Etiology and Determinants of Sexually Transmitted Infections in Karnataka State, South India

Background: Syndromic case management remains the cornerstone for STI (sexually transmitted infection) treatment in many countries. We undertook this study to better understand the etiology of STIs in adults in south India and to inform STI management guidelines. Methods: Adult males and females presenting with genital complaints were recruited from clinics in Karnataka state, south India. A questionnaire was administered, physical examination performed, and blood collected for herpes simplex virus-type 2 (HSV-2) and syphilis serology. Men with urethral discharge (UD) and women with vaginal discharge were tested for Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT) and Trichomonas vaginalis (TV). Vaginal swabs were also tested for bacterial vaginosis and yeast infection. Participants with genital ulcers were tested for Treponema pallidum (TP), Haemophilus ducreyi (HD), and HSV-2. human immunodeficiency virus (HIV) testing was offered to all individuals. Results: There were 401 male and 412 female participants, and rates of HIV infection were high (men, 17%; women, 15%). HSV-2 was significantly associated with HIV in men and women. Among men with the complaint of UD, NG was identified in 35%, CT in 10.5%, and TV in 8.5%. Very little NG or CT was detected among women with vaginal discharge. However, bacterial vaginosis was identified in approximately 40% of women, with significant amounts of TV and Candida also detected. HSV-2 was the most commonly identified pathogen among participants with genital ulcer disease, and the clinical distinction of herpetic versus nonherpetic lesions was not helpful. Conclusions: Current STI management guidelines should be re-evaluated in south India. Consideration should be given to treating all persons with GUD for both HSV-2 and syphilis, and to adding initial treatment for TV for men with UD in areas of high background prevalence of HSV-2 and TV, respectively. This population is at high risk for HIV, and should be counseled and tested appropriately.