A CROSS SECTIONAL STUDY OF SEXUALLY TRANSMITTED INFECTIONS
AMONG HIGH RISK GROUPS ATTENDING SEXUALLY TRANSMITTED
INFECTIONS CLINIC IN A TERTIARY CARE HOSPITAL
Dissertation Submitted to
THE TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY
IN PARTIAL FULFILMENT FOR THE AWARD OF THE DEGREE OF
DOCTOR OF MEDICINE
IN
DERMATOLOGY, VENEREOLOGY & LEPROSY
Register No.: 201730256
BRANCH XX
MAY 2020
DEPARTMENT OF DERMATOLOGY VENEREOLOGY & LEPROSY
TIRUNELVELI MEDICAL COLLEGE
TIRUNELVELI -11 CERTIFICATE
This is to certify that this dissertation entitled “A CROSS SECTIONAL STUDY OF
SEXUALLY TRANSMITTED INFECTIONS AMONG HIGH RISK GROUPS
ATTENDING SEXUALLY TRANSMITTED INFECTIONS CLINIC IN A TERTIARY
CARE HOSPITAL.” is a bonafide research work done by Dr.VIJAIKUMAR M.G,
Postgraduate student of Department of Dermatology, Venereology and Leprosy,Tirunelveli
Medical College during the academic year 2017 – 2020 for the award of degree of M.D.
Dermatology, Venereology and Leprosy – Branch XX. This work has not previously formed the basis for the award of any Degree or Diploma.
Guide Head of the Department
Dr.M.Selvakumar M.D. D.D., Dr.P. Nirmaladevi. M.D., Associate Professor, Professor& HOD, Department of DVL Department of DVL Department of Dermatology, Venereology & Leprosy Tirunelveli Medical College, Tirunelveli
Dr.S.M.Kannan M.S.Mch., The DEAN Tirunelveli Medical College, Tirunelveli - 627011 DECLARATION
I solemnly hereby declare that the dissertation entitled “A CROSS SECTIONAL STUDY OF
SEXUALLY TRANSMITTED INFECTIONS AMONG HIGH RISK GROUPS
ATTENDING SEXUALLY TRANSMITTED INFECTIONS CLINIC IN A TERTIARY
CARE HOSPITAL” was done by me at the Department of Dermatology, Venereology &
Leprosy, Tirunelveli Medical College under the guidance and supervision of my Professor.
Dr.M.Selvakumar. The dissertation is submitted for the Degree of Doctor of Medicine in
M.D., Degree Examination, Branch XX in DEPARTMENT OF DERMATOLOGY,
VENEREOLOGY AND LEPROSY.
This is my original work and the dissertation has not formed the basis for the award of any degree, diploma, associate ship, fellowship or similar other titles. It had not been submitted to any other university or Institution for the award of any degree or diploma.
Place: Tirunelveli Dr.VIJAIKUMAR.M.G. Register No.: 201730256 Date: Post graduate in M.D DVL, Department of DVL, Tirunelveli Medical College, Tirunelveli-627011 ACKNOWLEDGEMENT Language with all elaborations seems to be having limitation especially when it comes to expression of feelings. It is not possible to convey it in words all the emotions and feelings one wants to say. It would take pages to acknowledge everyone who, in one way or another has provided me with assistance, but certain individuals deserve citation for their invaluable help.
I am grateful to the Dean, Dr.S.M.Kannan MS MCh., Tirunelveli Medical College and Medical Superintendent, the Tirunelveli Medical College Hospital for allowing me to do this dissertation and utilize the institutional facilities.
I fall short of words to express my deep sense of gratitude for my esteemed and reverend teacher, Dr. P.Nirmaladevi MD, my professor & Head of the Department of Dermatology,
Venereology and Leprosy , Tirunelveli Medical College, for her ever-inspiring guidance and personal supervision. The finest privilege in my professional career has been the opportunity to work under her inspirational guidance.
I would like to express my sincere and heartfelt thanks to Dr.M. Selvakumar M.D.,
Head of department of Venereology, who has been a guiding light with his constant encouragement throughout my post-graduation course. I am honoured to have got an opportunity to be his student during my tenure at this prestigious institute.
I sincerely thank Dr.P.Sivayadevi MD., and Dr.K,Punithavathi MD., Associate
Professors for their valuable suggestions and support throughout the period of this study.
My special thanks to Dr. Seeniammal.S, Assistant Professor for having guided me with full support throughout the period of this study.
I immensely thank Dr.R.Karthikeyan (late), Dr.A.N.M.Maalik Babu MD, Dr.S.Judith
Joy MD, Dr.P.Kalyanakumar DDVL, Dr.M.Kalaiarasi DDVL, Dr.A.Kamala Nehru DDVL, my assistant Professors for their constant support and encouragement. I heartfully thank my seniors Dr.K.Amuthavalli and Dr.P.Sulochana, my colleague
PGs Dr.S.Soundharyaa moorthi, Dr.P.Karthikraja, Dr.M.Aravind Baskar,
Dr.B.Arunkumar, Dr.R.Monisha and friends for their encouragement and support during this study.
I heartfully thank my family, friends, seniors and junior colleagues for their involvement for completing this study.
Last but definitely not the least, I would like to thank my patients who cooperated with me throughout my work. Finally, it is endowment of spiritualism and remembrance of almighty for all that I achieved. I owe my sincere thanks to all those patients who participated in the study for their co-operation which made this study possible. Finally, I thank the Almighty for without Him nothing would have been possible.
CERTIFICATE-II
This is to certify that this dissertation titled “A CROSS SECTIONAL STUDY OF
SEXUALLY TRANSMITTED INFECTIONS AMONG HIGH RISK GROUPS
ATTENDING SEXUALLY TRANSMITTED INFECTIONS CLINIC IN A TERTIARY
CARE HOSPITAL” of the candidate Dr.VIJAIKUMAR M.G with registration number
201730256 for the award of degree of M.D. Dermatology, Venereology and Leprosy. I personally verified the urkund.com website for the purpose of plagiarism check. I found that the uploaded file contents from introduction to conclusion page shows 20 percentage of plagiarism in the dissertation.
Guide & Supervisor sign with seal
CONTENTS
SL.NO. TITLE PAGE NO.
1. INTRODUCTION 1
2. REVIEW OF LITERATURE 3
3. AIMS AND OBJECTIVES 59
4. MATERIALS AND METHODS 60
5. RESULTS 62
6. DISCUSSION 87
7. CONCLUSION 96
8. BIBLIOGRAPHY
9. ANNEXURES
PROFORMA CONSENT FORM
10. MASTER CHART INTRODUCTION
Sexually transmitted infections (STI’s) remains to be a most important health problem all over India. The prevalence of disease is not even in community, as behavioural pattern differs among individuals. High risk group population are more commonly affected with STI’s. Men who have sex with men
(MSM), Commercial Sex Workers (CSW), transgenders (TG), people with multiple partners, occupation related group like drivers, housekeepers, drug abusers and migrants are all included under high risk group. It is more and more felt that these sections of population are especially vulnerable because of their lack of information, defiance, poor socioeconomic factors, lack of social support, unprotected measure and other factors.
High-risk sexual behaviour people are those who are having unprotected sex with partner(s) during sexual intercourse.1 The behavioural risk factors include age at first intercourse, marital status, frequency of sexual intercourse, number of lifetime partners, age difference between partners, intravenous drug abuse, etc. These risk factors augment the increased risk of developing STI’s and create a great problem at the community level.
High risk sexual practices include oro-anal intercourse, oro-genital intercourse, ano-genital, dry sex, sex during menstruation, etc.2 Non-usage of barrier contraceptives are at risk of STI’S including HIV. Safer sex practices like condom usage is been encouraged by all organizations including NACO for reducing the STI risk. 1 More than 20 different bacteria, viruses and parasitic infections are responsible for sexually transmitted infections. Sexual history is very important for a healthcare provider for proper diagnosis and treatment. He can also advise on risk reduction by providing prevention counselling. Prevention counselling is an effective method, if given in an imagined manner to the people's principles, linguistic, sex, sexual orientation and developmental level. counselling is usually advised to all sexually active persons who had diagnosed as diseased or who had
STI in the past or who had multiple sex partners. Another major problem that arose was an increase in adolescent sexual activity in the mid-20th Century. This led to widespread infection among adolescents and also changed the way for healthcare policy makers to raise awareness through campaigns.
There is bigger need for detection of STIs, primarily where there is high concentration of high-risk group, as early diagnosis and treatment can lead to decrease in complications and reduce the transmission at the community level.
2 REVIEW OF LITERATURE
HISTORY OF STI
Sexually transmitted infections represent a chief public health problem.
STI’s are the cause of acute illness, long term disability, death in men, women and infants, with tremendous economic consequences at individual and community level. STIs were previously known as Venereal diseases. Due to the social stigma of these diseases in the 1970s, the name was changed to Sexually
Transmitted Diseases. Recently, it has been discussed that ‘disease’ is not the most appropriate term to describe infections, which may remain asymptomatic for many years or would never develop symptoms. Therefore, the World Health
Organization has suggested instead the use of sexually transmitted infections for the group of infectious diseases transmitted by sexual activity.3
HUMAN SEXUAL BEHAVIOUR
Human Sexual behavior means broad spectrum of behaviors in which humans display their sexuality. These behavioral expressions contain biological elements, cultural influences and sexual arousal (with its physiological changes, both pronounced and subtle, in the aroused person). It varies from the solitary
(such as autoerotic stimulus and masturbation) to joined sex (genital intercourse, oral sex, anal sex, non-penetrative sex, etc.) that is involved occasionally.
3 THEORIES OF HUMAN SEXUALITY
Sexual behavior is considered as an inborn energy in the humans: it is even seen in newborns. Sex drive is altered by various factors like communal, social and interpersonal factors. Freud ‘s (1905) stages of sex includes the oral stage, the anal stage, the genital stage, the latency stage and the reawakening of sexual impulses at puberty.4 Sexuality has a number of different characteristics and senses depending on variation in person, time, culture, age, and situation.
Sexuality is a part of social collaboration and best explained by opportunity and reinforcement acting upon a basic biological force. The sexual behavior is strongly channelized into particular cultural backgrounds. This enforced the humans to follow traditional sexual behavior patterns which are practiced by thousands of years ago. Human sexual behavior should be viewed with three aspects in mind: the biological factors, the learning processes, and finally the sociocultural environment. The variations in sexual behavior among individuals is due to various civilizations exists between various groups of individuals in different places in the world.
CONCEPT OF SEXUAL DEVIANCE
Deviance (psycho-pathology) is the sexual behavior that breaks the customs and principles of the humanity. The psychopathology is defined as medical rationalization of the social conditions like homosexuality. Because of concept of deviance, these individuals will have social stigma, which causes negative influence in the lives of these deviants (homosexuals). 4 Gagon et al5 proposed a distinction between 3 types of deviance.
1) Normal deviance - The sexual behaviors such as premarital sex, extra
marital sex, masturbation, and oro-genital sex.
2) subcultural deviances - homosexual subcultures
3) individual deviances - exhibitionism or incest
PREVALENCE
About 340 million new cases of the four curable sexually transmitted infections -gonorrhoea, chlamydia, syphilis, and chancroid are recorded every year in the world, according to the World Health Organization (WHO).6 National prevalence of early syphilis cases was 2.1 cases per 1lakh population in the year
2000 and 2001. The rising trend of syphilis has been primarily due to increased cases among MSM, bisexual and CSW. The increase in syphilis among women is of associated with an apparent increase in congenital syphilis.7
During 2016–2017, gonorrhoea rate among males increased from 169.7 to
202.5 cases per 100,000 males and the rate among females increased from 120.4 to 141.8 cases per 100,000 females.8 During 2008–2017, the number of reported cases ranged from 28 in 2009 to six in 2014. Reported cases of chancroid peaked in 1947 and then declined quickly through 1957, presumably due to the increasing use of antibiotics like sulphonamides and penicillin. Numerous localized epidemics, some of which were linked to commercial sex work were identified during the year 1981–1990.9
5 Prevalence of genital infection with any HPV was 42.5% among adults aged 18–59 years during 2013–2014. Persistent infection with some HPV serotypes can cause cervical cancer and recurrent genital warts. HPV serotypes
16 and 18 account for approximately 66% of cervical cancers and approximately
25% of low-grade and 50% of high-grade cervical dysplasia in India.
Genital HSV infection is not a nationally notifiable condition. The overall percentage of HSV-2 seropositive individuals aged 14–49 years between 1988–
1994 and 2007–2010 remained high-90.7% and 87.4% respectively and most of them do not report to doctors as it is self-limiting on its own.9
Trichomonas vaginalis is a common sexually transmitted protozoal infection associated with adverse health consequences such as preterm birth and symptomatic vaginitis. Prevalence of T. vaginalis in urine specimens obtained from adults aged 18–59 years was 0.5% among males and 1.8% among females.
MEN WHO HAVE SEX WITH MEN
Bisexual persons may choose persons of both sexes. Homosexual persons usually choose a sexual partner of the same sex. Homosexual can describe a person‘s sexual behavior- i.e., a person who predominantly or exclusively has sex with a person or persons of the same sex 10 and they are termed as - men who have sex with men‖(MSM). Homosexual can describe a person ‘s sexual identity
– i.e., a person who adopts a sexual life style which is consistent with and self- defined by same sex desire and same sex behavior can be said to have a homosexual identity. A man who considers himself homosexual may also have 6 sex with women and men who consider themselves heterosexual may also have sex with men. Thus, a man who prefers same sex partner may be considered as homosexual and men who prefers opposite sex partners are referred to as heterosexual. But if the heterosexual persons have sex with a same sex partner, they are referred broadly by “MEN WHO HAVE SEX WITH MEN” and
“WOMEN WHO HAVE SEX WITH WOMEN”. Thus, MSM includes both
Homosexuals and Bisexuals.11
HISTORY OF HOMOSEXUALITY:
Homosexual practices played an important role for man in ancient Greece and other cultures, whereas they have been ritualized and prohibited in various societies. The term homosexual was first coined by the Hungarian physician
Karoli Maria Kertbeny in 1869 and was later adopted by the influential German psychiatrist Richard Von Kraft Ebing in his classic Psychopathia Sexualis. It is often thought that the Greeks were liberal in their attitudes to homosexual and bisexual behavior. The roman also have accepted homosexuality as a foreseeable part of man’s sexual life. Julius Caesar was called as the husband of all women and the wife of all men. Priapus the God of gardens, with a human face was associated with fertility and thus hostile to homosexual rights.
Kamasutra written by sage vatsayana in 4th to 5th century A.D. contains an entire topic on homosexuality. In western countries, in 18th century, homosexual subcultures arose, that allowed people to consider themselves as being homosexual or Gay such subcultures allowed them to exclusively access 7 male partners. These subcultures allow gay people to live in almost exclusively gay context with gay doctors, lawyers, accountants, churches and other businesses catering to them.11
Due to stigmatization and unacceptability of the society, such way of living was not acceptable as openly as in western countries. In the Asian context, it must also be noted that unlike many western countries where sexuality and reproduction are not considered separate issue, the duty of reproduction and issue of sexual preferences are often entirely separate. Thus, while some persons who consider themselves as homosexual, they are still likely to get married because of family compulsions and ethnicities. As a result, the majority of homosexual people are likely to be married and seek their homosexual contacts secretly outside the marriage.
Male-to-male sex work is also a significant factor in India cities, where kothis/hijras, ‘massage boys’, male youth and other males will sell sex to men because of poverty and unemployment. Without a welfare system, and with unemployment or low-level incomes, male sex work can be a way out in terms of supporting the self and family.12
All urban areas have sexualized spaces, such as parks, toilets, railway and bus stations, specific bazaars, streets, and other public areas where kothis and hijras would meet potential giryas/panthis, marketing sexual availability through their feminized social behaviours. Many ‘real men’ also go to these sites, where they can get caught up “in the heat of moment” and access kothis and hijras there 8 at the time. Such activities play a very important role in the spread of sexually transmitted infections and HIV/AIDS in this society. Sexual behavioural studies in India have classified homosexual as anything from 1% of the sexually active mens to nearly 28% of the occasionally homosexually behavioural males.
In the Indian subcontinent, the most prominent groups are
HIJRAS – transgendered MSM, regarded as a ―third sex. They are often
castrated, dressed as women and are part of a clearly identified social
groups, which is endured by society but sometimes feared as well.
KOTHIS – also called as METIS in Nepal, these are MSM who adopt a
feminine lifestyle but who nevertheless may be married and father of
children.
PANTHIS – also called as Ta in Nepal, these are masculine men who
although live as ordinary males in the community sometimes have insertive
sex with Kothis. They do not have self-identity but are nick-named Panthis
by the Kothis.
DOUBLE DECKERS – mens who were both receptive and insertive
partners.
SEXUAL ROLE BEHAVIOR AMONG MSM
Men change their sexual partners in a number of different contexts and nowadays increasingly through internet as the world is quickly changing in all its aspects. They practice variety of sexual practices such as frottage, oro- genital, oro -anal, penile-anal intercourse, they may likewise use unique techniques of 9 sado-masochism and water sports. Barebacking is the term used for unprotected anal sex without condom usage and it is practiced by some MSMs who feel decreased sexual pleasure. These sexual practices are at increased risk of transmission of HIV and other STIs.13
Homosexuals with anal intercourse can play either the insertive or receptive role. This produces three role subgroups of men: insertive, receptive and versatile as opposed to the two role categories of male and female in heterosexual intercourse. This changes population transmission dynamics, and the impact depends on the prevalence of each role and the relative transmission probabilities of insertive and receptive sex.
REASONS FOR HIGH PREVALENCE OF STIS IN MSM
BIOLOGICAL
Semen with higher load of HIV - trauma to anal mucosa
Penis is penetrative organ and transmit semen
Highly receptive columnar epithelial surfaces are involved in Male to
Male sex:
Rectal mucosa, Anorectal squamous-columnar junction, Oropharyngeal
and tonsillar mucosa, Urethral meatal mucosa, Inner surface of prepuce,
SOCIOLOGICAL
Myths and unawareness about male homosexuals-e.g., in countries where
HIV spread is generally heterosexual, many men believe sex with men is
safer. 10 Barrier protection will not prevent reproduction, so condom use is rare.
Illegality discourages open expression of male to male love or sexual
behavior.
Societal stigmatization directly discourages regular open rapport between
two males.
Societal stigmatization thus indirectly encourages multiple casual
partners.
STUDIES OF STI PREVALENCE AND SEXUAL BEHAVIOUR DONE
IN INDIA
A study done in Delhi proposed the percentage of STI among MSM were
33.3%.14 A study at Puducherry showed the prevalence of STI among
MSM as 1.2% with increased prevalence among heterosexuals than
MSM.15
A different sexual behavior survey in Uttar Pradesh reported
approximately 54% of male respondents showed same sex behavior during
their lifetime.16
One study done in rural villages reported that nearly 10 percent of single
men and 3 percent of married men engaged in same sex behavior. 17
Another study conducted at a drop-in center for MSM in Mumbai
disclosed that nearly 23% of MSM were married and that being married
was actually associated with a much higher risk of being HIV positive
(23.8% for married men vs. 9.1% for others).18 11 In 2001 a study from Chennai, analysis of 51 MSM who attended a
community-based survey over a period of three months showed the
following outcomes. Thirteen (26%) MSM were clinically diagnosed to
have one or more STDs. Clinically the following pattern of STDs was
found: Perianal warts - 4 (8%), Genital Herpes - 4 (8%), Perianal herpes -
1 (2%), Secondary syphilis - 1 (2%), Gonococcal urethritis - 1 (2%),
Molluscum contagiosum - 1 (2%), Proctitis - 2 (4%), Scabies - 1 (2%) and
Prostatitis - 1 (2%). Genital dermatoses like Candidal intertrigo - 4 (8%),
Candidal balanoposthitis - 1 (2%), Perianal candidiasis - 1 (2%) and Tinea
cruris were also found. Seven (14%) self-reported as HIV-positive.
COMMERCIAL SEX WORKER
Commercial sex worker or prostitute or call-girl is an individual who offers sexual service for money or other needs. They are seen in brothels, bars, parlors and night clubs. They have increased rates of partner adjustment, poor access to health care, increased duration of contact to infection, and so sexual contact with CSW is a significant factor for transmitting STI. Sexual intercourse in exchange for payment is known as prostitution.19 Prostitution is prohibited and punishable by death in some countries, while completely legal in others.
Due to social stigmatization, prostitutes may also be called as commercial sex worker’, ‘female sex worker’ or ‘sex trade worker’. Male coordinators of prostitution are known as pimps. Female coordinators are known as madams.
Places where prostitution take place are called the brothels. These are often 12 located in ‘red light areas’ in big cities like (G.B. road) New Delhi, (Budhwar peth) Pune, (Sonagachi) Kolkata, (Kamath Pura) Mumbai.
Travelling to lots of poorer nations in search of sexual facilities that is unavailable or expensive or punishable in one’s own country is sex tourism.
