight the importance of screening all HIV positive women for various RTIs/STIs irrespective of symptoms and to determine the occurrence of RTIs/STIs in asymptomatic HIV positive women.
| ~ Materials and Methods|| |
This was a cross sectional study conducted prospectively between March 2010 to April 2011 at Integrated Counseling and Testing Centre (ICTC), Department of Microbiology in conjunction with Department of Obstetrics and Gynaecology and Department of Dermatology and STD in a tertiary care centre of northern India. Married women between 18-49 years of age were included in the study while those who were menstruating, pregnant, had received antiretroviral therapy in the past or had received treatment for any RTI in the past 4 weeks were excluded. Cases included 60 HIV positive women, 30 with symptoms (Group A1) and 30 without symptoms of RTI (Group A2). Controls comprised of 60 HIV negative women, 30 with symptoms (Group B1) and 30 without symptoms of RTI (Group B2). All study subjects were recruited in the study following institutional ethical committee clearance. Socio-demographic data and clinical signs and symptoms were recorded in a proforma after a written informed consent and proper counseling. Each study subject then underwent a general physical, per abdomen, per speculum and per vaginum examination.
At recruitment, 5 ml of blood was collected in plain vacutainer for HIV testing, syphilis serology and detection of Herpes simplex virus (HSV) antibody. High vaginal swabs were collected during per speculum examination for diagnosis of bacteria vaginosis (BV), trichomoniasis and candidiasis. Two endocervical swabs were collected for detection of Neisseria More Details gonorrhea (Ng) and Chlamydia trachomatis (CT) infection.
Diagnosis of HIV infection was done by following the standard protocol at our ICTC. For diagonosis of syphilis serum sample were screened for cardiolipin antibodies by Veneral Disease Research Laboratory test (VDRL). VDRL test was carried out using antigen from Serologist to Govt. of India, and all positive sera were confirmed by Treponema pallidum emagglutination Assay. (TPHA, Plasmatec Laboratory Products Ltd.). Presence of IgM antibodies to HSV (1+2) was determined by Enzyme Linked Immunosorbent Assay (ELISA, DIALAB). For diagnosis of BV, Gram stained smear were examined and graded as per standardized, quantitative, and morphological classification developed by Nugent.  For diagnosis of trichomoniasis saline wet mount were examined and for candidiasis Gram stained smear were examined. The presence of pseudohyphae and budding yeast cells was considered diagnostic of candidal infection. One endocervical swab was collected according to the instructions provided in the specimen collection and transport kit (Amplicor STD swab collection and transport set) for detection of CT by real-time PCR (COBAS® TaqMan® CT Test, v2.0) and another for Ng by direct microscopy and culture.
Difference of occurrence of STIs/RTIs among HIV positive asymptomatic versus HIV negative asymptomatic women were compared using chi square test and accepted statistically significant when P value is < 0.05. Risk of STIs/RTIs due to HIV status was also calculated using ODD's ratio with 95% confidence interval.
| ~ Results|| |
A total of 120 participants were enrolled for this study. Majority of cases and control were illiterate married women between 26-35 years of age. [Table 1] shows the laboratory confirmed prevalence of various RTIs/STIs in women belonging to the four study groups. STIs were diagnosed in 36.67% of the HIV-positive asymptomatic individual and ODD's ratio (at 95% CI) of HIV positive asymptomatic versus HIV negative asymptomatic is 5.21, with a significant difference in P value of 0.015 (P < 0.05) [Table 1].
|Table 1: Aetiological diagnosis of RTIs/STIs* among study subjects (n=120) |
Click here to view
| ~ Discussion|| |
Syndromic case management with appropriate laboratory tests is the cornerstone of STI/RTI management in our country at present. Under Syndromic case management of RTI/STI, treatment is given only to the symptomatic individuals.  Our study presents an insight into the occurrence of various RTIs/STIs in HIV positive asymptomatic women.
In the present study, as expected the percentage occurrence of RTIs/STIs was highest in the HIV positive symptomatic group and lowest in the HIV negative asymptomatic group while on the other hand STIs were diagnosed in nearly one-third (36.67%) of the HIV-positive asymptomatic women which is quite high and in asymptomatic control group only one- tenth (10%) of the population was infected. Our findings are consistent with several other studies which also found higher percentage of asymptomatic STIs in HIV positive individuals. ,,,
Thus the strategy of syndromic management works well in the HIV negative individuals where a very small percentage of patients who are actually infected but asymptomatic are missed. However in case of the HIV positive individuals the percentage of asymptomatic STIs is quite high and in this group the approach of syndromic management misses out large number of HIV positive asymptomatic patients who are actually infected with RTIs/STIs and remain untreated and are responsible for silently transmitting these infections in the community.
Though the sample size of the present study is not very large but the findings are significant enough to indicate that studies with a larger sample size should be conducted to authenticate/corroborate these findings so that the national strategy for STIs/RTIs control may be modified to include screening of all HIV positives for STIs and not just those presenting with symptoms of STIs/RTIs. Apart from detection of asymptomatic STIs in HIV positive population, screening provides opportunities for intervention and education about safe sex strategies to reduce both HIV transmission and future STI acquisition.
| ~ Acknowledgements|| |
The authors would like to thank the technical assistance provided by Mrs. Sujatha Grover and Mrs. Seema Malhotra.
| ~ References|| |
Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: The contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect 1999;75:3-17.
Cohen MS. HIV and sexually transmitted diseases: Lethal synergy. Top HIV Med 2004;12:104-7.
Ministry of Health and Family Welfare Government of India. Operational guidelines for programme manager and service providers for strengthening STI/RTI services. NACO; 2011.
Nugent RP, Krohn MA, Hillier SL. Reliability of diagnosing bacterial vaginosis is improved by a standardized method of gram stain interpretation. J Clin Microbiol 1991;29:297-301.
Lewis DA, Chirwa TF, Msimang VM, Radebe FM, Kamb ML, Firnhaber CS. Urethritis/cervicitis pathogen prevalence and associated risk factors among asymptomatic HIV-infected patients in South Africa. Sex Transm Dis 2012;39:531-6.
Kukanok S, Kiertiburanakul S. Prevalence of positive syphilis serology among HIV-infected patients: Role for routine screening in Thailand. Southeast Asian J Trop Med Public Health 2014;45:435-41.
Hodowanec A, Nayak S, Charurat M, Vaughan L, Kanno M, Fantry L. Prevalence of asymptomatic bacterial sexually transmitted infections in hospitalized HIV patients in Baltimore City. J Int Assoc Physians AIDS Care (Chic) 2012;11:16-9.
Shrestha A, Adhikari N, Shah Y, Poudel P, Acharya B, Pandey BD. Chlamydia trachomatis detection in HIV infected patients using polymerase chain reaction. Int J Infect Microbiol 2013;2:12-6.