Prostitutes are often defamed in all societies and religion, but their customers are defamed to a minor extent. Prostitutes have more STIs and abortions, so they can easily become sterile, but most of them still become pregnant and give birth to children. An estimated 85% of all prostitutes in Calcutta and Delhi enter the sex work at an early age.19
HISTORY OF CSW
India has history of prostitution as a profession. In vedic texts prostitutes were mentioned as ‘loose women’, ‘female vagabonds’ and ‘sadbarani’.
Prostitutes wore red costumes and jewels in vedic times to scare demons as they live in a wicked zone.
The devadasi system was a ritual in India by 300 AD. In this system, unmarried girls are dedicated to Hindu temples, where they are used as objects of sexual pleasure. In the eighteenth century, during the British period there were many reports of prostitution in large cities. During recent times, prostitution was not considered as a shameful profession.
Recent data regarding population of brothel-based women is 6000 in
Kolkata. 20 Exact number of sex workers in India would be hard to estimate because of the secret nature of sex business and their extensive distribution. 13 Present data reveals decreased sexual practices and routine lifestyle of sex workers has been reduced. The data of these studies revealed that prostitutes had low standard of living in a depreciated and soiled environment. Pimps, madams and investors share major portion of their payment. Majority of them are infected by different STIs irregularly. They usually visit local quacks for seeking health services who will charge them hugely for treatment, as they may not use government health facilities due to fear of prejudice.
FACTORS INDUCING WOMEN TO BECOME PROSTITUTES IN
INDIA
When the family and marital life of these CSW fail due to many reasons, the woman would not be having any confidence on her life. Various reasons of prostitution are lack of sex education, prior sexual exploitation, bad peer group, ignorance, acceptance of prostitution, abuse by husband and widowed young woman.
THEORIES OF PROSTITUTION
1. FUNCTIONALISM: Prostitution is functional for several parties in
society. It provides prostitutes a source of income, and it provides a sexual
alternative for men who lack a sexual partner or are dissatisfied with their
current sexual partner. According to Kingsley Davis, prostitution also
helps keep the divorce rate lower than it would be if prostitution did not
exist.
14 2. CONFLICT THEORY: Prostitution arises from women’s poverty in a
male-controlled society. It also reflects the continuing cultural treatment of
women as sex objects who exist for men’s pleasure
3. SYMBOLIC INTERACTIONISM: Prostitutes and their customers have
various understandings of their behaviour that help them justify why they
engage in this behaviour. Many prostitutes believe they are performing an
important service for their customers, and this belief is perhaps more
common among indoor prostitutes than among street prostitutes. 21
STUDIES COMPARISON
In a study conducted in Chennai, among 248 commercial sex workers,
46.8% were 35 years or more, 59% were educated and 56% were married.
Most of the FSWs (92%) were from different locality. The age at first
sexual intercourse was below 18 years in 48 % of them. In the period of
one month, 30% clients asked for anal sex and 25% of them accepted that
mode of sex too. Consistent condom usage was found in 16%. 27% were
alcoholics and among them, 91% had habit of consumption before sexual
act.22
In a study from Andhra Pradesh, 2005-2006, 3200 female sex workers
were included in the study with following results- 70% were uneducated,
50% were married and 41% of them had sex work as the lone source of
income.23
15 In India, high prevalence states of HIV are Andhra Pradesh, Tamil Nadu,
Karnataka, Maharashtra, Manipur and Nagpur. These states provide 63%
of the total HIV infected persons in whole India.
In a study done in Mexico among 924 FSWs, the prevalence of HIV
infection was 6%, gonococcal infection was 6.4% , chlamydial infection
was 13%, and syphilis was 14.2%.24
According to a ten year study done in Pune, 34% reported regular condom
usage, 52% reported irregular condom usage, 14% had never used condom
among FSW’s. 25
TRANSGENDERS
Transgender have a gender identity or gender appearance that differs from their own sex. Transgender often called as trans, is also an umbrella term: in addition to with people whose gender identity is the reverse of their assigned sex
-trans men and trans women. It may include people who are not completely manly or womanly. Some call transgenders as a third gender. The word transgender may be defined broadly as cross-dressers. Being transgender is independent of sexual orientation. Transgender may identify them as heterosexual, homosexual, bisexual, asexual or may decline to label their sexual orientation. The opposite of transgender is cisgender, which defines persons whose gender identity or appearance matches with their assigned sex.
Many transgender experience gender dysphoria, and some search for medical treatments such as hormone replacement therapy, sex reconstructive 16 surgery, or psychotherapy. Not all transgender desire these modalities and some cannot undergo these for financial or medical reasons. Many transgender face discriminations in the workplace and in accessing public accommodations and healthcare services.
In India, April 2014, the Supreme Court of India declared transgender to be a 'third gender' in Indian law. Justice KS Radhakrishnan noted in his decision that, "Seldom, our society appreciates or cares to realize the trauma, agony and pain which the members of Transgender community suffer, nor appreciates the innate feelings of the members of the Transgender community, especially of those whose mind and body disown their biological sex".
They are facing lots of difficulties in the society and have poor quality of living life as they are not supported with financial support nor from their families.
So, they are forced into high risk sexual practices for money and to survive in the community. As they are indulged with high risk practices, the chance of STI’s among them and among the community has increased.
STUDIES RELATED
A 2017 paper used meta-analysis and synthesized national surveys to estimate that nearly 1 million persons in the United States were transgender. From
2009-2014, 2351 transgenders received an HIV diagnosis in the United States.
84% were transgender women, 15% were transgender men and less than 1% had another gender identity. Around half of transgenders 43% of transgender women;
17 54% of transgender men who received an HIV diagnosis lived in the South regions.26
A study conducted in Australia in 43 participants showed 24% of TG and
35% of MSM positive for various STI; chlamydia was detected in 19% of samples and gonorrhoea in 9% samples. Of the 39 participants tested for syphilis, 3% were positive and there were no detected cases of HIV.27
A study by Tamilselvan in India, revealed 120 transgenders and they were all 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% were >40 years. All of them had multiple sex partners at certain point of time, of which 25% (31) are now dedicated to a single partner and 15% (19) were involved in commercial sex. The safe sexual practice was followed by 68% (84). Among sexual practices, oral intercourse contributed 97.3% (117), anal 92% (110.4), finger 9% (11), thigh 6%
(7) and vaginal route 24% (28.8). Of 120 patients, 63.3% (76) had infectious diseases, 42.5% (51) had non-infectious diseases, and 5.9% (7) had both.
RECREATIONAL DRUG USE
Rates of drug usage such as cigarette smoking, alcohol and substance abuse are higher in MSM when compared to the normal general population. This makes a potential impression on HIV infected MSMs:
This kind of lifestyle is associated with other high-risk behavior.
Increase risk of atherosclerotic disease and carcinomas which are related
with smoking are compounded by HIV infection. 18 Illicit drug use for-Crack, cocaine, crystal, and methamphetamine lead to
unsafe sexual practices.
Self-injecting the drugs in unsterile manner cause HIV transmission and
hepatitis.
Co-infection with hepatitis causes rapid progression of the disease.
This risky lifestyle will cause poor intake of antiretroviral therapy (ART)
and other medications.
Certain recreational drugs like sildenafil may disturb metabolism of
prescribed drugs.
There is relationship between alcohol and sex among MSM. Alcohol use
serve a unique function in the lives of MSM. Alcohol use among gay and
bisexual men can be a reaction to social marginalization resulting from
their sexual orientation and may be associated with other mental health
issues such as depression, anxiety, and substance use disorders.
Four domains were identified that described the role of substance use in sexual encounters:
Motivators, Allowers, Rationalizers, Facilitators.
A study of substance uses among HIV-positive MSM found that nearly all
(90%) of the men used drugs to enhance sexual pleasure, and that drug use dulled negative feelings about living with HIV. A study done in Delhi, 62.4% of IDUs inject drugs >5 years; whereas in Punjab, it was only 32.4%. The overall HIV positivity in Delhi and Punjab was 18.3% and 21.2%, respectively. Delhi, the 19 highest HIV positivity is found among the IDUs whose duration of injecting drug is from 6 months to 1 year (34.5%). In Punjab, the highest positivity is found among the IDUs who are injecting drugs for more than 5 years (33.5%). In both the states, the positivity among the IDUs whose frequency of drug use once a week or less has the maximum positivity; 24.9% in Punjab and 50% in Delhi. 28
OCCUPATIONAL RISK BEHAVIOURS
Occupation is one of the socio-demographic factors, which not only act as a risk factor for acquiring STI’s but also as a factor of spread of acquired infection. Major characteristics include:
a high prevalence of unprotected anal intercourse among manual labourers.
increased prevalence of STI’s among truck drivers and housekeepers
a high prevalence of unprotected vaginal intercourse with concurrent alcohol
use and sex with females among hospitality workers
high prevalence of STI’s among salesman and professional industries
people who frequently change their places- migrants
Most individuals are introduced to their sex partners through social interactions in formal and informal institutional places that work as sex marketplaces. A study in the United States of America, most individuals meet long-term buddies through social relations in high school, college or the workplace, while casual partners are often met through informal sex marketplaces such as public house and nightclubs. Working in the manual labour and hospitality industries was related with more sexual risk behaviours than people 20 working in the sales, retail and skilled industries. Those working in manual labour had higher rate of unprotected anal sex in the past two months than those working in the hospitality, retail, sales and skilled industries.29 There is a theory that variance stressors in the work settings by type of occupation lead to sexual risk behaviours. Conversely, the sexual market structure and social status changes by sector can be seen as serious factors increasing the possibility of sexual health liabilities.
A study in India showed that 28% of total STI’s were attributed to unskilled profession and 50% to job requiring frequent travel. This can be attributed to widespread unemployment resulting in poverty thereby indulging in various sex practices and development of various STI’s.30
SEXUALLY TRANSMITTED INFECTIONS AMONG HIGH RISK
GROUPS:
A wide range of microorganisms depend upon human genital tract and sexual behavior for their survival. More than 20 pathogenic organisms, including
HIV are sexually transmissible and are responsible for high degree of mortality and morbidity.
It includes,
Syphilis
Gonorrhea
Chancroid
Chlamydia 21 Lymphogranuloma Venereum
Granuloma inguinale
Herpes
Molluscum contagiosum
Warts
Hepatitis B and C
HIV/AIDS
Balanoposthitis
Scabies
Trichomonas vaginalis
Bacterial vaginosis
Vulvovaginal candidiasis 31
Most important concern is the rise of resistance to drugs in these organisms. It makes the organism more lethal and harder to treat.
22 BACTERIAL INFECTIONS
SYPHILIS
Syphilis caused by the bacteria Treponema pallidum with incubation period is 9 to 90 days. From a low of fewer than 4 cases of syphilis per one lakh population in the year 2000, the syphilis incidence has now raised to more than 6 cases per one lakh population.32 Events of active disease occur, followed by latent periods, where the patient remains infected without signs or symptoms.
Initially syphilis has painless ulcer where the infection entered generally around the genitals, anus or mouth and may remain unseen. The ulcer is known as a chancre and this stage is called as primary syphilis. Extensive rash and flu-like symptoms appear next, which is known as secondary syphilis. If left untreated, tertiary syphilis develops years later and cause a variety of problems affecting the brain, eyes, heart and bones.
Syphilis cases are increased among MSM, CSW, persons having multiple sex partners with unprotected sexual intercourse. Syphilis ulcers are commonly seen over genitals and anal area but may also be seen on the lips or mouth. Hence, vaginal, anal or oral sex is the key way of transmitting the infection from one person to another. Both men and women are equally at risk of syphilis. The peak incidence rises among the age of 16 and 35 years.
23 PRIMARY SYPHILIS
Approximately 9 to 90 days after the first exposure a skin lesion, called a chancre, develops at the site of contact. This is classically a single, firm, painless ulcer with a clean base and sharp borders around 0.5–3.5 cm in size.33 In the classic form, it evolves from macule to papule and finally to an ulcer. Occasionally, presents with multiple lesions when coinfected with
HIV. Lesions may be painful in 30% and they may occur at extragenital site (2–
7%). The most common site in women is the cervix (44%),penis in heterosexual men (99%), anus and rectum in MSM (34%). Lymphadenopathy occurs frequently (80%) at the site of infection and it occurs 7 to 10 days after chancre formation. Chancre redux is form of relapsing syphilis in which a chancre appears at the site of the original infection. It should not be confused with Pseudochancre redux, in which a tertiary syphilitic gumma develops at the site of the original chancre. 34
SECONDARY SYPHILIS
Patient is highly infectious during this stage. If chancre left untreated or treatment was unsuccessful, approximately 3 weeks to 3 months after the 1st stage, an extensive skin rash develops. Rash may be subtle or appear as reddish- brown papules or patches. It typically occurs over the trunk and frequently affects palms and soles not associated with itching. It spontaneously resolves within weeks to months. Corymbose syphilis describes a central plaque surrounded by cluster of erythematous papules (resembling a flower). Patchy alopecia over 24 frontal and occipital area. Mucous patches over mouth, throat, genital area, vagina and anus. Greyish-white moist raised broad based flat topped lesions over the groin, inner thighs, armpits, perianal region called as condyloma lata.33 Other symptoms include fever, fatigue, myalgia, headache, joint pains and swollen lymph glands. Other organs like liver, kidneys, central nervous system and eyes also affected.
EARLY LATENT (<2 YEARS OF CONTACT)
The patient is infectious at this stage and can transmit the infection to the partner. Usually there is no signs on clinical examination whereas, treponemal antibody tests will be positive.
LATE LATENT SYPHILIS (>2 YEARS OF CONTACT)
Patient is non-infectious. Usually there is no signs on clinical examination whereas, treponemal antibody tests will be positive.
TERTIARY SYPHILIS
Tertiary syphilis may occur roughly 3 to 15 years after the initial infection, and may be divided into three forms: Gummatous stage
(15%), neurosyphilis (6.5%), and cardiovascular syphilis (10%).35 Tertiary syphilis patients are not infectious.
Gummatous syphilis or late benign syphilis usually occurs 1 to 45 years after the primary infection, with an average of 15 years. This stage consists of chronic gummas, which are soft and vary much in size. They classically affect the skin, liver, and bone. 25 Neurosyphilis may occur early, being either symptomless or in the form of meningitis, or late as meningovascular syphilis, general paresis, or tabes dorsalis, which is associated with poor balance and lightning pains in the lower limbs. Late neurosyphilis typically occurs 4 to 25 years after initial infection. There may be Argyll Robertson pupils in which accommodation reflex is present but light reflex absent.
Cardiovascular syphilis occurs 10–30 years after the primary infection.
The common complication is syphilitic aortitis, associated with aortic aneurysm development.
A study in India with a total of 124 patients were VDRL reactive, of which
33 (2.25%) were false positive cases and TPHA was reactive in 91 cases (6.22%).
Totally, 91 (6.22%) cases were diagnosed as syphilis. Out of 91 cases, 78
(85.71%) were males and 13 (14.29%) were females. Primary syphilis was detected in 21 (13.08%), secondary in 38 (41.76%), and latent in 32 (35.16%) patients. Mixed infection was detected in 7 patients and 8 (8.79%) were HIV positive. 36
CONGENITAL SYPHILIS
Congenital syphilis can be prevented by treatment before 16 weeks gestation. The risk to the foetus is high with early untreated maternal syphilis. In the first few weeks of life it resembles secondary syphilis including vesicle and bulla, scaly rash, mucous patches and condyloma lata, Snuffles, bone changes, hepatomegaly and lymphadenopathy are common. Late congenital syphilis 26 affects eyes (interstitial keratitis), ears, joints and CNS. The characteristic signs include Hutchinson's teeth, typical facial appearance and bowed sabre shins , higoumenakis sign, saber shin, or Clutton's joints among others.37
In 2012, an estimated 9,30,000 maternal syphilis infections caused
3,50,000 bad pregnancy outcomes, including 143,000 early fetal deaths/stillbirths, 62,000 neonatal deaths, 44,000 preterm/low weight births and
102,000 infected infants. Nearly 80% of adverse outcomes occurred among ANC attendees. From 2008 to 2012 estimates, maternal and congenital syphilis decreased by 38% (560,000 and 226,000 cases respectively). Despite these declines, maternal syphilis still causes considerable adverse pregnancy outcomes, even among women attending ANC. 38
SYPHILIS AND HIV
In the past five years the relation between HIV and syphilis has become interesting issue for debate and research. As syphilis is an ulcerative sexually transmitted disease, people with syphilis are at high risk transmitting and acquiring HIV.39
The clinical presentation of syphilis in HIV patients are
Primary syphilis: bigger, tender multiple ulcers
Secondary syphilis: more genital ulcers with high titres of RPR and
VDRL.
More chance for neurosyphilis.
27 Out of the total 110 patients with syphilis, 27 (24.5%) patients were seropositive for HIV-1. Of the 27 HIV-positive cases, 18 were diagnosed as secondary syphilis, 5 were primary, and 4 patients were diagnosed as latent syphilis. Thirteen patients (48.1%) with HIV co-infection presented with condyloma lata and two of the HIV-positive patients had persistent generalized lymphadenopathy.40
TREATMENT GUIDELINES
The diagnosis of syphilis is done by the using dark field microscopy.
Serological non-treponemal tests like VDRL and RPR tests are done. The commonly used confirmatory test is Treponema Pallidum Hemagglutination Test
(TPHA). Inj. Benzathine Penicillin G single dose given for early syphilis whereas three doses should be given to late stage of syphilis and persons co-infected with
HIV. Regular follow up is needed at 3, 6, 9, 12, and 24 months post treatment. A fourfold decline in titre at 6 months after injection is considered as good treatment response.
GONORRHOEA
Gonorrhoea, colloquially known as the clap, is a sexually transmitted infection caused by the Neisseria gonorrhoeae, a gram negative bacteria. Infection may involve the genitals, mouth, and rectum.41 Its incubation period varies between 1-14 days, with an average 2-5 days. For men in the community, the prevalence rate varies from 1.7-2.1% and in STI clinics it ranges from 8.5-25.9%.42 28 Infected Males
Inflammation of the urethra
Creamy or green pus-like discharge from the penis; blood can also be
present
Painful urination
Painful testicles
There are no symptoms at all in 10–15% of men. Rectal symptoms include rectal pain, pharyngitis that may cause mild to severe difficulty in swallowing may also occur in MSM with oro-receptive and oro-insertive. Gonococcal infection can be transmitted by infected fingers to the eyes causing unilateral conjunctivitis with severe inflammation and a yellowish discharge.
A study by El-Gammel et al, a total of 475 patients over a period of 1 year attended the study. The subjects were screened for both gonorrhoea and chlamydia with polymerase chain reaction and Gram's stain using specimens from the urethral discharge. Out of 475 patients, 125 (26.3%) had gonorrhoea, 47
(9.8%) had chlamydia, and 11 (7.31%) had both diseases. This emphasizes that co-occurrence of chlamydia and gonorrhoea may be common among males presenting with urethral discharge.
Infected Females
Often there are no symptoms until the infection has progressed to a more
advanced stage
Creamy or green, pus-like or bloody vaginal discharge 29 Infants
If not treated, gonococcal ophthalmia neonatorum will develop in 28% of
infants born to women with gonorrhoea.
Complications
Ascending infection in the urogenital tract in men, causing painful
inflammation of epididymis and prostate
Urethral scarring in men – possible decreased fertility or bladder-outlet
obstruction
Scarring of the upper reproductive tract in women with PID – possible
infertility, chronic pelvic pain, ectopic pregnancy
Neonatal infection and miscarriage from gonococcal infection in pregnant
women
Systemic involvement such as dermatitis, arthritis, septicaemia,
meningitis, conjunctivitis, pneumonitis, Fitz-Hugh Curtis syndrome,
watercan perineum, perihepatitis.
Treatment guidelines
The gonorrhoea can be diagnosed by gram stain, culture, and PCR.43
The suggested treatment for uncomplicated gonococcal infection is Inj.
Ceftriaxone 250mg I.M stat (or) Azithromycin 2grams stat when
associated with Chlamydial infection .44
30 Antimicrobial susceptibility testing of N. gonorrhoeae isolated in Pune during the past decade was characterized by high rates of resistance to penicillin and ciprofloxacin. Cefixime is the first-line drug recommended under syndromic management of STIs according to the NACO guidelines for treatment of gonorrhoea. However, emergence of less susceptible strains to ceftriaxone and cefixime have been reported from WHO regional and reference centre, Delhi which highlights the importance of routine monitoring antibiotic resistance.
Results of the study support the current recommendations of NACO for use of third-generation as the first-choice drugs for treatment of gonorrhoea in India.45
NONGONOCOCCAL URETHRITIS (NGU)
Non gonococcal urethritis is an inflammation of the urethra that is not caused by gonorrhoeal infection.
Symptoms
For men symptoms are discharge from the penis, burning or dysuria, itching, irritation, increased frequently or tenderness. In women, symptoms are discharge from vagina, burning or pain during urinating. Abdominal pain or abnormal vaginal bleeding are indication that the infection has advanced to Pelvic
Inflammatory Disease.
Causes of NGU
Infectious
The most common bacterial cause of NGU is Chlamydia trachomatis, but it can also be caused by Ureaplasma urealyticum, Haemophilus vaginalis, Mycoplasma 31 genitalium, Mycoplasma hominis, Gardnerella vaginalis, and E.coli. Viruses like
Herpes simplex virus, Adenovirus, Cytomegalovirus .Fungus like Candida
Albicans .Parasite like Trichomonas vaginalis (rare)
Noninfectious
Urethritis can be caused by mechanical injury from a urinary catheter or a cystoscope or by an irritating chemical like antiseptics or spermicides.
Diagnosis
This can be confirmed by demonstration of polymorphonuclear leucocytes
(PMNL) this can be done by (i) gram stain of urethral discharge should contain
>5 PMNL per high power microscopic fields.46 (ii) positive leucocyte esterase test on first voided urine. (iii) gram stain of centrifuged sample of first passed urine should contain >10 PMNL per high power microscopic fields.
Treatment guidelines
Most cases respond to traditional therapy for NGU with
Cap.Doxycycline 100 mg twice a day orally for 7 days or Azithromycin 1 g stat orally once.
A Thailand study with 237 male urethritis patients were included with GU and NGU found in 120 (52.9%) and 107 (47.1%) of patients, respectively.
Recurrent urethritis was found in 23.8% of patients and HIV infection was identified in 11.6%.47
32 CHANCROID
Chancroid is a sexually transmitted infection caused by fastidious gram- negative bacteria Haemophilus ducreyi. It is characterised by painful ulcers on the genitals and painful swollen lymph glands. The incubation period ranges from
1 to 14 days. 48
Signs and Symptoms
The ulcer size ranges from 3 to 50 mm. The ulcer is painful, sharply
defined borders with undermined edges. Its base is covered with a grey or
yellowish-grey material and bleeds on manipulation.
dysuria and dyspareunia in females.
Painful swollen lymph nodes occurs in 30 to 60% of patients.
The swollen inguinal lymph nodes and abscesses are often referred to
as buboes.
Common sites
In males , Internal and external surface of prepuce, Coronal sulcus, Frenulum
,Shaft of penis, Preputial orifice, Urethral meatus, Glans penis, Perineum area
In females, Labia majora is most common site. "Kissing ulcers" may develop.
These are ulcers that occur on opposing surfaces of the labia, Labia minora,
Fourchette, Vestibule, Clitoris, Perineal area, Inner thigh.
Clinical variants 49
They are Dwarf chancroid, Giant chancroid, Follicular chancroid, Transient chancroid, Serpiginous chancroid, Mixed chancroid, Phagedenic chancroid. 33 Diagnosis
Gram stain shows “school of fish appearance”. (ii) culture shows small non-mucoid yellowish semi opaque colonies appear 2 to 4 days after inoculation.
Studies show that molecular techniques can detect the presence of H. ducreyi
DNA in clinical sample. M-PCR and nested single tube PCR techniques are more sensitive than standard methods. This can be extremely useful in designing appropriate syndromic management algorithm for genital ulcer.49
Treatment guidelines
The CDC(2006) guidelines for chancroid is 1 gram of azithromycin stat or
single IM dose (250 mg) of ceftriaxone or erythromycin 500 mg three
times a day orally for 7 days, or oral 500 mg of Ciprofloxacin twice a day
for 3 days.
The buboes should be aspirated, incision and drainage should not be done.
LYMPHOGRANULOMA VENEREUM
Lymphogranuloma venereum (LGV) (also known as Climatic bubo ,
Durand–Nicolas–Favre disease , Lymphogranuloma inguinale and tropical bubo)50 is a sexually transmitted disease caused by the invasive serovars L1, L2,
L2a, L2b or L3 of Chlamydia trachomatis. incubation period is 3 to 12 days.
Signs and Symptoms 50
The clinical manifestation of LGV depends on the site of entry of the infectious organism (the sex contact site) and the stage of disease progression.
34 Inoculation at the mucous lining of external sex organs (penis and vagina)
can lead to the inguinal syndrome named after the formation of buboes
or abscesses in the groin. These signs usually appear from 3 days to a
month after exposure.
The rectal syndrome arises if the infection takes place via the rectal
mucosa and is mainly characterized by proctocolitis.51
The pharyngeal syndrome is rare.
Stage 1
Small painless papule appears.
Ulcerates, heals and disappears within a few days and may go unnoticed
Stage 2
Most male patients present during this stage
About 2-6 weeks after the 1st stage painful and swollen inguinal lymph
glands (buboes) develop on one (most common) or both sides of the
groin.in 20% femoral lymph nodes separated by Poupart’s ligament from
enlarged inguinal lymph node producing “GROOVE SIGN OF
GREENBLATT “
Women may present with lower abdominal or back pain (deep pelvic node
involvement).
Other symptoms include malaise, fever, chills, joint and muscular pain and
vomiting.
35 Stage 3
Most female patients present during this stage with fever, pain, itch, pain
on passing stools and urinating, and pus-filled or bloody diarrhoea.
Chronic inflammation may lead to abscesses fistulas, lymphatic
obstruction, rectal strictures and proctocoliltis.
Chronic infection may result in severe scarring causing major deformation
of the genitals.
A Quebec study with 338 cases of LGV, all cases were male, excluding one transsexual. Most were MSM (99%). 83% reported four sexual partners or more in the last year, met mostly through the Internet (77%). 83% were HIV- infected. Recreational drug use was frequent (57%). 52
Treatment guidelines
The diagnosis usually is made serologically (complement fixation) and
Recently a fast Realtime PCR (TaqMan analysis) has been developed to
diagnose LGV.
Treated with Doxycycline 100mg orally bd x 3 weeks or Erythromycin
500mg orally qid x 3 weeks 53
DONOVANOSIS
Granuloma inguinale is a bacterial disease caused by Klebsiella granulomatis (formerly known as Calymmatobacterium granulomatis) characterized by genital ulcers. It is also known as granuloma inguinale, granuloma inguinale tropicum, granuloma venereum, granuloma 36 venereum genitoinguinale, lupoid form of groin ulceration, serpiginous ulceration of the groin, ulcerating granuloma of the pudendum, and ulcerating sclerosing granuloma.54
Signs and Symptoms
After contracting the infection, it may take from 1 week to 3 months for any signs and symptoms to appear. There are several types of lesions that may occur and symptoms are mild.
The nodular type consists of soft lumps that are typically beefy red in
colour and tend to bleed easily. These are usually painless
despite ulceration.
The hypertrophic or verrucous type consists of large dry warty masses
that resemble genital warts.
The necrotic type presents as dry ulcers that evolve into scarred areas.
A study in Durban, South Africa showed 171 patients with donovanosis in which Ulcers were present for longer than 28 days in 72 (55.4%) men and 19
(46.3%) women. 95 (55.6%) came from rural areas.55 This shows ulcers are most common presentation in donovanosis.
Treatment guidelines
The main method of diagnosis is the demonstration of Donovan bodies in a tissue sample taken by crush preparation or biopsy. Other tests such as culture, polymerase chain reaction (PCR) or serology are not routinely available. 37 The recommended regimen is azithromycin 1gram oral/iv once per week,56 alternatively doxycycline 100 mg bd orally or ciprofloxacin 750 mg bd orally or erythromycin 500 mg orally four times a day or trimethoprim- sulfamethoxazole one double-strength (160 mg/800 mg) tablet orally twice a day.
BACTERIAL VAGINOSIS
Bacterial vaginosis is a common cause of abnormal vaginal discharge and malodour in women. Some women have similar findings on vaginal wet mount and culture but do not have any symptoms. Bacterial vaginosis affects women of reproductive age. The organisms like Gardnerella, Bacteroides, Peptostreptococcus and Mobiluncus species shows over growth.57 These are anaerobic bacteria, that is, they grow in the absence of oxygen.
Risk factors include vaginal douching, multiple sex partners, antibiotics, and using an intrauterine device.
According to a study in Nepal, of total 160 cases of vaginal discharge, BV was seen in 24.4% patients. BV in unmarried women were at higher risk (100% tested positive) compared to married women (24.2%). Several studies have documented the occurrence of BV in sexually inactive females or virgins. This provides support that sexual activity is not a prerequisite for BV. The change in lifestyle, improper perineal care, food habits, tight clothing, lack of attention towards menstrual hygiene, and sedentary factor might be the reasons for the acquisition of BV in unmarried women.58 38 Signs and Symptoms
Common symptoms consist of increased vaginal discharge that usually has fishy odour. The discharge is white or grey in colour. There may be burning with urination.59 Occasionally, they are symptomless. The discharge coats the walls of the vagina, and is generally without irritation, pain, or erythema although mild itching can sometimes occur.
BV increases the risk of other sexually transmitted infections, including HIV/AIDS.60 Complications like miscarriage, pre-term delivery, Low birth weight, Premature rupture of membrane, postpartum endometritis, vaginal cuff endometritis, Pelvic inflammatory disease and abortions can occur.
BV and HIV
Normally Lactobacilli produce H2O2 which is toxic to HIV, in BV lactobacilli is reduced. In BV vaginal pH is increased which activates CD4 lymphocytes and become target cells for HIV. BV has also been shown to increase intravaginal levels of IL-10 which increases susceptibility of macrophage to HIV.
Treatment guidelines
Clinically BV can be diagnosed using the Amsel criteria 61
Thin, white, homogeneous discharge.
Clue cells on microscopy
pH of vaginal fluid >4.5
39 Release of a fishy odour on adding alkali -10% potassium
hydroxide (KOH) solution.
At least three of the four criteria should be present to confirm the diagnosis.
Gram stain
An alternative is to use a Gram-stained vaginal smear the Nugent criteria.
A score of 0-10 is obtained from combining three other scores. The scores are as follows:
0–3 is negative for BV
4–6 is intermediate
7+ is indicative of BV.
At least 10–20 high power (1000× oil immersion) fields are counted and an average determined. Upon examination of 160 nonpregnant women with symptomatic vaginal discharge, the overall prevalence of BV was 24.4% based on Nugent’s scoring system.58
Treatment is Metronidazole 400 mg BD orally for 7 days (or)
Metronidazole 2gms single oral dose. Nearly 30% of patients have recurrence of symptoms within 3 months.62
40 VIRAL INFECTIONS
HERPES GENITALIS
Herpes simplex is one of the commonest genital infections all over the world. There are two types of herpes simplex virus (HSV); type 1, which is mostly associated with facial infections and type 2, which is primarily genital, although there is overlap.
HSV causes lifelong infection with possible reactivation or recurrence.
People often refer only to HSV-2 when discussing genital herpes but both types can lead to infection in the genital area. Clinically, about 60–70% of primary genital infections are due to HSV-2 whereas the rest is due to HSV-1.
Primary genital herpes infection
Primary or first genital HSV infections may be mild and unseen, but should lesions develop, the severity is usually more than in recurrences.
Genital ulceration from herpetic infection is the most common complaint
seen in sexual health clinics. The ulcers are common over the glans,
foreskin and shaft of the penis. They are painful and last for 2 to 3 weeks,
if untreated. The local lymph glands are enlarged and become tender 63.
In women, lesions occur over the external genitalia and mucosae of
the vulva, vagina and cervix. Pain and difficulty in passing urine are
common symptoms.
Some people also have flu-like symptoms like fever, headache and myalgia.
Symptoms tend to be severe in women than in men. 41 Recurrent genital herpes infection 64
After the primary infection, there may be no further clinical manifestations throughout life. Recurrences are more frequent with type 2 genital herpes than with type 1.
Recurrences can be triggered by:
Trauma.
Ultraviolet radiation (sun).
Other infections.
Menstruation (flare-ups may occur before period).
Emotional stress.
Recurrent infections differ from primary infections in that the vesicles are usually smaller in size. They also tend to be of shorter period than the primary infection, usually 5-7 days.
These produce shallow ulcers, over the glans or shaft of the penis in men and on the labia, vagina or cervix in women. Recurrences can cause painful symptoms or the lesions can be unnoticed. Lesions usually heal within 7–10 days without scarring.
Complications of genital herpes
Urethritis.
Proctitis, rectal pain, watery discharge,
and autonomic nerve dysfunction that may produce difficulty in passing
urine.65 42 Neurogenic pain over leg and thigh pain. This often leads to recurrence.
esophagitis, encephalitis retinitis, thrombocytopenia, mollarets'
meningitis.
Widespread infection.
HSV and HIV
Clinically the lesions are atypical, large often haemorrhagic, deep painful ulcers with raised margins. Other atypical lesions include hyperkeratotic verrucous lesions vegetating plaques and a zosteriform appearance.
A study by Chopra et al showed 8 (16%) HIV positive women and 4 (8%)
HIV negative women with genital ulcers among 50 patients. Herpes genitalis was the cause of genital ulcers in 5 (10%) HIV positive women and 3 (6%) HIV negative women, trailed by syphilis in 3 (6%) HIV positive women and 1 (2%)
HIV negative women. This shows increased incidence of herpes genitalis among
HIV infected people.(66)
Diagnosis &Treatment guidelines
Tzanck smear, biopsy, blood test for antigen and culture are useful diagnostic tools. Culture remains the Gold Standard.
Treated with Oral acyclovir 200mg 5 times daily (or) 400mg 3 to 4 times daily till clinical resolution attained (7-10 days) (or) Famciclovir 500mg twice daily x 5-10 days (or) valacyclovir 1 g daily x 5-10 day.(67)
A study by Maharajan et al showed 90 clinically diagnosed herpes genitalis cases, confirmed by Tzanck test and were divided into 3 groups of 30 patients 43 each which were applied topical ZnSO 4 in concentrations of 1%, 2% and 4% respectively over a period of 3 months. Ten patients of group 1 (1% ZnSO 4) showed recurrence, 6 patients in group 2 (2% ZnSO 4) and only one patient in group 3 (4% ZnSO 4) showed recurrence. No serious side effects were noted. Thus, topical ZnSO 4 has been found to be an effective treatment for increasing remissions in herpes genitalis. Topical 4% ZnSO 4 has been found to be most successful out of the three concentrations.68
MOLLUSCOM CONTAGIOSUM
Molluscum contagiosum (MC), also called as water warts or Bateman disease. Molluscum contagiosum is caused by a poxvirus, the molluscum contagiosum virus. There are 4 viral subtypes.69
A study was done in Pondicherry for comparing the incidence of genital
MC among children and adults, which showed 14.5% in children and 23% in adults signifying increased risk of genital MC among sexually active adults.70
Mode of transmission:71
Direct skin-to-skin contact
Sexual transmission in adults.
Indirect contact through shared towels or other items
Auto-inoculation into another site by shaving or scratching.
Signs and Symptoms
Molluscum contagiosum lesions are pearly dome shaped umbilicated waxy papules with 1–5 mm in diameter.72 Molluscum lesions commonly found on the 44 face, arms, legs in children. Adults classically have MC lesions in the genital region and this is considered to be a sexually transmitted infection. Because of this, if children have genital lesions then sexual abuse should be suspected. These lesions are commonly not painful, but they may be associated with itching or become irritated. Picking or scratching the lesions may lead to a spread of the infection, an additional bacterial infection, and scarring. In about 10% of the cases, eczema develops around the lesions.
Molluscum and HIV
Between 10% to 30% of patients with symptomatic HIV disease have molluscum contagiosum. MC2 is common in adult men and patients with HIV infection. The lesions in HIV will be giant(>1cm), multiple (upto 100), distributed over face, including the eye lids and ears, neck and in intertriginous areas. In homosexual men the lesions are often seen in ano-genital area. It is important to differentiate it from keratoacanthoma, cryptococcosis, histoplasmosis and penicilliosis.
Incidence of MC in HIV infected persons is 5-18%. In patients with CD4 count <200 cells/mm 3, incidence increases to 25-35%. Unusual morphological variants including giant, tumour like nodular lesions (>1 cm), necrotic lesions, abscesses, polypoidal or pseudo cystic variants and cutaneous horn have also been described in HIV seropositive patients.73
45 Treatment guidelines
Molluscum is usually diagnosed by its typical clinical appearance.
Molluscum bodies can often be expressed from the centre of the umblicated papules. Sometimes, the diagnosis is made by skin biopsy. Histopathology shows typical intracytoplasmic inclusion bodies.74
There is no single perfect treatment of molluscum contagiosum since we are currently unable to kill the virus. Physical treatments include needling,
Cryotherapy, Gentle curettage or electrodessication, Laser ablation. Medical treatments include 10% KOH, Podophyllotoxin cream, salicylic acid ,
Cantharidin solution, cimetidine.75 Imiquimod cream and sinecatechins can be used but are unproven.
GENITAL WARTS
Anogenital wart is the common superficial skin infection in an anogenital area that is caused by human papillomavirus (HPV).76 Anogenital warts also known as condyloma acuminata, genital warts and squamous cell papilloma.
They are generally due to HPV types 6 and 11.
An anogenital wart is a skin coloured papule a few millimetres in diameter.
Warts may join together to form plaques. They may occur in the following sites like vulva, vagina, corona , prepuce, scrotum, perianal region.77 Warts due to the same types of HPV can also occur over oral mucosa.
Transmission of warts 78
Sexual contact. This is the most common way among adults. 46 Transmission is likely from visible warts than from subclinical HPV
infection.
Oral sex.
Vertical transmission.
Auto inoculation from one site to another.
Fomites.
HPV and HIV
HIV infected patients have multiple lesions and diffuse involvement of the anogenital areas. They develop very large genital warts and these become locally invasive and destructive.79 These tumours are called giant condylomas (or)
BuschkeLowenstein tumours. They do not cause metastasis, but carry a significant risk of transformation into squamous cell carcinoma. In vitro studies have revealed that intracellular HIV-1 tat m RNA can transactivate HPV type 16
E6 & E7 an action that is significant in the development of squamous cell carcinoma. Women with HIV infection appear to be at increased risk for HPV and related cervical intra epithelial neoplasia.
Treatment guidelines
Genital warts are usually identified clinically. Biopsy is sometimes necessary to confirm the diagnosis of viral wart or to diagnose an associated carcinoma.
Treatment for external genital warts includes application of liquid
Nitrogen, Podophyllin 25%, TCA 90%, 5% Imiquimod (or) Podofilox gel 0.5%.80 47 HEPATITIS B & C
Hepatitis B & C is an infectious disease caused by the hepatitis B & C virus (HBV) that affects the liver.81 It can cause both acute and chronic infections. Many people have no symptoms during the initial infection. It is 50 to
100 times more infectious than human immunodeficiency virus (HIV). Possible forms of transmission include sexual contact, blood transfusions and transfusion with other human blood products, re-use of contaminated needles and syringes, and vertical transmission from mother to child (MTCT) during childbirth.
Acute viral infection
Symptoms are generally mild and vague, and may include fatigue, nausea and vomiting, fever, muscle or joint pains, abdominal pain, decreased appetite and weight loss, jaundice occurs in ~25% of those infected), dark urine, and clay-coloured stools
Chronic viral infection
Chronic infection after several years may cause cirrhosis or liver cancer.
Liver cirrhosis may lead to portal hypertension, ascites (accumulation of fluid in the abdomen), easy bruising or bleeding, varices (enlarged veins, especially in the stomach and oesophagus), jaundice, and a syndrome of cognitive impairment known as hepatic encephalopathy. Ascites occurs at some stage in more than half of those who have a chronic infection.
48 Treatment guidelines
HBsAg (Hepatitis B surface antigen) can be present in acute and chronic
HBV infection. Its presence for greater than six months is suggestive of chronic infections. Anti-HCV indicates prior exposure or infection. PCR for HCV particles is the most specific test.
Alpha interferon and pegylated interferon slow the replication of the virus and stimulate immune clearance of the virus. Other effective drugs include lamivudine, adefovir, entecavir, and telbivudine.
SCABIES
Scabies is an itchy rash caused by a parasitic mite that burrows in the skin.
The human scabies mite's scientific name is Sarcoptes scabiei var. hominis.82
Scabies affects families and communities worldwide. It is most common in children, young adults and the elderly. Factors leading to the spread of scabies include Poverty and overcrowding, Institutional care (rest homes, hospitals, prisons, Refugee camps), immune deficiency or that are immune suppressed, Low rates of identification and proper treatment of the disease.
Transmission
Scabies is nearly always acquired by skin-to-skin contact with someone else with scabies.
The contact may be quite brief such as holding hands with an infested
child.
It is sometimes sexually transmitted. 49 Occasionally scabies is acquired via bedding or furnishings.
Signs and Symptoms
The characteristic symptoms of a scabies infection include intense itching and superficial burrows.83 It is almost diagnostic of the disease. It involves wrist, inner aspect of arm and forearm, axilla, nipple, umbilicus and genitals called as “CIRCLE OF HEBRA”.
Scabies and HIV
The clinical features of scabies in the HIV positive patients are often determined by the degree of immune suppression. As the immunity decreased
(CD4+cells <200/ µL) the more contagious forms of scabies called crusted scabies (Norwegian (or) hyperkeratotic) become apparent. These patients may harbour millions of scabies mites. 84
Treatment guidelines
The diagnosis of scabies is made by history and physical findings. Rarely, lesions can be scraped and mite or mite feces identified by microscopy under oil immersion.
Treatment is with Permethrin cream 5% applied overnight and
Oral ivermectin 200 mcg/kg is convenient. Rare complications include seizures.
Some experts recommend repeat treatment at 1 week.
50 VULVOVAGINAL CANDIDIASIS
Vulvovaginal candidiasis refers to vaginal and vulval symptoms caused by a yeast, most commonly Candida albicans.85 It affects 70% of women on at least one occasion over a lifetime.
Risk factors for VVC are due to increased usage of antibiotics, Oral contraceptive pills, vaginal douching, IUCDs and tight dresses.
Signs and Symptoms 86
Itching, burning and soreness in the vagina and vulva.
pain when passing urine (dysuria)
Vulval oedema and fissures.
Dense white curdy vaginal discharge
Pustules over inner and outer parts of the vulva, sometimes spreading
widely in the groin to include pubic areas, groin and thighs.
Centres for Disease Control and Prevention had classified VVC:
1. Uncomplicated
Sporadic or infrequent
Mild to moderate VVC
Likely to be candida albicans
Immunocompetent women
2. Complicated 87
Recurrent VVC
Severe VVC 51 Non candida albicans
women with uncontrolled diabetes mellitus or immunosuppression or
pregnant
Treatment guidelines
Diagnosis of VVC depends upon demonstration of pseudo hyphae from vaginal discharge in 10% KOH mount, culture and PCR. Treatment is by oral
Fluconazole
150mg stat and topical 2% Clotrimazole cream.88
TRICHOMONAS VAGINALIS
Trichomoniasis is an extremely common, sexually transmitted infection (STI) caused by the protozoan parasite, Trichomonas vaginalis.89 Females can acquire the disease from infected males or females; but males usually acquire it only from infected females. The incubation period is generally between 4 and 28 days. Trichomoniasis is a marker of high-risk sexual behaviour. Co-infection with other STIs is common, especially Chlamydia trachomatis and Neisseria gonorrhoeae. It serves as a “TROJAN HORSE”.
Signs and Symptoms
In men it can display symptoms of urethritis. 'Frothy', greenish vaginal discharge with a 'musty' malodorous smell is characteristic. Only 2% of women with the infection will have a "strawberry" cervix (colpitis macularis, an erythematous cervix with pinpoint areas of exudation) or vagina on
52 examination.90 This is due to capillary dilation as a result of the inflammatory response.
Complications of T. vaginalis in women include: preterm delivery, low birth weight, and increased mortality as well as predisposing to HIV infection, AIDS, and cervical cancer. T.vaginalis has also been reported in the urinary tract, fallopian tubes, and pelvis and can cause pneumonia, bronchitis, and oral lesions. Condoms are effective at reducing, but not wholly preventing, transmission. Trichomonas vaginalis infection in males has been found to cause asymptomatic urethritis and prostatitis.
Treatment guidelines
Diagnosis is done by demonstration of organism in wet mount of vaginal discharge, phase contrast microscope, culture, immunological and molecular methods.
According to CDC 2006 guidelines recommended treatment is
Metronidazole 2 g orally single dose or Metronidazole 500 mg twice orally for 7 days. Sex Partner should be treated and avoid sex till completion of the treatment.91
53 BALANOPOSTHITIS
Balanitis is inflammation of the glans penis. When the foreskin is also affected, it is called as balanoposthitis.92
Etiology
Irritation by environmental substances, trauma, and infection such as
bacterial, viral, and fungal. Some of these infections are sexually
transmitted diseases.93
It is less among people who are circumcised as in many cases the prepuce
contributes to the disease. Both not enough cleaning and too much
cleaning can cause complications. Diabetes can make balanoposthitis
more likely, especially if the blood sugar is poorly controlled.
Signs and Symptoms
First signs – small red erosions over glans
Redness of the prepuce.
Erythema of the penis.
Other rashes on the head of the penis
Foul smelling sub preputial discharge
Painful prepuce and penis.
Treatment guidelines
To determine the factors contributing to balanoposthitis, a swab may be taken for bacterial and yeast culture. Urethral cultures may be necessary and occasionally, serological tests for syphilis and diabetes. In persistent cases, 54 a skin biopsy is appropriate to determine whether there is an underlying skin disease or carcinoma.
Treatment modalities consist of Astringent compresses using dilute vinegar
(1% acetic acid ), Burrow's solution (aqueous solution of aluminium acetate)
or potassium permanganate, Topical antifungal medication, Topical antiseptic
or antibiotic, Mild topical steroid. Depending on culture, an oral antifungal
and/or an oral antibiotic may be prescribed. In refractory
cases, circumcision may be necessary to prevent recurrence.
HUMAN IMMUNO DEFICIENCY VIRUS (HIV)
HIV is the etiological agent of AIDS which belongs to the lentivirus subgroup of family retroviridae. HIV is a RNA virus, a cytopathic virus. 2 major types are HIV1 and HIV 2. There are three groups of HIV1 group "M" (major), group "O" (outlier) and group "N. The M group consists of eight subtypes A, B,
C, D, F, G, H and J and as well as four major circulating recombinant forms.
Host factors
The cell surface receptor for HIV-1 is CD4 differentiation antigen. CD4 is expressed on T helper lymphocytes and less on Dendritic cell, Macrophages and microglial cells. Another receptor called "galactosyl ceramide" can also serve as a receptor for HIV in glial and neuroblastoma cell lines. The CC- Chemokine receptor - 5 (CCR-5) is considered as main coreceptor used by macrophage - trophic HIV -1 strains. The role of CCR-2 is not well-known.
55 During the early stage, virus propagates mostly in peripheral blood mononuclear cells. HIV infection usually elicits strong cell mediated immune response (CD8 + Cytotoxic T-cells) which helps to clear the high viral load but fail to eradicate HIV infection. During asymptomatic period, virus is active in lymphoid tissue. In untreated patients after a variable period, CD4 T cell count falls below a serious level and patient develops highly susceptible to opportunistic diseases.
The main endogenous factors that control HIV expression are cytokines and exogenous factors are other microbes with effects on HIV replication.
Coinfections upregulate HIV expression and hasten the progression. The virus during early, asymptomatic phase are non syncytium inducing variants and during late stages syncytium inducing variants.
Transmission of HIV
1.Sexual transmission.
In India the epidemic spreads mainly through sexual route. According to phylogenetic analysis most of Indian HIV-1 strains belong to sub type "C".
Sexual transmission can occur following vaginal and anal intercourse and also through oral sex.80 Male to female transmission is twice as effective as female to male transmission.
2.Transmission through pregnancy and breast feeding.
HIV infection to the foetus / new born may occur during Intrauterine, peripartum and postpartum periods. 50% - 70% of transmission occurs at time of 56 delivery with 30% - 50% in utero. The risk of postpartum infection from breast feeding is estimated to be approximately 15% - 30%.
3.Blood - borne Transmission.
The connection between the transfusion of blood products and AIDS was first discovered in 1982. Donor screening and HIV testing of donors can prevent
HIV transmission from blood and blood products. HIV infected injecting drug users may transmit HIV by syringe (or) needle sharing.
4.Occupational Exposure.
Health care workers are at risk through a percutaneous injury by needles or other sharp instruments. The risk is found to be approximately 0.3%.
5.Organ and Tissue Donation
HIV transmission can occur following the transplantation of human organs
(or) following bone marrow or bone chip transplantation from infected donors.
6.Household transmission, casual contact and insect factors.
There is considerable epidemiological data available that HIV transmission not occurs through hugging (or) kissing, sharing clothes or eating and drinking utensils. There is also no evidence that insects can act as vectors for transmission.
Clinical staging of HIV disease
1.Acute seroconversion syndrome.
It is the complex symptom that is experienced in 80-90% of patients but not frequently registered. The time of onset is 2-4 weeks from exposure. This presents as influenza - like illness (or) as infectious mononucleosis like illness. 57 2.Early HIV Disease
Most of the patients are asymptomatic with CD4 cell count greater than
500 cells / mm3 Generalised lymphadenopathy is the common manifestation.
Dermatologic symptoms like seborrheic dermatitis, Eosinophilic folliculitis etc are common.
3.Intermediate Stage
It Also called as symptomatic HIV infection parallels to category B, CDC clinical classification with CD4 count between 200-500 cells / mm3 AIDS state
(or) late stage
This stage in characterized by opportunistic infections and malignancies. It corresponds to CDC category C classification with CD4 cell count 50-200 cells / mm3.
4.Advanced HIV disease
In this stage CD4 count less than 50 cells / mm3 with infections like
Mycobacterium avium complex, cytomegalovirus retinitis, disseminated fungal infections, AIDS dementia complex.
58 AIM & OBJECTIVES:
1. To assess and provide clinical and epidemiological data of STIs
among high risk groups attending STI OPD.
2. To study the Age wise distribution of STIs in high risk groups.
3. To study the sexual behaviour pattern and mode of sex among high
risk groups.
4. To study the prevalence of HIV infection in high risk groups.
59 MATERIALS AND METHODS
STUDY DESIGN: Cross sectional observational study
STUDY AREA: Sexually transmitted infections (STI) OPD in Tirunelveli medical college.
STUDY PERIOD: 18 months (January 2018 – June 2019)
SAMPLE SIZE: The study population included were patients attending our
OPD with history of high-risk sexual behavior. They are registered during the period from 1st January 2018 to 30th June 2019 in STI OPD in Tirunelveli medical college. During the study period, a total of 460 patients were registered and observed.
STUDY SUBJECT: Men who have sex with men, female sex workers and transgender attending sexually transmitted infections OPD.
INCLUSION CRITERIA:
1. MSM
2. Female sex workers
3. Transgender
4. Multiple sexual partners
5. Drivers, Housekeeping, Migrants.
Methodology
The study patients were questioned regarding their age, occupation, marital
status, presenting complaints, sexual history and their condom use. All the
patients were counselled on STD/ HIV, genital hygiene, sexual practices, 60 regular treatment and follow up. They were given pre and post-test
counselling. All the patients underwent a complete physical examination and
genital examination. All these patients were clinically analysed for the genital
manifestations and supported by laboratory diagnosis. Serological tests for
syphilis including blood RPR, TPHA, HIV, HBsAg and Anti HCV antibodies
were done. In the case of genital ulcers, the following tests were done.
1. Dark field microscopic examination for Treponema pallidum. 2. Gram’s stain for Chancroid and Candida. 3. Tissue smear and Leishman stain for Klebsiella granulomatis. 4. Tzanck test for Multinucleated giant cells. In the case of genital discharge, the following tests were done. 1. Wet film for Trichomonas vaginalis 2. 10% potassium hydroxide preparation for Candida albicans 3. Gram’s stain to identify Neisseria gonorrhoeae, clue cells and Candida hyphae. In addition, the examination of urine, culture of Neisseria gonorrhoea from
specimens of urethral discharge were done. Discharge from ulcers were
subjected to culture and sensitivity if necessary.
Routine baseline laboratory investigations including complete blood count, urine for albumin, sugar deposits, USG abdomen were done. Liver function test,
Renal function test, Random blood sugar, chest x-ray, ECG, sputum smear for
AFB, blood and urine culture sensitivity were also done if mandatory. Patients were offered standard treatment according to clinical condition and prophylaxis for opportunistic infections. Epidose were given to their known contacts.
61 RESULTS
STATISTICS AMONG HIGH RISK GROUPS These statistics comprises of 460 high risk individuals attended STI OPD during study period of 18 months (January 2018 – June 2019).
TABLE 1: ANALYSIS OF AGE GROUP AMONG HIGH RISK GROUPS
Age group Frequency Percent 10-19 3 0.7 20-39 295 64.1 40-64 158 34.3 >65 4 0.9 Total 460 100.0
AGE DISTRIBUTION
295
300 250 158 200 150 100 3 4 50 0 10-19 20-39 40-64 >65
Out of 460 high risk group patients, 295 patients belong to the age group of 20-
39 years followed by 158 patients belongs to 40-64 years of age. Only 3 and 4 patients were in the age group of 10-19 and >65 years respectively.
62 TABLE 2: ANALYSIS OF PATIENT’S GENDER ATTENDING OPD
Gender Frequency Percent Male 351 76.3 Female 69 15.0 Transgender 40 8.7 Total 460 100.0
40
69 Male Female 351 Transgender
In the study, 351(76.3%) were males, 69(15%) were females and 40(8.7%) were transgenders. Among 460 high risk group cases, males were the predominant sex.
63 TABLE 3: LIST OCCUPATION STATUS
Occupation Frequency Percent FEMALE SEX WORKER 28 6.1 COOLIE 2 0.4 DRIVER 67 14.6 HOUSEKEEPING 56 12.2 MIGRANTS 33 7.2 OTHERS 263 57.2 STUDENT 11 2.4 Total 460 100.0
In the study, high risk occupational groups were truck drivers (14.6%), housekeepers (12.2%), migrants (7.2%) and female sex workers (6.1%). 57.2% of patients had various other occupation which were not considered as high-risk occupation.
TABLE 4: MARITAL STATUS OF HIGH-RISK GROUPS
Marital Status Frequency Percent Married 366 79.6
Unmarried 93 20.2
Widower 1 0.2
Total 460 100.0
Among 460 patients, 79.6% were married, 20.2% were unmarried and 0.2% were widower.
64 TABLE 5: ANALYSIS OF SEXUAL BEHAVIOUR PROFILE
Sexual Behaviour Frequency Percent
EMC/PMC 263 57.2
MSM 197 42.8
Total 460 100.0
43% 57% EMC/PMC MSM
Regarding sexual behaviour, out of 460 were high risk patients 263(57.2%) had extra and pre-marital heterosexual contact and 197(43%) were MSM. This implies heterosexual contact were at increased risk than homosexuals.
65 TABLE 6: LIST OF CONTACT PERSON
Status of contact person Frequency Percent Known male 108 23.5 Known female 48 10.4 Unknown male 139 30.2 Unknown female 165 35.9 Total 460 100.0
Regarding status of partner, 66% had recent exposure with unknown partners and 44% with known partners. This signifies increased risk of transmission of STI’s among unknown partners.
66 TABLE 7: MODE OF SEX AMONG HIGH RISK GROUPS
Age group Total Percent 10-19 20-39 40-64 >65 Mode of Sex Count Count Count Count 258 56.1 Vaginal route 1 181 76 0 173 37.6 Anoreceptive 2 101 66 4 130 28.3 Anoinsertive 2 80 44 4 193 42.0 Ororeceptive 2 109 78 4 158 34.3 Oroinsertive 2 93 59 4
200 181 180 160 140 Age group 10-19 120 109 101 Age group 20-39 100 93 76 80 78 Age group 40-64 80 66 59 Age group >65 60 44 40 20 1 0 2 4 2 4 2 4 2 4 0
In the study, predominant route of intercourse was vaginal (56.1%) followed by ororeceptive (42%), anoreceptive (37.6%), oro-insertive (34.3%) and anoinsertive (28.3%)
67 TABLE 8: CONDOM USAGE AMONG HIGHRISK GROUPS
Condom use Frequency Percent Protected 32 7.0 Unprotected 428 93.0 Total 460 100.0
32
PROTECTED UNPROTECTED
428
In this study, consistent condom usage is present in 7% of high-risk group.
93% patients had never used condoms. This is the reason for increased STI transmission among high-risk group people which in turn increase the burden of
STI in the community.
68 TABLE 9: STATUS OF CIRCUMCISION & CASTRATION
Circumcision Frequency Percent Circumcised 2 0.4 Uncircumcised 374 81.3 None 67 14.6 Castrated 17 3.7 Total 460 100.0
2 17 67 CIRCUMCISED UNCIRCUMCISED NONE 374 CASTRATED
In the study, 81.3% were uncircumcised and only 0.4% were circumcised.
Among 40 transgenders, 17 (42%) were castrated and remaining 23 (58%) were not castrated.
69 TABLE 10: TOTAL STI’S DIAGNOSED AMONG HIGH RISK GROUPS
Diagnosis Frequency Percent Nil 272 59.1 STI 188 40.9 Total 460 100.0
Among 460 patients, 188 (40.9%) were diagnosed to have STI and 272
(59.1%) were devoid of STI. All these 272 high risk group cases had routine STI screening for early diagnosis.
70 TABLE 11: LIST OF INFECTIONS DIAGNOSED BY CLINICAL
EXAMINATION AND INVESTIGATIONS IN TOTAL HIGH-RISK
GROUPS
Diagnosis group Frequency Percent Nil 272 59.1 HG-HERPES GENITALIS 39 8.5 GON-GONORRHOEA 4 .9 MC-MOLLUSCUM CONTAGIOSUM 13 2.8 WART 25 5.4 VVC-VULVO VAGINAL CANDIDISIS 21 4.6 SCABIES 6 1.3 BAL-BALANOPOSTHITIS 43 9.3 SY 1-PRIMARY SYPHILIS 5 1.1 SY 2-SECONDARY SYPHILIS 6 1.3 ELS-EARLY LATENT SYPHILIS 16 3.5 LLS-LATE LATENT SYPHILIS 7 1.5 NGU-NON GONOCOCCAL URETHRITIS 2 .4 HL-HERPES LABIALIS 1 .2 Total 460 100.0
The most common STI’s among 188 cases in the study were balanoposthitis
(9.3%) followed by herpes genitalis (8.5%), genital warts (5.4%), VVC (4.6%), early latent syphilis (3.5%) and molluscum contagiosum (2.8%).
71 TABLE 12: ORAL MUCOSA EXAMINATION
ORAL MUCOSA Frequency Percent NORMAL 423 92 ORAL CANDIDIASIS 35 7.6 ORAL HAIRY LEUKOPLAKIA 1 .2 HERPES LABIALIS 1 .2 Total 460 100.0
In the study, oral candidiasis was seen in 7.6% of patients, oral hairy leukoplakia and herpes genitalis was seen in 0.2% each and normal in 92%.
TABLE 13: STATUS OF HIV, HBV & HCV INFECTIONS IN HIGH RISK GROUPS
HIV HBV HCV Nonreactive 359 457 459 Reactive 101 3 1 Total 460 460 460
Among 460 patients, 101 cases were HIV reactive, 3 cases were HBsAg positive and 1 case was HCV positive.
72 TABLE 14: RPR & TPHA STATUS
POSITIVE NEGATIVE
RPR 34 426
TPHA 34 426
Among 460 high risk group patients, 34 were RPR and TPHA positive implying 34 cases of syphilis. This indicates increased prevalence of syphilis still exists in our country.
TABLE 15: STATUS OF DIABETES MELLITUS
frequency Percent
Absent 440 95.7
Present 20 4.3
Total 460 100
Prevalence of diabetes mellitus among 460 high-risk group patients were
20(4.3%) which is of decreased significance. Non-diabetics in the study were
95.7%.
73 STATISTICS AMONG HIGH RISK GROUP WITH STI’S These statistics comprises of 188 STI cases among 460 high risk individuals in the study.
TABLE 16: DISTRIBUTION OFAGE GROUP AMONG DISEASED
Age group Frequency Percent 20-39 107 56.9 40-64 80 42.6 >65 1 .5 Total 188 100.0
120 107 100 80 80 60
FREQUENCY 40 20 1 0 20-39 40-64 >65 AGE GROUP
Among 188 STI cases in the study, the prevalence of STI’s are more common between 20-39 years of age (56.9%) followed by 40-64 years of age
(42.6%).
74 TABLE 17: ANALYSIS OF GENDER PROFILE
Gender Frequency Percent Male 142 75.5 Female 43 22.9 Transgender 3 1.6 Total 188 100.0
3 43 Male Female Transgender 142
Among 188 STI cases, 142(75.5%) were males followed by 43(22.9%) females and 3(1.6%) transgenders.
75 TABLE 18: LIST OF OCCUPATION STATUS AMONG STI’S
Occupation Frequency Percent Female sex worker 26 13.8 Coolie 2 1.1 Driver 27 14.4 Housekeeping 24 12.8 Migrants 11 5.9 Others 88 46.8 Student 10 5.3 Total 188 100.0
Among 188 STI cases, predominant high-risk group of occupation was drivers (14.4%), female sex workers (13.8%) and housekeepers (12.8%).
TABLE 19: MARITAL STATUS
Marital status Frequency Percent Married 140 74.5 Unmarried 47 25.0 Widower 1 .5 Total 188 100.0
In the group of 188 STI’s, 140 (74.5%) were married, 47(25%) were unmarried and 1(0.5%) was a widower.
76 TABLE 20: ANALYSIS OF SEXUAL BEHAVIOUR
Sexual behaviour Frequency Percent EMC/PMC 144 76.6 MSM 44 23.4 Total 188 100.0
44
EMC/PMC MSM 144
P<0.0001 signifies high association between sexual behaviour and prevalence of STI’s in the study. Predominant high-risk sexual behavior was seen in EMC/PMC 144(76.6%) followed by 44(23.4%).
77 TABLE 21: ANALYSIS OF PERIOD OF LAST CONTACT
Last contact Frequency Percent <2WEEK 38 20.2 2WEEEK TO 57 30.3 1MONTH 1MONTH TO 1 YEAR 59 31.4 >1YEAR 34 18.1 Total 188 100.0
Diagnosis group Last contact <2 weeks 2 weeks to 1 month to 1year Total 1 month 1 year
HG-HERPES 11 14 9 5 39 GENITALIS GON-GONORRHOEA 1 1 2 0 4 MC-MOLLUSCUM 1 5 6 1 13 CONTAGIOSUM WART 2 8 12 3 25 VVC-VULVO 8 8 4 1 21 VAGINAL CANDIDISIS SCABIES 2 1 2 1 6 BAL- 9 13 6 15 43 BALANOPOSTHITIS SY 1-PRIMARY 2 2 1 0 5 SYPHILIS SY 2-SECONDARY 1 2 3 0 6 SYPHILIS ELS-EARLY LATENT 1 0 13 2 16 SYPHILIS LLS-LATE LATENT 0 1 1 5 7 SYPHILIS NGU-NON- 0 2 0 0 2 GONOCOCCAL URETHRITIS HL-HERPES 0 0 0 1 1 LABIALIS Total 38 57 59 34 188
78 TABLE 22: LIST OF CONTACT PERSON
Contact person Frequency Percent Known male 43 22.9 Known female 22 11.7 Unknown male 43 22.9 Unknown 80 42.6 female Total 188 100.0
Among 188 cases of STI’s, the prevalence of STI’s were more common among unknown partners (65.5%) than known partners (34.5%).
79 TABLE 23: ANALYSIS OF MODE OF SEX
Mode of Age group Sex 10-19 20-39 40-64 >65 Coun Coun Coun Coun TOTA PERCEN P t t t t L T VALU E Vaginal 0 54 33 0 route 87 46.3% Anoreceptiv 0 45 36 1 e 82 43.6% Anoinsertiv 0 32 24 1 e 57 30.3% Ororeceptiv 0 52 45 1 e 98 52.1% Oroinsertive 0 43 33 1 0.008 77 41.0%
60 54 52 50 45 45 43 40 36 33 32 33 30 24 Age group 10-19 20 Age group 20-39
10 Age group 40-64 1 1 1 1 0 0 0 0 0 0 Age group >65 0
P value for all routes is < 0.05 showing significance between mode of sex and prevalence of STIs. The increased risk of STI’s was through ororeceptive and vaginal routes.
80 TABLE 24: CONDOM USAGE AMONG INFECTED PERSONS
Condom use Frequency Percent Protected 14 7.4 Unprotected 174 92.6
Total 188 100.0
14
PROTECTED UNPROTECTED
174
In the study of 188 STI cases, p value was >0.05 signifying no association between condom protection and prevalence of STI’s.
81 TABLE 25: STATUS OF CIRCUMCISION / CASTRATION
Circumcision Frequency Percent
Circumcised 2 1.1 Uncircumcised 142 75.5 None 41 21.8 Castrated 3 1.6 Total 188 100.0
142 160 140 120 100 80 41 60 40 2 3 20 0
P value is 0.0001, which shows significance between uncircumcised and prevalence of STIs which proves increased risk of STI’s among uncircumcised men.
82 TABLE 26: CLINICAL EXAMINATION FINDINGS OF DISEASED
GENITAL ULCER / FISSURE
GENITAL ULCER/FISSURE Frequency Percent Painless indurated ulcer 6 3.2 Painful ulcer 38 20.2 Erosions/fissures 43 22.9 Scar 6 3.2 None 95 50.5 Total 188 100.0
GENITAL DISCHARGE
Genital discharge Frequency Percent Urethral discharge 6 3.2
Curdy white discharge 21 11.2
Homogenous paste discharge 1 0.5
Sub preputial discharge 43 22.9
None 117 62.2 Total 188 100.0
83 GENITAL PAPULES
Papules Frequency Percent verrucous papules 26 13.8 Umblicated papules 13 6.9 Excoriated papules 6 3.2 None 143 76.1 Total 188 100.0
LYMPHNODES Lymph nodes Frequency Percent Present 51 27.1 Absent 137 72.9 Total 188 100.0
TABLE 27: STATUS OF HIV, HBV, HCV & DIABETES MELLITUS STATUS Frequency Percent HIV 31 16.4 HBsAg 0 0 HCV 0 0 DM 20 10.6
P value is 0.019 which shows significance between HIV and prevalence of STI’s. There is no association between HBsAg, HCV and prevalence of
STI’s.
84 TABLE 28: DISTRIBUTION OF STI’S IN HIV POSITIVE GROUP
Diagnosis group Frequency HG-HERPES GENITALIS 5 GON-GONORRHOEA 1 MC-MOLLUSCUM CONTAGIOSUM 1 WART 8 SCABIES 2 BAL-BALANOPOSTHITIS 8 SY 1-PRIMARY SYPHILIS 1 ELS-EARLY LATENT SYPHILIS 2 LLS-LATE LATENT SYPHILIS 2 NGU-NON-GONOCOCCAL URETHRITIS 1 HL-HERPES LABIALIS 1 TOTAL 31
Among 31 HIV infected STI cases, the most common diagnosis was genital warts and balanoposthitis followed by herpes genitalis, syphilis and scabies.
Other STI’s like gonorrhea, molluscum contagiosum, non-gonococcal urethritis and herpes labialis are seen in one patient each only.
85 TABLE 29: LIST OF INFECTIONS DIAGNOSED BY CLINICAL EXAMINATION AND INVESTIGATIONS AMONG DISEASED. Diagnosis group Frequency Percent HG-HERPES GENITALIS 39 20.7 GON-GONORRHOEA 4 2.1 MC-MOLLUSCUM CONTAGIOSUM 13 7 WART 25 13.3 VVC-VULVO VAGINAL CANDIDISIS 21 11.2 SCABIES 6 3.2 BAL-BALANOPOSTHITIS 43 22.9 SY 1-PRIMARY SYPHILIS 5 2.7 SY 2-SECONDARY SYPHILIS 6 3.2 ELS-EARLY LATENT SYPHILIS 16 8.5 LLS-LATE LATENT SYPHILIS 7 3.7 NGU-NON-GONOCOCCAL URETHRITIS 2 1.1 HL-HERPES LABIALIS 1 0.5 Total 188 100.0
50 43 45 39 40 35 30 25 25 21 16 20 13
TOTAL TOTAL CASES 15 7 10 4 6 5 6 5 2 1 0
The most common STI’s among 188 cases in the study were balanoposthitis
(22.9%) followed by herpes genitalis (20.7%), genital warts (13.3%), VVC
(11.2%), early latent syphilis (8.5%) and molluscum contagiosum (7%).
86 DISCUSSION
In our study 460 cases were enrolled with high risk behaviour. Among 460 cases, 188 high risk behavior cases were found to have STI’s and remaining 272 cases were not diagnosed with any of the STI and had routine screening for high risk behaviour. Most of the cases bought by NGOs were MSM and FSW.
In our study comprising 188 patients with STI’s, most common age group was between 20 – 39 years (56.9%). It is consistent with study done by Arpit C.
Prajapati et al where the most common age group was between 25-35 years.94 As in this age group , young sexually active people increasingly engage in high risk sexual behavior like unprotected anal sex, multiple sex partners, MSM and they use the internet to recruit sex partners which leads on to increased transmission of STIs. 95
Among 188 STI patients, almost two-third were males (75.5%) whereas females and transgenders were only 22.9% and 1.6% respectively. This is similar to the study done in north India by Suvirya et al wherein males were three-fourth involved.96 This shows men were most commonly indulging in high risk sexual practices.
In our study out of 188 STI acquired persons, 13.8% were female sex workers, 14.4% were drivers, 12.8% were housekeeping, migrants were 5.9%, students were 5.3% and 46.8% belong to non-high-risk occupation groups like tailors, teachers, clerks, carpenters, homemakers and farmers. This clearly shows
87 that more than half of STI acquired persons belongs to high risk occupation groups.
In this study among188 STI’s, 140 (74.5%) were married, 47(25%) were unmarried and 1(0.5%) was a widower. This shows the prevalence of STIs were more common in married individuals and this leads to risk of STI transmission to their spouse, thus increasing burden of STI in community. This is similar to the study done by Kwena et al in Lake Victoria in Kisumu, Kenya where 70% of individual were married.97
In our study the Predominant high-risk sexual behavior was seen in
EMC/PMC 144(76.6%) followed by MSM 44(23.4%). This is similar to study done in Malawi where multiple sexual partners(EMC/PMC) are at more risk.98 P
= 0.0001 signifying association within multiple sexual partners and prevalence of
STI.
In our study 50.3% had STI’s when exposed within 1month duration, 31.4% within 1 month to 1 year and 18.1% when exposed more than 1 year.
Regarding status of partner, 65.5% patients had exposure with unknown partners and 34.5% had with known partners. This implies the prevalence of STIs transmission is more in patients who had exposure with unknown partner.
In our study the commonest mode of sex was ororeceptive and vaginal route. These results were comparable with Kolkata study 99 where penovaginal is
88 the most common mode of sex. P value for all routes is < 0.05 showing significance between mode of sex and prevalence of STIs.
In our study, the prevalence of STIs are more common in the persons who did not use condom (92.6%). Our study highlights the fact that barrier usage should be encouraged strictly in young people, particularly those at high risk of developing STIs and HIV. Nayyar et al study in 2015 also emphasizes the usage of condom among high risk sexual behaviour populations.14
Among 188 STI cases 75.5% were uncircumcised followed by 1.1% who were circumcised. All the transgenders with STI were castrated. P value is
0.0001, which signifies increased risk of STI transmission among uncircumcised men. The role of circumcision in prevention of HIV/STIs is still debatable. Some studies have showed that penile foreskin offers a portal of entry for pathogens, including HIV, as it is more vulnerable to trauma during intercourse, the internal mucosa of the foreskin has less keratinization and a higher density of target cells for HIV infection moreover, the microenvironment in uncircumcised foreskin may be warm, moist offers a suitable site for the pathogens to reproduce. All these aspects support the role of circumcision in prevention of HIV/STIs. This was confirmed in Nayyar et al study in 2015 where, the prevalence of STI and HIV was found to be 14% in circumcised cases and 42.7% in uncircumcised.14
The common clinical finding of genital ulcer in our study was erosions and fissures 22.9% mostly seen in balanoposthitis followed by painful ulcer 20.2% 89 seen in herpes genitalis. Lymph nodes was present in 27.1% among 188 STI’s in our study. Various presentation of genital discharge includes urethral discharge
3.2%, curdy white discharge 11.2%, homogenous paste like discharge in 0.5% and sub preputial discharge in 22.9%. Many cases presented with verrucous papules 13.8% suggestive of anogenital wart, 6.9% umbilicated papules suggestive of genital molluscum contagiosum and excoriated papules of scabies with 3.2%.
The high prevalence of STD's in HIV positives shows the status of infectivity and predilection cofactors in HIV transmission and acquisition. This shows the importance of early diagnosis and management of STDs to control HIV transmission and acquisition.
In our study 31 persons (23 EMC/PMC & 8 MSM) with STI’s were co- infected with HIV infection. This shows large group of individuals involved in sexual practices with multiple sexual partners, early age of first sexual exposure and non-usage of condoms. In our study genital wart (8), balanoposthitis (8), herpes genitalis (5) were commonly coinfected with HIV. Among 460 total high- risk population 101 persons were infected with HIV this shows significance (P =
0.019) of HIV infection with high risk groups. So, our study highlights the importance of strengthening the surveillance, early diagnosis and joint strategies to control and manage STD's and HIV.
90 Here in our study among 460 patients 35 patients had oral candidiasis and
1 had oral hairy leukoplakia. All these patients are associated with HIV infections.
In our study we newly diagnosed 20 cases of diabetes mellitus among them
16 patients had balanoposthitis. They were referred to physician and were started on anti-diabetic drugs.
PATTERNS OF SEXUALLY TRANSMITTED DISEASE IN HIGH RISK
GROUPS
Most of STIs were seen in age group between 20-39 years (56.9%) followed by 40-60 years of age (42.6%) and majority of them had EMC/PMC
(76.6%) and MSM (23.4%) this shows the most common mode of transmission in our study India remains heterosexual only i.e. multiple sexual partners
(EMC/PMC). 40.9% of our patients with high risk behaviour had atleast one significant STI. Among 188 people men (75.5%) were most commonly indulged in high risk behaviour followed by women (22.9%) and transgenders (1.6%).
SYPHILIS
Total number of high-risk group positive for Syphilis during routine RPR testing was 34 (18.1%) which was then confirmed with Treponema Pallidum hemagglutination assay (TPHA). Of the 34 positive patients, 5(14.3%%) were diagnosed to have primary syphilis, 6 (17.6%) were diagnosed to have secondary syphilis, 16(47.1%) were early latent syphilis and 7(20.6%) were late latent syphilis. In patients with primary, secondary and early syphilis one dose inj. 91 Benzathine penicillin 2.4 million units is given and in late syphilis 3 doses of inj.
Benzathine penicillin 2.4 million units is given and advised for follow up. Patients were asked to bring partner. Among 34 syphilis patients 28 were male and 6 were female. Among them 19 patients had EMC/PMC whereas 15 had MSM sexual behaviour and 5(14.8%) patients are co-infected with HIV. This is similar to study done by sethi et al in north India where more males are infected than females.100 In study done by Prakash Narayanan 101, the prevalence of syphilis among MSMs was 6.6% which lesser when compared to our study.
HERPES GENITALIS
It is one of the most common sexually transmitted infection worldwide including India. In our study 39(20.7%) cases of herpes genitalis were found and asked to bring partner for screening. Of the 39 patients 30 were male, 8 were female and 1 transgender. Among them 32 patients had EMC/PMC whereas 7 had MSM sexual behaviour and 5(12.9%) patients are co-infected with HIV. It is the commonest ulcerative STI diagnosed among HIV positive patients according to our study. Some cases showed typical morphological features whereas HIV infected patients showed atypical presentations. They all were treated with red kit and advised to bring their partners.
GENITAL WART
In our study the prevalence is 26 (13.8%). It is the most common STI noticed in MSM in our study. out 26, we had 22(85%) penile wart, 4(15%) perianal wart which were treated with podophyllin toxin. Around 22 males and 4 92 females were affected with 16 (61.5%) EMC/PMC and 10 (38.5%) MSM. Nearly
8 (36.3%) patients were coinfected with HIV which is also highest in our study.
All patients with perianal warts gave history of being anoreceptive. HPV infection among MSM is highest in those who are coinfected with HIV. The prevalence of genital wart among MSM in our study was 38.5%, which is of increased incidence than the study done Garg et al which showed the prevalence of 26%.102
MOLLUSCUM CONTAGIOSUM
The prevalence of genital molluscum contagiosum has also raised. In present study 7% (13 cases) were positive for MC. He was treated by doing needling. Only one case was coinfected with HIV.
URETHRAL DISCHARGE
In our study, 6 (3.2%) patients presented with urethral discharge and urethritis, among them 4 were due to gonococcal urethritis and 2 were non gonococcal urethritis (NGU). We encountered a rare complication of gonococcal infection in MSM – “WATERCAN PERENIUM”. Gonococcal urethritis was diagnosed by Gram stain and culture and treated with grey kit and episodic treatment was given for partners. 1 case from each gonococcal and NGU were
HIV positive.
93 VAGINAL DISCHARGE SYNDROME
During our study period 23 high risk cases presented with vaginal discharge which include 22 vulvovaginal candidiasis (VVC) and 1 bacterial vaginosis (BV).
BALANOPOSTHITIS
In our study 43 (22.9%) were diagnosed with balanoposthitis with 35 patients had EMC/PMC and 8 had MSM. HIV coinfection was seen in 8 patients and comorbidity like diabetes mellitus was found in 16 patients. Mostly these patients presented with fissures over prepuce and sub preputial discharge. Swab was taken from the discharge for gram stain, KOH and sent for culture. Mostly candida albicans was grown in culture.
GENITAL SCABIES
In our study the prevalence was 3.2% (6 cases) all of them were male cases, who presented with the multiple itchy excoriated papules over penis and scrotum and treated with 5% permethrin cream overnight application and wash in the morning and asked to bring the partner for treatment. In a study and 4.4% 102 had genital scabies.. This may be due unhygienic practices among high risk groups and poor health seeking behavior. HIV is associated with 2 cases.
94 HEPATITIS B AND C
Infections caused by hepatitis B virus (HBV) and hepatitis C virus (HCV) show an increasing trend among high risk groups. In our study, among 460 patients 3 were diagnosed with HBV and 1 were diagnosed with HCV interestingly all four cases had MSM sexual behaviour. In another study done by
Vaux et al 103 also states that MSM sexual behaviour has significant risk factor for transmission of hepatitis infection.
95 CONCLUSION
High risk groups are the ―bridging population for transmission of STIs and
HIV.
The prevalence of STIs is seen commonly in 2nd to 4th decade of age,
hence they are main target population to be focused in order to prevent
STI/HIV.
Men are most commonly indulged in high risk sexual practice than
female so, they need to be screened regularly.
The population with EMC/PMC sexual behaviour had more STI’s than
MSM and most of them had unprotected intercourse.
Increased prevalence is seen among married high-risk groups with
unknown paid partners.
Increased prevalence of STIs are seen in high risk groups with
unprotected sex.
Most common mode of sex in high risk groups with STI’s was vaginal
route among heterosexual and ororeceptive among MSM.
Most common examination findings among high risk groups was painful
ulcer, fissure, and papules over genitals.
Viral STIs are on the rise when compared to the bacterial infections
among high risk groups. Among viral STIs HIV, Herpes genitalis and
Warts is the commonest, and among bacterial infections, Latent Syphilis
is the common infection and it shows increase in trend of syphilis among 96 high risk groups. Hence consistent screening with RPR and ELISA for
HIV is a must in high risk groups.
Among 101 HIV reactive individual 31 persons were co-infected with
other STIs.
Sex education is essential for high risk groups as earlier the age of sexual
activity.
Discourse the stigma among FSW and TGs to increase the health care
awareness among them.
Partner identification treatment needs to be initiated.
Vaccination for Hepatitis B should be advised.
Counselling for consistent use of condom should be done especially
when contact with unknown partners and during anal sex.
Promoting awareness about HIV-AIDS transmission & its prevention
may alert them to use condom properly during each sexual act.
STIs management in high risk groups requires the expert clinician to be
conversant with risk valuation, the clinical presentation, and current
diagnosis of certain diseases, and to be familiar with new medications.
Successful STI care can be achieved because many infections are easily
identified and treatable with simple single dose therapy.
The current challenges lie in effective risk reduction and enhancing
preventive care in a cost-effective way. Newer diagnostic studies will
97 offer visions into the etiology of several clinical syndromes, but the basis
of care will always rely on listening and talking to patients.
More work is required to govern how to help high risk group minimize
sexual risk, address their mental health concerns, and engage them in
disease free lives.
Regular monitoring of programs and research are necessary for further
success of prevention and control of HIV in this HRG.
98 CLINICAL PICTURES
PRIMARY SYPHILIS
CONDYLOMA LATA PAPULOSQUAMOUS LESION SECONDARY SYPHILIS – ERYTHEMATOUS ANNULAR SCALY PLAQUES
EXTRA GENITAL CHANCRE SY 2- ERYTHEMATOUS PAPULES GONOCOCCAL URETHRITIS WATERCAN PERENIUM – MULTIPLE FISTULA
GONOCOCCAL CULTURE- SMALL PIN POINT COLONIES HERPES GENITALIS
HERPES GENITALIS - MULTINUCLEATED GAINT CELLS MOLLUSCUM CONTAGIOSUM
GENITAL WARTS BALANOPOSTHITIS
VULVO VAGINAL CANDIDIASIS GRAM STAIN FOR CANDIDA- PSEUDOHYPHAE & SPORES IN GRAM +VE COCCI KOH
CHROMOGENIC AGAR FOR CANDIDA ALBICANS & NON ALBICANS SPECIES PINK – CANDIDA KRUSEI GREEN- CANDIDA ALBICANS GENITAL SCABIES
RPR - 1:4 DILUTION POSITIVE
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97. Kwena ZA, Bukusi EA, Ng’ayo MO, Buffardi AL, Nguti R, Richardson B, et al. Prevalence and risk factors for sexually transmitted infections in a high-risk occupational group: the case of fishermen along Lake Victoria in Kisumu, Kenya. Int J STD AIDS. 2010 Oct;21(10):708–13.
98. N WC, A S. Associated Risk Factors of STIs and Multiple Sexual Relationships among Youths in Malawi. PLoS ONE [Internet]. 2015 Aug 6 [cited 2019 Sep 22];10(8). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4527764/
99. Pal D, Raut DK, Das A. A study of HIV/STD infections amongst commercial sex workers in Kolkata. (India) Part-IV laboratory investigation of STD and HIV infections. J Commun Dis. 2004 Mar;36(1):12–6. 100. Sethi S, Mewara A, Hallur V, Prasad A, Sharma K, Raj A. Rising trends of syphilis in a tertiary care center in North India. Indian J Sex Transm Dis AIDS. 2015 Jul 1;36(2):140. 101. Narayanan. P.An exploration of elevated HIV and STI risk among male sex workers from India | BMC Public Health.2013 Nov 9;13:1059. 102. Garg T, Chander R, Jain A, Barara M. Sexually transmitted diseases among men who have sex with men: A retrospective analysis from Suraksha clinic in a tertiary care hospital. Indian J Sex Transm Dis AIDS. 2012;33(1):16–9.
103. Vaux S, Chevaliez S, Saboni L, Sauvage C, Sommen C, Barin F, et al. Prevalence of hepatitis C infection, screening and associated factors among men who have sex with men attending gay venues: a cross-sectional survey (PREVAGAY), France, 2015. BMC Infect Dis. 2019 Apr 11;19(1):315. PROFORMA CASE NO: 1. STI NO: OP NO. 2. DATE: 3. AGE: 4. SEX: M / F / TG 5. OCCUPATION: 6. COMPLAINTS DURATION GENITAL ULCER URETHRAL DISCHARGE ANORECTAL DISCHARGE BURNING MICTURITION
SUBPREPUCIAL DISCHARGE GENITAL PAIN SORE THROAT BUBO VESICLES ORAL ULCERS
LOWER ABDOMINAL PAIN OTHER COMPLAINTS 7. MARITAL HISTORY: 1. married /single LMC- Protected/ unprotected-
8. CONTACT HISTORY: 1. Last contact 2. known/unknown 3. Married/ unmarried 4. Protected /unprotected 5. ororeceptive/ oroinsertive/ anoreceptive/ anoinsertive
9. H/O BLOOD TRANSFUSION: 1O. H/O DRUG ABUSE: 11. ASSOCIATED MEDICAL / SURGICAL CO-MORBIDITIES:
12. GENERAL EXAMINATION: 1. Anaemia / jaundice/ cyanosis/ clubbing/ pedal edema 2. BP 3. Pulse rate 4. Respiratory rate 5. CVS- 6. RS- 7. P/A- 8. CNS- 13. LOCAL EXAMINATION: 1. Circumcised/ uncircumcised 2. Genital ulcers Site- Size- Border- Induration- Tenderness- Floor-
3. Genital discharge (i). Urethral/ anorectal- Mucopurulent- Purulent- Serous-
(ii). Vaginal discharge- Colour- Quantity- Odour- Nature- 4. lymphadenopathy 1. unilateral/bilateral 2. Tenderness 3. Consistency 4. Matted/ discrete 5. Skin surface 5. Lower abdominal tenderness- 6. Oral mucosa- 7. per rectal examination- 8. Palms and soles- 9. Scalp and hair- 10. nails- 11. Bones and joints- 12. Other cutaneous sites-
13. INVESTIGATIONS (for all patients): 1. RPR- 2. TPHA- 3. ICTC- 4. HBsAg- 5. Anti-HCV-
14. GENITAL ULCER EXAMINATION: GRAM STAIN- TZANCK SMEAR PUS CULTURE AND SENSITIVITY-
15. GENITAL DISCHARGE EXAMINATION: GRAM STAIN- KOH MOUNT- WET MOUNT-
16. HISTOPATHOLOGICAL EXAMINATION (If applicable)-
17. PROVISIONAL DIAGNOSIS: KEY TO MASTER CHART
AGE GROUP 1- 10 to 19 years 2- 20 to 39 years 3- 40 to 64 years 4- >65 years’ SEX M- Male F- Female TG- Transgender OCCUPATION MSW- Male Sex Worker FSW- Female Sex Worker C- Coolie D- Driver H- Housekeeping M-Migrants S-Students O-Others MARITAL STATUS M- Married UN- Unmarried W-Widow EMC- Extra Marital Contact PMC- Pre-Marital Contact MSM- Men having Sex with Men LAST CONTACT 1- <2 weeks 2- 2weeks to 1 month 3- 1month to 1 year 4- >1 year CONTACT PERSON 1- known male 2- known female 3- unknown male 4- unknown female PROTECTED / UNPROTECTED SEX 1- condom used 2- condom not used MODE OF SEX 1- vaginal route 2- anoreceptive 3- anoinsertive 4- ororeceptive 5-ororeceptive CIRCUMCISION 1- circumcised 2- un circumcised 3- castrated 4- none GENITAL ULCER/FISSURE 1-Painless Indurated Ulcer 2-Painful Ulcer with Polycyclic Border 3-Erosions/Fissures 4-Scar 5-None GENITAL DISCHARGE 1-Urethral Discharge 2-Curdy white Discharge 3-Homogenous Paste Discharge 4-Frothy Greenish Discharge 5-Subpreputial Discharge 6-None LYMPHNODES 1-Present 2-Absent PAPULES 1-Verrucous Papules 2-Umblicated Papules 3.Excoriated Papules 4-None ORAL MUCOSA OC- Oral Candidiasis OHL- Oral Hairy Leucoplakias O- Others N-Normal HL- Herpes Labialis DIABETES MELLITUS P- Present A- Absent RPR- Rapid Plasma Reagin test TPHA- Treponema Pallidum Hemagglutination Test HIV- Human Immunodeficiency Virus HBV- Hepatitis B Virus HCV- Hepatitis C Virus R- Reactive NR- Non-Reactive KOH 1- Pseudo Hyphae with Spores 2- Scabies Mite 3- None WET MOUNT 1- Motile Organisms 2- Clue Cells 3-None GRAM STAIN 1- Gram +Ve Cocci 2- Clue Cells 3- Gram -Ve Diplococci
4- Gram -Ve Bacilli 5- None
TZANCK SMEAR
1- Multinucleated Giant Cells 2- None DIAGNOSIS HG- Herpes Genitalis Gon- Gonorrhoea MC- Molluscum Contagiosum VVC-Vulvo Vaginal Candidiasis
BAL- Balanoposthitis SY2-Primary Syphilis
SY2- Secondary Syphilis ELS- Early Latent Syphilis
LLS- Late Latent Syphilis NGU- Non-Gonococcal Urethritis
HL- Herpes Labialis.
S.NO 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 7 6 5 4 3 2 1 9 8 MAHALINGAM PONRAM GURUNATHAN MUTHAIAH KARTHI SENTHUR MARIAPPAN MUTHU DEV ARCHANA VASANTHAKUMAR SURESH MARIE SINDARAPANDI MANIKANDAN GANESAN ESWARAN HEPSI SUNDARAM GANAPATHY SIVA POOSAIPANDI MAHARAJA MUTHUKUMAR 40 XAVIER ANTONY BHUVAN ARUMUGAM
NAME
AGE 46 33 60 31 30 23 50 34 27 26 30 38 40 28 33 32 39 32 38 59 23 26 21 45
3 2 3 2 2 2 3 2 2 2 2 2 3 2 2 2 2 2 2 3 2 2 3 2 3 AGE F M M M M F M M M M M M M M M M M M M M M F M M M SEX H H O H D O D FSW O D D FSW D O H H FSW O D H S D O O O
OCCUPATION M UM M M UN UN M M M UN M M M UN UN UN UN UN M M UN M M M M MARITAL STATUS
1 3 1 1 3 3 3 1 3 2 3 1 3 3 3 3 2 3 3 1 3 1 3 3 1 EMC/PMC/MSM
4 4 2 2 2 1 4 2 2 3 1 3 2 2 2 1 2 3 1 2 3 3 3 1 2 LAST CONTACT
4 3 2 3 1 1 1 3 3 4 1 2 1 1 1 1 1 1 1 4 3 4 3 3 2 CONTACT PERSON PROTECTED OR 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 2 2 2 2 2 2 2 2
2,3,4,5 2,3 2,3,4,5 4,5 2,3,4,5 4,5 2,3,4,5 2,3,4,5 4,5 4,5 2,3,45 2,3,4,5 2,3,4,5 2,3,4,5, 2,3,4,5 UNPROTECTED
MODE OF SEX 1 1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 3 2 2 2 3 2 2 2 2 3 2 2 2 2 2 2 2 1 CIRCUMCISION
2 3 2 2 5 5 5 2 5 5 5 5 5 5 5 5 5 5 2 5 1 5 5 5 5 GENITAL ULCER/FISSURE
6 5 6 6 6 6 6 6 6 6 6 2 6 6 6 6 6 6 6 1 6 1 6 6 1 GENITAL DISCHARGE
1 2 1 1 2 2 2 1 2 2 2 2 2 2 2 2 2 1 1 2 1 1 2 2 1 LYMPHNODES
4 4 4 4 4 4 4 1 1 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 PAPULES N N N N N N N N N N N N N N N N N N N N N N N N N ORAL MUCOSA A A A A A A A A A A A A A A A A A A A A A A A A A DIABETES MELLITUS NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR R NR NR R NR R R NR RPR N N N N N N N N N N N N N N N N N P N N P N P P N TPHA NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR R NR R NR R NR NR NR ICTC NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR HBsAG NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR ANTI HCV
3 1 3 3 3 3 3 3 3 3 3 1 3 3 3 3 3 3 3 3 3 3 3 3 3 KOH
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 WET MOUNT
5 1 5 5 5 5 5 5 5 5 5 1 5 5 5 5 5 5 5 5 5 3 5 5 3 GRAM STAIN
1 2 1 1 2 2 2 1 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2 2 2 TZANCK SMEAR HG BAL HG HG NIL NIL NIL HG WART NIL NIL VVC NIL NIL NIL NIL NIL ELS HG NGU 1 SY GON ELS ELS GON
DIAGNOSIS S.NO 50 49 48 47 46 45 44 43 42 41 40 39 38 37 36 35 34 33 32 31 30 29 28 27 26 PERUMAL SIVASUBRAMANIAN MADASAMY SANKARAN AMUTHA POOVARASAN RAVI MAHADEVI ATHIMUTHU KARTHIKETAN BALAKRISHNAN MUTHAIAH BALASUBRAMANIAN DEVDASAN STEFY MANIKAM FRANCIS MURUGAN VINOTH JEEVA SURESH JANAKIRAM SUBRAMANI BABU RAJA
NAME
AGE 42 28 34 41 38 21 36 24 49 43 32 48 39 44 28 57 32 26 29 34 40 37 47 30 30
3 2 2 3 2 2 2 2 3 3 3 3 3 3 2 3 2 2 2 2 3 2 3 2 2 AGE M M M M M M M M M M M M M M M M M M F M M F M M M SEX O O O H O H D FSW O O D D O D O D O D O O O O H O O
OCCUPATION M UM M UM W UM M UM M M M M M M M M M M UM M M M M UN UN MARITAL STATUS
1 3 3 3 1 3 1 2 1 3 1 1 1 1 3 1 1 1 3 3 1 1 1 3 3 EMC/PMC/MSM
4 2 3 3 2 2 3 3 3 2 4 4 3 4 1 3 4 3 3 1 1 1 2 3 3 LAST CONTACT
2 1 1 3 3 3 4 3 4 1 2 2 4 4 3 4 4 2 1 1 2 4 4 3 1 CONTACT PERSON PROTECTED OR 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
2,4,5 4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 4,5 2,3,4,5 2,3,4,5 UNPROTECTED
MODE OF SEX 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 CIRCUMCISION
5 5 5 5 2 2 5 5 5 3 5 5 5 5 5 3 2 4 5 5 2 2 5 5 5 GENITAL ULCER/FISSURE
6 6 6 6 6 6 6 6 6 5 6 6 6 6 6 5 6 6 6 6 6 6 6 6 6 GENITAL DISCHARGE
2 2 2 2 1 1 2 2 2 2 2 2 2 2 2 2 2 1 2 2 1 1 2 1 2 LYMPHNODES
4 4 4 4 4 4 3 4 3 4 4 4 4 4 4 4 4 4 4 4 4 4 1 4 1 PAPULES N N N N OC N N N N OC N N OC OC N OC N N N N N N N N N ORAL MUCOSA A A A A A A A A A A A A A A A A A A A A A A A A A DIABETES MELLITUS R NR NR NR NR NR NR R NR NR R NR NR NR NR NR NR R R NR NR NR NR R NR RPR P N N N N N N P N N P N N N N N N P P N N N N P N TPHA R NR R R R NR NR NR NR NR NR R R R NR R NR NR NR NR NR NR R NR NR ICTC NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR HBsAG NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR ANTI HCV
3 3 3 3 3 3 3 3 3 1 3 3 3 3 3 1 3 3 3 3 3 3 3 3 3 KOH
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 WET MOUNT
5 5 5 5 5 5 5 5 5 1 5 5 5 5 5 1 5 5 5 5 5 5 5 5 5 GRAM STAIN
2 2 2 2 1 1 2 2 2 2 2 2 2 2 2 2 1 2 2 2 1 1 2 2 2 TZANCK SMEAR LLS NIL NIL NIL HG HG SCABIES ELS SCABIES BAL LLS NIL NIL NIL NIL BAL HG ELS ELS NIL HG HG WART 2 SY WART
DIAGNOSIS S.NO 75 74 73 72 71 70 69 68 67 66 65 64 63 62 61 60 59 58 57 56 55 54 53 52 51 KUMAR THANGAMARIAMMAL DILIP SARKAR SENTHILKUMAR RAMBA SENTHILKUMAR GANAPATHY MARIAMMAL CHANDRAN MADASAMHY VALIAMAL KARUPAIAH MUTHUKRISHNAN AYYADURAI RANI SUBRAMANIAN SUNDARAJAN LAKSHMANARAJ ESAKKIMUTHU PAULDURAI PARAMESWARAN MAHARAJAN KARUPUSAMY VANDIMALAYAN MURALI
NAME
AGE 39 36 30 35 41 32 53 35 31 32 50 65 58 45 33 37 35 35 27 27 48 21 58 28 28
2 2 2 2 3 2 3 2 2 2 3 3 3 3 2 2 2 2 2 2 3 2 3 2 2 AGE M M M F M M M M M M M M M M M F M M TG M M F M M F SEX D FSW O O O D D FSW D O FSW O O O FSW H O O O O O S O O D
OCCUPATION M M UM M UM M M M M M M M M M M M M M UM UM M UM M M M MARITAL STATUS
1 1 3 3 3 1 1 1 1 3 1 1 1 1 1 1 3 1 1 1 1 2 1 1 1 EMC/PMC/MSM
3 3 2 2 4 4 4 2 4 1 2 4 3 4 3 4 4 1 2 4 4 3 4 3 2 LAST CONTACT
4 3 1 1 3 2 4 3 4 2 3 2 4 4 3 4 2 2 4 4 4 2 2 4 2 CONTACT PERSON PROTECTED OR 2 2 2 1 2 2 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2 2 2 2 2
2,3,4,5 4,5 2,4 2,3,4,5 UNPROTECTED
MODE OF SEX 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
2 2 2 2 4 2 2 2 2 2 3 2 2 2 3 2 2 2 2 2 2 2 2 2 3 CIRCUMCISION
5 5 5 5 5 3 3 2 5 5 5 2 5 5 5 5 5 5 5 5 5 5 3 5 5 GENITAL ULCER/FISSURE
6 6 6 6 6 5 5 6 6 6 2 6 6 6 3 6 6 6 6 6 6 6 5 6 6 GENITAL DISCHARGE
2 2 2 2 2 2 2 1 2 2 2 1 2 2 2 2 2 2 2 2 2 2 2 2 2 LYMPHNODES
4 2 4 4 4 4 4 4 4 1 4 4 1 1 4 4 1 4 2 3 4 2 4 1 1 PAPULES N N N N HL N N N OHL N N N N OC N N N OC N N OC N N N N ORAL MUCOSA A A A A P A P A A A A A A A A A A A A A A A A A A DIABETES MELLITUS NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR RPR N N N N N N N N N N N N N N N N N N N N N N N N N TPHA NR R NR NR NR NR NR NR R R NR NR NR R NR R NR R NR NR R NR R NR NR ICTC NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR HBsAG NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR ANTI HCV
3 3 3 3 3 1 1 3 3 3 1 3 3 3 3 3 3 3 3 3 3 3 1 3 3 KOH
3 3 3 3 2 3 3 3 3 3 3 3 3 3 2 3 3 3 3 3 3 3 3 3 3 WET MOUNT
5 5 5 5 5 1 1 5 5 5 1 5 5 5 2 5 5 5 5 5 5 5 1 5 5 GRAM STAIN
2 2 2 2 2 2 2 1 2 2 2 1 2 2 2 2 2 2 2 2 2 2 2 2 2 TZANCK SMEAR NIL MC NIL NIL HL BAL BAL HG NIL WART VVC HG WART WART BV NIL WART NIL MC SCABIES NIL MC BAL WART WART
DIAGNOSIS 100 S.NO 99 98 97 96 95 94 93 92 91 90 89 88 87 86 85 84 83 82 81 80 79 78 77 76 AROKIYASAMY KUMARAVINUSH JOSEPH RAMAR KANAMAL ESAKKI MUTHU KASI MOHAMED PETCHIAMMAL MANIKANDAN PONNUSAMI PARAMESWARI MUTHAIAH RAMAN SIVA SUBRAMANIAN SUNDARAMAHALINGAM SARAVANAN JEEVA ULAGANATHAN MUTHALAISAMI SUNDARAJAN RAJA VELUSAMY MADASAMY
NAME
AGE 50 35 25 45 42 55 34 20 43 43 59 27 44 45 38 40 36 39 34 63 24 37 30 75 43
3 2 2 3 3 3 3 2 3 3 3 2 3 3 2 3 2 2 2 3 2 2 2 4 3 AGE F M M M M M M M M M M M M M M M M M F M F M F M M SEX O C M O FSW D FSW M FSW D O FSW O D O C D O O O S D H O D
OCCUPATION M M UM M M M M UM M M M M M M M M M M M M UM M M M M MARITAL STATUS
1 1 2 1 1 1 1 2 1 1 1 1 3 3 3 3 1 1 3 1 1 1 1 1 1 EMC/PMC/MSM
1 1 2 1 2 1 2 3 3 1 4 3 3 3 1 1 1 2 3 2 2 4 2 4 3 LAST CONTACT
4 4 4 4 3 4 3 4 1 4 4 3 1 1 3 1 4 4 1 2 4 4 4 4 4 CONTACT PERSON PROTECTED OR 2 2 2 2 1 1 1 2 2 2 1 1 2 2 2 2 2 2 2 1 2 2 2 2 1
2,3,4,5 2,3,4,5 2,5 2,3,4,5 2,3,4,5 UNPROTECTED
MODE OF SEX 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
2 2 2 2 3 2 3 2 3 2 2 3 2 2 2 2 2 2 2 2 2 2 2 2 2 CIRCUMCISION
3 3 5 2 5 3 2 5 2 2 5 5 5 3 2 3 2 3 5 5 5 3 3 5 5 GENITAL ULCER/FISSURE
5 5 6 6 2 5 6 6 6 6 6 6 6 5 6 5 6 5 6 6 6 5 5 6 6 GENITAL DISCHARGE
2 2 2 1 2 2 1 2 1 1 2 2 2 2 1 2 1 2 2 2 2 2 2 2 2 LYMPHNODES
4 4 4 4 4 4 4 2 4 4 4 2 4 4 4 4 4 4 4 1 1 4 4 4 4 PAPULES N N N N N N N N N N N N N OC N OC N N N N N N N OC N ORAL MUCOSA P P A A P A A A A A A A A A A A A A A A A A A A A DIABETES MELLITUS NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR RPR N N N N N N N N N N N N N N N N N N N N N N N N N TPHA NR NR NR NR NR NR NR NR R NR R NR R R NR R NR NR NR NR NR NR NR R NR ICTC NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR HBsAG NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR ANTI HCV
1 1 3 3 1 1 3 3 3 3 3 3 3 1 3 1 3 1 3 3 3 1 1 3 3 KOH
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 WET MOUNT
1 1 5 5 1 1 5 5 5 5 5 5 5 1 5 1 5 1 5 5 5 1 1 5 5 GRAM STAIN
2 2 2 1 2 2 1 2 1 1 2 2 2 2 1 2 1 2 2 2 2 2 2 2 2 TZANCK SMEAR BAL BAL NIL HG VVC BAL HG MC HG HG NIL MC NIL BAL HG BAL HG BAL NIL WART WART BAL BAL NIL NIL
DIAGNOSIS 125 124 123 122 121 120 119 118 117 116 115 114 113 112 111 110 109 108 107 106 105 104 103 102 101 S.NO MARIATHANGAM MOOKAIAH DHANABAKIYAM SELVI RAMALAKSHMI KARTHI PANDARAPANDIYAN SIVANESAN LAKSHMIGANTHAN CHANDRAN HARIHARARAJ MARIAMMAL SUBAIAH INDRA MARIAPPAN THANGARAJ PREMKUMAR KALAISELVSN GANESAN MARIAPPAN SUMAN VIJAIKUMAR MARIAPPAN KANNAN MARY ALPHONSE
NAME
AGE 37 52 32 43 31 36 29 34 35 29 36 35 55 47 28 58 27 31 38 31 28 32 42 33 53
2 3 2 3 2 2 2 2 2 2 3 3 3 3 2 3 2 2 2 2 2 2 3 2 3 AGE F M F M M M M M M M M M M F F M F F F M M M M F M SEX FSW H FSW H FSW O M O D FSW H FSW O M O O D M D O M O O D O
OCCUPATION M M M M M M UM M M M M M M M UM M UM UM UM M M UM M UM M MARITAL STATUS
1 1 1 1 1 1 2 1 1 1 1 1 1 1 3 3 2 2 1 3 3 1 1 2 1 EMC/PMC/MSM
3 4 1 2 2 2 2 3 3 2 3 2 3 1 1 2 3 4 1 4 3 2 2 4 3 LAST CONTACT
3 4 3 1 1 4 4 4 4 3 2 3 2 1 1 1 4 4 4 3 3 4 4 4 3 CONTACT PERSON PROTECTED OR 2 2 2 2 2 2 2 2 2 1 2 2 2 1 2 2 1 2 2 2 2 1 2 2 2
2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 UNPROTECTED
MODE OF SEX 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
3 2 3 3 3 2 2 2 2 3 2 3 2 3 2 2 2 2 2 2 2 2 2 2 3 CIRCUMCISION
5 3 5 5 5 5 3 5 2 5 5 5 2 5 5 5 3 2 3 5 1 5 3 3 5 GENITAL ULCER/FISSURE
2 5 2 6 6 6 5 6 6 6 6 2 6 2 6 6 5 6 5 6 6 1 5 5 2 GENITAL DISCHARGE
2 2 2 2 2 2 2 2 1 2 2 2 1 2 2 2 2 1 2 2 1 2 2 2 2 LYMPHNODES
4 4 4 4 2 2 4 4 4 1 1 4 4 4 1 4 4 4 4 4 4 4 4 4 4 PAPULES N N N N N N N N N N N N N N OC N N N N N N N N N N ORAL MUCOSA A A A A A A A A A A A A A A A A A A A A A A A A P DIABETES MELLITUS NR NR NR R NR NR NR R NR NR NR NR NR NR NR NR NR NR NR NR R NR NR NR NR RPR N N N P N N N P N N N N N N N N N N N N P N N N N TPHA NR NR NR NR NR NR NR NR NR NR R NR NR NR R NR NR NR NR NR NR NR NR NR NR ICTC NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR HBsAG NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR ANTI HCV
1 1 1 3 3 3 1 3 3 3 3 1 3 1 3 3 1 3 1 3 3 3 1 1 1 KOH
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 WET MOUNT
1 1 1 5 5 5 1 5 5 5 5 1 5 1 5 5 1 5 1 5 5 5 1 1 1 GRAM STAIN
2 2 2 2 2 2 2 2 1 2 2 2 1 2 2 2 2 1 2 2 2 2 2 2 2 TZANCK SMEAR VVC BAL VVC 2 SY MC MC BAL ELS HG WART WART VVC HG VVC WART NIL BAL HG BAL NIL 2 SY NGU BAL BAL VVC
DIAGNOSIS 150 149 148 147 146 145 144 143 142 141 140 139 138 137 136 135 134 133 132 131 130 129 128 127 126 S.NO PALANIVEL GOMATHI THANGAM RAMANATHAN MARIA STEPHEN MASOOD MARIAMMAL SHANMUGAPANDIAN PERUMAL MURUGESWARI ANDIAPAN MARIAPPAN KARPAGAM MATHIVANAN RAMACHANDRAN KASI MANIKANDA PRABHU RADHAKRISHNAN SRINIVASAN SORNAMMUDI KITTU ARUMUGANAINAR RAMALAKSHMI ARUNACHALAM PONMANI
NAME
AGE 28 45 43 54 52 23 42 54 45 37 28 41 30 42 53 46 25 55 33 29 51 42 29 56 33
2 3 3 3 3 2 3 3 3 2 2 3 2 3 3 3 2 3 2 2 3 3 2 3 2 AGE M F M M M M M M M M M F M M M F F M M F F M M F M SEX O FSW FSW D O O H O D O D M FSW H O D H O H M O H H O O
OCCUPATION M M M M M M M M M M UM M M M M M UM M M UM M M M M M MARITAL STATUS
1 1 1 1 1 1 1 1 3 1 2 1 1 1 1 1 3 1 1 2 3 1 1 1 3 EMC/PMC/MSM
1 1 1 4 2 1 3 3 1 1 2 2 1 4 4 4 2 4 1 2 2 4 1 2 4 LAST CONTACT
4 1 1 2 4 3 1 4 1 3 4 4 3 4 4 4 1 4 4 4 3 4 1 4 1 CONTACT PERSON PROTECTED OR 2 2 2 2 2 2 1 1 2 2 2 2 2 2 2 2 2 2 2 2 1 2 1 2 1
2,3,4,5 2,3,4,5 3,4,5 2,3,4,5 UNPROTECTED
MODE OF SEX 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
2 3 3 2 2 3 3 2 2 3 2 2 3 2 2 2 2 2 2 2 2 2 3 2 2 CIRCUMCISION
3 5 5 3 5 2 5 3 2 5 2 3 5 3 3 5 1 5 3 5 3 5 5 2 5 GENITAL ULCER/FISSURE
5 2 2 5 6 6 6 5 6 2 6 5 2 5 5 6 6 6 5 6 5 6 2 6 6 GENITAL DISCHARGE
2 2 2 2 2 1 2 2 1 2 1 2 2 2 2 2 1 2 2 2 2 2 2 1 2 LYMPHNODES
4 4 4 4 4 4 1 4 4 4 4 4 4 4 4 4 4 4 4 3 4 4 4 4 4 PAPULES N N N N OC N N N OC N N N N N N N N N N N N N N N N ORAL MUCOSA A A A P A A A P A A A A A A P A A A A A P A A P A DIABETES MELLITUS NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR R R R NR NR NR NR NR NR NR RPR N N N N N N N N N N N N N N N P P P N N N N N N N TPHA NR NR NR NR R NR NR NR NR NR NR NR NR R NR NR NR NR NR R NR R NR NR NR ICTC NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR HBsAG NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR ANTI HCV
1 1 1 1 3 3 3 1 3 1 3 1 1 1 1 3 3 3 1 3 1 3 1 3 3 KOH
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 WET MOUNT
1 1 1 1 5 5 5 1 5 1 5 1 1 1 1 5 5 5 1 5 1 5 1 5 5 GRAM STAIN
2 2 2 2 2 1 2 2 1 2 1 2 2 2 2 2 2 2 2 2 2 2 2 1 2 TZANCK SMEAR BAL VVC VVC BAL NIL HG WART BAL HG VVC HG BAL VVC BAL BAL LLS 1 SY LLS BAL SCABIES BAL NIL VVC HG NIL
DIAGNOSIS 175 174 173 172 171 170 169 168 167 166 165 164 163 162 161 160 159 158 157 156 155 154 153 152 151 S.NO MANIKANDAN THALAVAI SHANMUGAM PETHCIAMMAL MURUGAN SURESH KUMAR RAMAKRISHNAN SUBRAMANIAN HASSAN ESAKKI SIVASAKTHI SAKTHIVEL SORNALAKSHMI MANI KANAGARAJ MARAGATHAM SIVASHANKAR PREETHI MUTHUKUMAR SATHISH MANI COLUMBUS KRISHNAN DURAIRAJ
NAME
AGE 24 54 26 21 43 24 26 47 33 32 43 29 29 27 63 51 44 31 36 39 28 51 25 65 41
2 3 2 2 3 2 2 3 2 2 3 2 2 2 3 3 3 2 2 2 2 3 2 3 3 AGE M M F M M F M TG M M M M M M M M M F M M M M M M M SEX O H O S O O H O O M O H M FSW H H FSW O O O D O O O M
OCCUPATION M M UM UM M UM UM M M M M UM M M M M M UM UM M UM M UM M M MARITAL STATUS
1 3 3 2 1 3 3 1 1 3 3 2 1 1 1 1 1 3 3 1 2 1 2 1 1 EMC/PMC/MSM
4 2 1 2 4 1 1 3 1 1 2 3 4 2 3 3 2 3 1 3 3 2 2 1 1 LAST CONTACT
4 3 3 1 4 3 1 4 4 1 3 4 4 3 4 4 3 3 1 4 4 4 4 4 4 CONTACT PERSON PROTECTED OR 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 UNPROTECTED
MODE OF SEX 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1
2 2 2 3 2 2 2 2 2 2 2 2 2 3 2 2 3 2 4 2 2 2 2 2 2 CIRCUMCISION
5 3 5 5 5 5 1 5 1 5 3 5 5 5 3 5 5 5 5 5 5 2 2 3 3 GENITAL ULCER/FISSURE
6 5 6 2 2 6 6 6 6 1 5 1 6 2 5 6 2 6 6 6 6 6 6 5 5 GENITAL DISCHARGE
2 2 2 2 2 2 1 2 1 1 2 1 2 2 2 2 2 2 2 2 2 1 1 2 2 LYMPHNODES
1 4 3 4 4 4 4 4 4 4 4 4 2 4 4 1 4 1 2 2 2 4 4 4 4 PAPULES OC N N N N N N N N N N N N N OC N N N N N N N N N N ORAL MUCOSA A P A A A A A A A A P A A A P A A A A A A A A P P DIABETES MELLITUS NR NR NR NR NR R R R R NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR RPR N N N N N P P P P N N N N N N N N N N N N N N N N TPHA R NR R NR NR NR NR R NR NR NR NR NR NR R R NR NR NR NR NR NR NR NR NR ICTC NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR HBsAG NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR ANTI HCV
3 1 3 1 1 3 3 3 3 3 1 3 3 1 1 3 1 3 3 3 3 3 3 1 1 KOH
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 WET MOUNT
5 1 5 1 1 5 5 5 5 3 1 3 5 1 1 5 1 5 5 5 5 5 5 1 1 GRAM STAIN
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 2 2 TZANCK SMEAR WART BAL SCABIES VVC VVC 2 SY 1 SY ELS 1 SY GON BAL GON MC VVC BAL WART VVC WART MC MC MC HG HG BAL BAL
DIAGNOSIS 200 199 198 197 196 195 194 193 192 191 190 189 188 187 186 185 184 183 182 181 180 179 178 177 176 S.NO KANNAMMAL ROHINI PARTHIBAN VASANTHI MURUGAN SARAVANAN KARUTHAPANDI MAHARAJAN PATTAMMAL PALANIAPPAN CHELLADURAI MARIAANTONY PRIYA KATHIRAVAN ARUL SUDALAIMUTHU PRABAKARAN KALIRAJ PAPANASAM KUTRALAM RAJAKUMARI MURUGAN SUBRAMANIAN RAJA MUTHUSELVI
NAME
AGE 42 22 21 30 50 41 59 33 22 32 58 39 23 36 28 32 28 28 38 72 38 46 47 31 41
3 2 2 2 3 3 3 2 2 2 3 2 2 2 2 2 2 2 2 4 2 3 3 2 3 AGE M F M M M M M M M F M M M F F F M F M M M M TG M M SEX FSW S S FSW O D O H M H O O S O O O D H O O FSW O H O FSW
OCCUPATION M UM UM M M M M M UM M M M UM M M M UM UM M M M M M UM M MARITAL STATUS
1 2 3 1 1 3 1 3 3 1 1 1 2 1 1 3 2 2 1 1 1 3 1 3 1 EMC/PMC/MSM
2 2 3 2 3 3 3 4 1 4 4 4 3 4 3 3 3 3 1 4 1 4 2 3 3 LAST CONTACT
1 1 1 1 2 3 2 3 1 4 2 4 1 4 4 3 4 4 2 2 1 1 4 1 3 CONTACT PERSON PROTECTED OR 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2
2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,3 2,3,4,5 UNPROTECTED
MODE OF SEX 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
3 3 2 3 2 2 2 2 4 2 2 2 3 2 2 2 2 2 2 2 3 2 2 2 3 CIRCUMCISION
2 5 5 2 2 3 2 2 2 3 5 3 5 3 5 4 4 5 5 3 5 5 5 5 5 GENITAL ULCER/FISSURE
6 2 6 6 6 5 6 6 6 5 6 5 6 5 6 6 6 6 6 5 6 6 6 6 2 GENITAL DISCHARGE
1 2 2 1 1 2 1 1 1 2 2 2 2 2 2 2 1 2 2 2 2 2 2 2 2 LYMPHNODES
4 4 4 4 4 4 4 4 4 4 4 4 1 4 4 4 4 4 3 4 4 4 1 1 4 PAPULES N N N N N N N N N N N N N O N N N N N N N N N N N ORAL MUCOSA A A A A A A A A A A A P A A A A A A A P A A A A A DIABETES MELLITUS NR NR R NR NR NR NR NR NR NR NR NR NR NR R R R R NR NR NR NR NR NR NR RPR N N P N N N N N N N N N N N P P P P N N N N N N N TPHA NR NR NR NR NR NR NR NR NR NR NR NR NR R NR NR NR NR NR NR NR R R NR NR ICTC NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR HBsAG NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR ANTI HCV
3 1 3 3 3 1 3 3 3 1 3 1 3 1 3 3 3 3 3 1 3 3 3 3 1 KOH
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 WET MOUNT
5 1 5 5 5 1 5 5 5 1 5 1 5 1 5 5 5 5 5 1 5 5 5 5 1 GRAM STAIN
1 2 2 1 1 2 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 TZANCK SMEAR HG VVC 2 SY HG HG BAL HG HG HG BAL NIL BAL WART BAL LLS ELS ELS ELS SCABIES BAL NIL NIL WART WART VVC
DIAGNOSIS 225 224 223 222 221 220 219 218 217 216 215 214 213 212 211 210 209 208 207 206 205 204 203 202 201 S.NO GANESAN MANI ASWIN RAJ NAGAMUTHU SASIKALA TAMILSELVAN MARIAMMAL SARANYA GUNASEELAN SUBRAMANI RAJINI SANYASI KAVITHA THANGAVEL KARUPUSAMY MURUGAN SUMATHI SENTHILKUMAR VIJAYALAKSHMI MANONMANI ESAKKI MUTHU NAMBIRAJAN AMALRAJ MAHARASI
NAME
AGE 40 50 28 32 31 42 30 23 22 44 36 39 28 38 48 39 45 29 22 47 58 53 24 40 33
3 3 2 2 2 3 2 2 2 3 3 2 2 3 3 3 3 2 2 3 3 3 2 3 2 AGE M F M M M F M F F F M M M F M M M M F M F F M M M SEX O O O O O O O S S O O O O O O O FSW O S O O O O D FSW
OCCUPATION M M UM M M M M UM UM M M M M M M M M UM UM M M M UM M UM MARITAL STATUS
3 1 3 3 1 3 1 2 3 1 1 1 1 1 1 3 1 2 2 1 1 1 3 1 2 EMC/PMC/MSM
3 2 3 2 3 4 1 2 3 2 2 2 2 2 3 2 2 3 3 4 4 3 3 1 2 LAST CONTACT
1 4 1 1 1 1 1 1 1 4 4 4 1 4 4 1 3 1 1 1 1 4 3 4 1 CONTACT PERSON PROTECTED OR 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 UNPROTECTED
MODE OF SEX 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
2 2 2 2 3 2 3 3 2 2 2 2 3 2 2 2 3 2 3 3 3 2 2 2 3 CIRCUMCISION
2 2 5 5 4 4 5 5 5 3 5 3 5 3 2 1 5 4 5 5 5 2 5 2 5 GENITAL ULCER/FISSURE
6 6 6 6 6 6 2 6 6 5 6 5 2 5 6 6 6 6 6 6 6 6 6 6 6 GENITAL DISCHARGE
1 1 2 2 2 2 2 2 2 2 2 2 2 2 1 1 2 2 2 2 2 1 2 1 2 LYMPHNODES
4 4 1 4 4 4 4 1 1 4 2 4 4 4 4 4 4 4 4 4 4 4 1 4 2 PAPULES OC N N N N N N N N N N N N N N N N N N N N N N N N ORAL MUCOSA A A A A A A A A A A A P A P A A A A A A A A A A A DIABETES MELLITUS NR NR NR R R R NR NR NR NR NR NR NR NR NR R R R R R NR NR NR NR NR RPR N N N P P P N N N N R N N N N P P P P P N N N N N TPHA R R NR NR NR NR NR NR NR R NR NR NR NR R R NR NR NR NR NR NR NR NR NR ICTC NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR HBsAG NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR ANTI HCV
3 3 3 3 3 3 1 3 3 1 3 1 1 1 3 3 3 3 3 3 3 3 3 3 3 KOH
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 WET MOUNT
5 5 5 5 5 5 1 5 5 1 5 1 1 1 5 5 5 5 5 5 5 5 5 5 5 GRAM STAIN
1 1 2 2 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2 2 2 1 2 1 2 TZANCK SMEAR HG HG WART 2 SY ELS ELS VVC WART WART BAL MC BAL VVC BAL HG 1 SY LLS ELS ELS ELS NIL HG WART HG MC
DIAGNOSIS 250 249 248 247 246 245 244 243 242 241 240 239 238 237 236 235 234 233 232 231 230 229 228 227 226 S.NO NANDHINI JAMUNA VINO VICTOR JEROME ALIMOHAMMED RAM JOTHISWARAN RAMYA PRIYA PARAMASIVAM VELAMMAL GANGA GURUSAMY BEER ESAKKIAMMAL MURUGAN MUTU ZAHIR APPAS RAJA NAGURAMMAL KANCHANA AROKYASUDHAN RAJ GANESAN MURUGAIAH
NAME
AGE 33 25 23 28 54 28 29 23 33 44 43 29 28 39 43 23 31 29 33 48 34 30 48 55 36
2 2 2 2 3 2 2 2 2 3 3 2 2 2 3 2 2 2 2 3 2 2 3 3 2 AGE TG M M M M M M M F TG M M M M TG TG TG M M M M TG TG M F SEX O O O O O O O O M D H M O O O O H D D H O O O O D
OCCUPATION UM UM UM M M M M UM UM M M UM UM M M M M M M M UM M M M M MARITAL STATUS
3 3 3 3 3 2 3 3 3 3 1 3 3 3 1 3 1 1 1 1 3 3 1 1 1 EMC/PMC/MSM
4 2 4 4 3 4 3 3 4 3 1 3 2 4 3 2 4 3 1 3 2 2 4 2 4 LAST CONTACT
1 3 1 1 1 2 4 1 1 3 1 3 1 1 4 1 2 4 4 3 1 3 4 4 4 CONTACT PERSON PROTECTED OR 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
2,4 2,4 2,4 2,3,4,5 2,3,4,5 2,3,4,5 2,4 2,4 2,3,4,5 2,4 2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,4 2,3,4,5 UNPROTECTED
MODE OF SEX 1 1 1 1 1 2
2 2 2 2 2 2 2 4 4 2 3 2 2 2 2 2 2 2 2 3 4 2 2 2 2 CIRCUMCISION
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 3 3 GENITAL ULCER/FISSURE
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 5 5 GENITAL DISCHARGE
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 LYMPHNODES
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 PAPULES N N N N N N N N N N N N N N N N N N N N N N OC N N ORAL MUCOSA A A A A A A A A A A A A A A A A A A A A A A A A A DIABETES MELLITUS NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR R NR NR RPR N N N N N N N N N N N N N N N N N N N N N N P N N TPHA NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR R R NR R NR NR ICTC NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR R NR NR NR HBsAG NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR ANTI HCV
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 1 1 KOH
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 WET MOUNT
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 1 1 GRAM STAIN
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 TZANCK SMEAR NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL LLS BAL BAL
DIAGNOSIS 275 274 273 272 271 270 269 268 267 266 265 264 263 262 261 260 259 258 257 256 255 254 253 252 251 S.NO PERIYARAJ MURUGAN KANNAM SAMEER VINOD KANNAN SANKAR GANESH MARIAPPAN MUTHURAMALINGAM ESWARAN RAJA NIRMALADEVI SNEHA RASHEEQ KATHIRESAN SWATHI ALAGESAN RAJA SOWMYA HASINI STELLA VITHIYASHREE SAMBAVI ANJALI HARINI
NAME
AGE 37 54 27 25 25 27 21 27 44 27 27 44 28 44 25 24 38 35 33 23 29 21 23 27 23
2 3 2 2 2 2 2 2 3 2 2 3 2 3 2 2 2 2 2 2 2 2 2 2 2 AGE F F M M TG M M TG TG TG TG TG TG TG M M M M M M M M M M M SEX D O O O O O O O O O D O O H H O O O M O O O O O M
OCCUPATION UM M M M UM M M UM M M M M M M M M M M UM UM UM UM M UM UM MARITAL STATUS
2 1 3 3 2 3 3 2 3 3 3 1 1 3 1 3 1 3 3 3 3 3 3 3 3 EMC/PMC/MSM
3 2 4 3 2 3 1 3 2 4 4 3 3 4 4 2 3 1 2 4 3 2 3 1 2 LAST CONTACT
2 4 3 1 2 3 3 2 1 3 3 1 1 1 1 3 2 1 1 1 3 3 3 1 3 CONTACT PERSON PROTECTED OR 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2 2 2 2 2 2 2 2
4,5 2,3 2,3,4,5 2,3,4,5 3,4,5 2,4,5 4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,4 2,4 2,4 2,4 2,4 2,4 2,4 UNPROTECTED
MODE OF SEX 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2 2 2 2 3 3 2 2 4 2 2 2 2 2 2 4 2 2 CIRCUMCISION
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 GENITAL ULCER/FISSURE
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 GENITAL DISCHARGE
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 LYMPHNODES
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 PAPULES N N N N N N N N N N N N N N N N N N N N N N N N N ORAL MUCOSA A A A A A A A A A A A A A A A A A A A A A A A A A DIABETES MELLITUS NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR RPR N N N N N N N N N N N N N N N N N N N N N N N N N TPHA NR NR NR NR NR NR NR NR NR NR NR NR R NR NR R NR NR NR NR NR NR NR NR NR ICTC NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR HBsAG NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR ANTI HCV
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 KOH
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 WET MOUNT
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 GRAM STAIN
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 TZANCK SMEAR NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
DIAGNOSIS 300 299 298 297 296 295 294 293 292 291 290 289 288 287 286 285 284 283 282 281 280 279 278 277 276 S.NO ISAC THANGAM VIGNESH NISHI MANIKANDAN ARULPARAI UMAYAL SWAPNA TEJASWINI MUTHUGANESH LAKSHMI RAMESH MANOHAR PRABU MALAIRAJAN ALAGENDRAN VEDAMUTHU GANESAN MARY RAJAN SUNDARI KRISHNAMOORTHY INDRA MARY NAMBI
NAME
AGE 44 32 34 34 24 30 29 28 24 26 33 37 25 22 50 23 63 30 38 40 39 29 48 37 34
3 2 2 2 2 3 2 2 2 2 2 2 2 2 3 2 3 2 2 3 2 2 3 2 2 AGE M M M M M M M F M F M F F M M F M M M M TG TG TG M F SEX O O O O O O M M M O O O O O O O O D O O O O M O H
OCCUPATION M M M M M M M M M M M M M M M UM M M M M M M M M UM MARITAL STATUS
1 1 3 3 3 3 3 3 3 3 1 3 3 3 1 2 1 3 1 3 1 1 1 1 2 EMC/PMC/MSM
3 2 4 3 4 3 2 2 3 2 3 2 4 3 2 3 2 4 3 1 2 4 3 2 3 LAST CONTACT
2 4 3 1 1 3 3 3 3 1 4 1 3 3 4 2 4 3 4 3 4 4 4 4 2 CONTACT PERSON PROTECTED OR 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2
2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,4 2,4 2,4 2,3,4,5 2,3,4,5 4,5 4,5 2,3,4,5 4,5 UNPROTECTED
MODE OF SEX 1 1 1 1 1 1 1 1 1 1 1 1
2 3 2 2 2 2 4 2 2 2 3 2 2 2 2 2 2 2 3 2 3 2 3 3 2 CIRCUMCISION
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 GENITAL ULCER/FISSURE
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 GENITAL DISCHARGE
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 LYMPHNODES
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 PAPULES N N N N N N N N N N N N N N N N N N N N N N N N N ORAL MUCOSA A A A A A A A A A A A A A A A A A A A A A A A A A DIABETES MELLITUS NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR RPR N N N N N N N N N N N N N N N N N N N N N N N N N TPHA R NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR R NR NR NR NR NR NR NR NR ICTC NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR HBsAG NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR ANTI HCV
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 KOH
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 WET MOUNT
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 GRAM STAIN
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 TZANCK SMEAR NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
DIAGNOSIS 325 324 323 322 321 320 319 318 317 316 315 314 313 312 311 310 309 308 307 306 305 304 303 302 301 S.NO RAJA SABARIRAJ AVUDAIAPPAN MARIMUTHU KARTHI VIKY ISMAIL DANIEL SANKARAN MURUGAN MAHEEB PETER JOHN SANKAR RAJA SELVASANTHANAM MUTHUPANDI SUNDARRAJ MANIKANDAN BARATH SABRUDEEN SUNDAR VELMURUGAN ELANGOMANI VINOTH GANESAN
NAME
AGE 21 40 29 25 29 27 29 26 27 47 35 61 29 32 35 29 28 38 24 48 58 34 36 25 28
2 3 2 2 2 2 2 2 2 3 2 3 2 2 2 2 2 2 2 3 3 2 2 2 2 AGE M M M M M M M M M M M M M M M M M M M M M M M M M SEX D D D O D O O O O H D H O O O O H O O D D O O O O
OCCUPATION M M M M M M M M M M M M M M M M M M M M M M M M M MARITAL STATUS
3 1 3 3 3 3 3 3 3 1 1 3 3 1 1 1 1 1 3 2 1 3 1 3 3 EMC/PMC/MSM
4 3 3 2 2 3 4 4 4 2 4 2 3 4 3 3 2 3 4 4 4 3 3 2 1 LAST CONTACT
3 4 3 3 1 1 1 3 3 4 4 3 3 4 4 4 4 4 3 2 2 1 4 3 3 CONTACT PERSON PROTECTED OR 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 4,5 4,5 2,3,4,5 4,5 2,3 2,3,4,5 2,3,4,5 2,3,4,5 UNPROTECTED
MODE OF SEX 1 1 1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 CIRCUMCISION
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 GENITAL ULCER/FISSURE
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 GENITAL DISCHARGE
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 LYMPHNODES
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 PAPULES N N N N N N N N N N N N N N N N N N N N N N OC N N ORAL MUCOSA A A A A A A A A A A A A A A A A A A A A A A A A A DIABETES MELLITUS NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR RPR N N N N N N N N N N N N N N N N N N N N N N N N N TPHA NR R NR NR NR NR NR NR NR NR R NR NR NR NR NR R NR NR NR NR NR R NR NR ICTC NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR HBsAG NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR ANTI HCV
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 KOH
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 WET MOUNT
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 GRAM STAIN
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 TZANCK SMEAR NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
DIAGNOSIS 350 349 348 347 346 345 344 343 342 341 340 339 338 337 336 335 334 333 332 331 330 329 328 327 326 S.NO MUTHAIYAH CHARULATHA KAMARAJ VICTOR RAM SANTOSH SELVAM NARAYANAMOORTHI RAJA MAHI AMMU VELMURUGAN DAS AMMU MANMATHARAJ KULANTHAIPANDI MURUGAN AJMAL RAMKUMAR GANESAN GANESAN BALA SENTHILKUMAR KRISHNAN PRAKASH
NAME
AGE 47 25 45 45 24 30 31 33 32 27 36 39 32 38 31 62 33 22 26 29 39 23 26 25 34
3 2 3 3 2 2 2 2 2 2 2 2 2 2 2 3 2 2 2 2 2 2 2 2 2 AGE M M M M M M M M M M M M M M M TG M M M M M M M M M SEX O O O M S H O O O O O O O H H D D H O O O O O H H
OCCUPATION M M M M UM M M M M M M M M M M M M M M M M M M M M MARITAL STATUS
1 3 3 1 3 3 3 2 3 3 1 1 3 1 1 1 1 3 3 3 3 3 3 3 3 EMC/PMC/MSM
2 2 4 3 4 3 2 4 3 1 2 2 4 3 4 3 4 3 4 4 3 2 2 2 4 LAST CONTACT
4 3 3 4 3 3 3 2 3 1 4 4 1 4 4 4 4 3 3 3 3 3 3 3 3 CONTACT PERSON PROTECTED OR 2 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2 2 2 2 2 2 2 1 2 2
2,3,4,5 2,3,4,5 2,4,5 2,3,4,5 4,5 2,3,4,5 3,4,5 4,5 4,5 4,5 4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 3,5 UNPROTECTED
MODE OF SEX 1 1 1 1 1 1 1 1 1
2 4 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 CIRCUMCISION
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 GENITAL ULCER/FISSURE
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 GENITAL DISCHARGE
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 LYMPHNODES
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 PAPULES N N N N N N N N N N N N N N N N N N N N N N N N N ORAL MUCOSA A A A A A A A A A A A A A A A A A A A A A A A A A DIABETES MELLITUS NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR RPR N N N N N N N N N N N N N N N N N N N N N N N N N TPHA NR NR NR NR NR NR NR R NR NR NR NR NR NR R R R NR NR NR NR NR NR NR NR ICTC NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR HBsAG NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR ANTI HCV
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 KOH
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 WET MOUNT
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 GRAM STAIN
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 TZANCK SMEAR NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
DIAGNOSIS 375 374 373 372 371 370 369 368 367 366 365 364 363 362 361 360 359 358 357 356 355 354 353 352 351 S.NO DEIVENDRAN SARAVANAMUTHU RAJAGOPAL RAJA VIGNESH HAKKINRAJA MURUGESAN TAMIL OVIYA INDARAAJ THANGARAJ NASRUDEEN SUDHA SIVASANKARAN JEYASRI KUMAR PONNUPANDIYAN VELLADURAI GHANARAJ STALIN VENKAR EDWIN BANU ROHINI ESAKIRAJA
NAME
AGE 31 30 35 42 25 31 28 29 30 64 38 32 37 23 31 28 55 56 27 38 26 49 17 30 22
2 2 2 3 2 2 2 2 2 3 2 2 2 2 2 2 3 3 2 2 2 3 1 2 2 AGE M F M TG M M M M M M M F TG M M M M M M M M M TG M M SEX O O O O O O O O M O O M O H M O O O O O O H O M D
OCCUPATION M M M M M M M M M M M M M M M M M M M M M M UM M M MARITAL STATUS
3 3 3 3 1 3 3 1 3 1 3 3 1 3 3 3 3 1 3 3 3 3 2 3 3 EMC/PMC/MSM
3 2 3 2 3 2 4 3 2 1 2 2 3 4 3 2 3 4 2 3 4 3 2 4 3 LAST CONTACT
3 3 3 3 4 3 3 4 1 4 3 3 4 1 3 3 3 4 1 3 3 3 4 3 1 CONTACT PERSON PROTECTED OR 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2 2 2
2,3,4,5 2,3,4,5 2,3,4,5 4,5 2,3,4,5 2,4,5 2,4 2,3,4,5 4,5 2,3,4,5 2,4 2,3,4,5 2,3,4,5 2,5 2,3,4,5 4,5 2,3,4,5 2,4 2,3,4,5 UNPROTECTED
MODE OF SEX 1 1 1 1 1 1
2 2 2 2 2 2 2 2 2 2 2 2 3 2 4 2 2 2 2 2 2 2 3 2 2 CIRCUMCISION
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 GENITAL ULCER/FISSURE
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 GENITAL DISCHARGE
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 LYMPHNODES
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 PAPULES N N N N N N N N N N N N N N N N N N N N N N N N N ORAL MUCOSA A A A A A A A A A A A A A A A A A A A A A A A A A DIABETES MELLITUS NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR RPR N N N N N N N N N N N N N N N N N N N N N N N N N TPHA NR NR NR NR R R NR R NR R NR NR NR NR NR NR R R NR NR NR NR NR NR NR ICTC NR NR NR NR NR NR R NR NR NR NR NR NR NR NR NR NR NR R NR NR NR NR NR NR HBsAG NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR R NR NR NR ANTI HCV
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 KOH
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 WET MOUNT
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 GRAM STAIN
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 TZANCK SMEAR NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
DIAGNOSIS 400 399 398 397 396 395 394 393 392 391 390 389 388 387 386 385 384 383 382 381 380 279 378 377 376 S.NO MAHESHWARI ARUN KARUPPAN UIKATTAN MAHESHWARI MANIKANDAN PATTURAJAN ARUMUGAM27 MANIKAM MURUGAN MANIKANDAN MANIARASAN CHIPPU AVANTHIKA JINCHANA NAKSHTRA KIRTHIKA AIYSHA PONKALA RAJAMANI VINOTH VIJAYASUBBURAJ KARTHIKETAN NITHYA MUTHUPANDI
NAME
AGE 37 23 67 45 42 26 22 27 38 65 24 50 36 21 19 27 22 30 35 54 30 39 19 34 23
2 2 4 3 3 2 2 2 2 4 2 3 2 2 1 2 2 2 2 3 2 2 1 2 2 AGE M M TG TG TG TG TG TG F M M M TG M F M M M F M M M M M M SEX O O O O O O O H D D O O O O M O O O M O O O O M D
OCCUPATION M M M UM M M UM M M M UM M M M M M M M M M M UM M M M MARITAL STATUS
1 3 1 2 1 3 2 3 3 1 2 3 3 3 3 3 3 3 3 1 1 2 3 3 3 EMC/PMC/MSM
3 3 4 2 4 2 3 4 2 4 3 2 4 3 4 3 2 3 4 3 4 3 4 4 3 LAST CONTACT
4 3 4 2 4 3 2 1 3 4 2 3 3 3 3 1 3 3 3 4 4 2 1 3 3 CONTACT PERSON PROTECTED OR 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2
2,4 2,3,4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,4 2,4 2,4 2,4 2,4 2,4 2,4 2,3,4,5 2,4 2,3,4,5 UNPROTECTED
MODE OF SEX 1 1 1 1 1 1 1 1 1 1
3 2 2 2 3 2 2 2 2 2 2 2 2 2 2 2 4 2 4 3 2 2 2 2 2 CIRCUMCISION
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 GENITAL ULCER/FISSURE
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 GENITAL DISCHARGE
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 LYMPHNODES
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 PAPULES N N N OC N N N N N N N N N N N N N N N N N N N N N ORAL MUCOSA A A A A A A A A A A A A A A A A A A A A A A A A A DIABETES MELLITUS NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR RPR N N N N N N N N N N N N N N N N N N N N N N N N N TPHA NR NR R R NR NR R NR NR R R R NR NR NR NR NR NR R R NR NR NR NR NR ICTC NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR HBsAG NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR ANTI HCV
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 KOH
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 WET MOUNT
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 GRAM STAIN
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 TZANCK SMEAR NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
DIAGNOSIS 425 424 423 422 421 420 419 418 417 416 415 414 413 412 411 410 409 408 407 406 405 404 403 402 401 S.NO RAJA NARAYANAN PERUIYASAMY ANTONY KANNAN SELVAM NAGOORAMMAL MANIVEL LAKSHMI NARAYANAN VIJAYASANKARAN SANKARAMMAL SIVAPNDI VIJAYAN THANGADURAI VIJAYALAKSHMI CHANDRALEKAN MEERAN SUNDAR JEYARAMAN KUMAR ELAVARASI SUDALAIMUTHU SANSIYA CHANDRAN
NAME
AGE 26 38 41 48 35 47 40 44 41 51 34 58 59 37 40 29 52 44 30 28 60 27 58 38 54
2 2 3 3 2 3 3 3 3 3 2 3 3 2 3 2 3 3 2 2 3 2 3 2 3 AGE F M M M TG M M M M M F M TG M M M M M M M F M F M M SEX O O O O O O O M D H D O O O O O O O M H D O O M O
OCCUPATION M M M M M M M M M M M M M M M UM M M M M M M M UM M MARITAL STATUS
3 1 1 2 2 3 1 1 1 1 3 1 1 1 1 3 1 1 1 3 1 1 1 3 1 EMC/PMC/MSM
3 4 2 1 2 3 4 2 4 3 4 1 3 4 2 4 2 4 3 3 2 3 2 4 3 LAST CONTACT
3 2 4 4 2 3 4 4 4 4 3 4 4 4 4 3 4 4 2 3 4 4 4 3 4 CONTACT PERSON PROTECTED OR 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
2,3,4,5 2,3,4,5 2,3,4,5 2,4 2,3,4,5 2,4 UNPROTECTED
MODE OF SEX 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 3 2 3 2 2 3 2 2 2 4 2 2 2 2 2 3 2 2 2 CIRCUMCISION
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 GENITAL ULCER/FISSURE
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 GENITAL DISCHARGE
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 LYMPHNODES
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 PAPULES N OC OC OC OC N OC OC N OC N N N N N N OC N OC N OC N OC N N ORAL MUCOSA A A A A A A A A A A A A A A A A A A A A A A A A A DIABETES MELLITUS NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR RPR N N N N N N N N N N N N N N N N N N N N N N N N N TPHA NR R R R R R R R NR R NR R NR R R NR R NR R NR R R R NR NR ICTC NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR HBsAG NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR ANTI HCV
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 KOH
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 WET MOUNT
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 GRAM STAIN
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 TZANCK SMEAR NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
DIAGNOSIS 450 449 448 447 446 445 444 443 442 441 440 439 438 437 436 435 434 432 432 431 430 429 428 427 426 S.NO RAGHU SINDHUKUMAR ARUMUGAVADIVU MUTHU SABARIRAJ PERUMAL MICHEAL PRIYA MOTHILAL ESAKIAMMAL SUNDARRAJ VITTAL VIJAY KUMAR DEEPSINGH ALI SAMUEL MAHABOOB KUMAR ARUMUGAPANDI MADASAMY MAYA VINO VINOSRI DHANIYA AMUDHA
NAME
AGE 45 22 34 24 28 34 48 28 32 44 40 25 40 64 47 20 47 40 34 55 26 26 25 25 35
3 2 2 2 2 2 3 2 2 3 3 2 3 3 3 2 3 3 2 3 2 2 2 2 2 AGE M M M M M M M M M TG TG TG TG TG M M F M M M M F M F M SEX O O O O H D D H O O O O H H D D D H D O O O M O M
OCCUPATION M M M M M M M M M M M M M M M UM M M M M UM UM UM UM M MARITAL STATUS
3 3 1 3 3 1 1 1 1 1 3 2 2 1 2 3 1 1 1 1 3 3 3 3 3 EMC/PMC/MSM
3 2 3 4 2 3 4 3 4 3 2 3 4 2 3 4 3 4 3 2 4 3 3 3 4 LAST CONTACT
1 1 2 3 3 3 4 4 4 4 3 2 2 4 4 3 4 4 4 4 1 1 1 1 3 CONTACT PERSON PROTECTED OR 2 2 2 2 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
2,3,4,5 2,3,4,5 4,5 2,3,4,5 2,3,4,5 2,3,4,5 2,4 2,4 2,4 2,4 2,4 UNPROTECTED
MODE OF SEX 1 1 1 1 1 1 1 1 1 1 1 1 1 1
2 2 3 2 2 2 2 3 2 3 2 2 2 2 2 2 2 2 2 2 2 2 4 4 2 CIRCUMCISION
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 GENITAL ULCER/FISSURE
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 GENITAL DISCHARGE
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 LYMPHNODES
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 PAPULES N OC N N N N OC N N N N N N N N N N N N N N N N N N ORAL MUCOSA A A A A A A A A A A A A A A A A A A A A A A A A A DIABETES MELLITUS NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR RPR N N N N N N N N N N N N N N N N N N N N N N N N N TPHA NR R NR NR NR R R NR NR NR NR NR R R NR NR R NR NR R NR NR NR NR NR ICTC NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR HBsAG NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR ANTI HCV
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 KOH
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 WET MOUNT
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 GRAM STAIN
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 TZANCK SMEAR NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
DIAGNOSIS 460 459 458 457 456 455 454 453 452 451 S.NO RAJA SUNDARI VINOSHRI SHEIKMOHAMMED VIGNESH SUSAIYAPPAN RAJAIYA PRASAD RAJANDRA MANIKANDAN RAJESHKUMAR
NAME
AGE 24 31 24 34 24 42 49 44 26 41
2 2 2 2 2 3 3 3 2 3 AGE M F TG M M M M M M M SEX O O O O O H D D H O
OCCUPATION UM M UM M UM M M M M M MARITAL STATUS
3 1 3 3 3 3 1 1 3 2 EMC/PMC/MSM
2 3 4 2 3 4 3 4 3 2 LAST CONTACT
3 4 3 3 3 3 4 4 3 2 CONTACT PERSON PROTECTED OR 2 2 2 2 1 2 2 2 2 1
2,3,4,5 2,4 2,3,4,5 2,3,4,5 2,3,4,5 2,4,5 UNPROTECTED
MODE OF SEX 1 1 1 1
2 3 4 2 2 2 2 2 2 2 CIRCUMCISION
5 5 5 5 5 5 5 5 5 5 GENITAL ULCER/FISSURE
6 6 6 6 6 6 6 6 6 6 GENITAL DISCHARGE
2 2 2 2 2 2 2 2 2 2 LYMPHNODES
4 4 4 4 4 4 4 4 4 4 PAPULES N N N N N OC N OC N N ORAL MUCOSA A A A A A A A A A A DIABETES MELLITUS NR NR NR NR NR NR NR NR NR NR RPR N N N N N N N N N N TPHA NR NR NR NR R R R R NR NR ICTC NR NR NR NR NR NR NR NR NR NR HBsAG NR NR NR NR NR NR NR NR NR NR ANTI HCV
3 3 3 3 3 3 3 3 3 3 KOH
3 3 3 3 3 3 3 3 3 3 WET MOUNT
5 5 5 5 5 5 5 5 5 5 GRAM STAIN
2 2 2 2 2 2 2 2 2 2 TZANCK SMEAR NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
DIAGNOSIS