We report a high prevalence of RTIs in a relatively stable population of women in India, living in a state with a moderate prevalence (0.5–1%) of HIV/AIDS (www.nacoonline.org/index.htm
accessed 14 April 2005). Endogenous infections were the most prevalent (24.9%) and BV was the most common infection; the three sexually transmitted infections (CT, NG, TV) were relatively infrequent (4.2%). Older and married women, and those who were socioeconomically disadvantaged—for example, being a migrant, being illiterate, not having access to tap water, living in a small home, and being in debt, had a greater risk for RTI. The main limitation of our study is the possibility of a selection bias because of the refusal to participate (particularly of younger women, also reported in other studies15
). We did not include all STIs, such as viral STIs and syphilis. We did not have independent data on spousal sexual behaviour or symptoms. However, to the best of our knowledge, this is the largest population based study of RTI in women in India, and one of the largest from any developing country. We used gold standard diagnostic tests and ensured high levels of quality assurance. We used standardised and locally validated measures of risk factors and symptoms. Despite the invasive nature of the study, we enjoyed good participation rates.
The main similarity of our findings with those reported from the few Asian population based studies of RTI is the confirmation that, although rates of RTIs are high, the majority of RTIs are endogenous and BV is the commonest RTI. Cervical STIs are uncommon. In a review of studies of RTIs in south Asia,2
rates of cervical infections were reported to range from 0–5.2% while those of TV rates were higher (0.8–14.0%). A recent population based study from rural south India reported higher rates of gonorrhoea (3.6%) and trichomoniasis (5.2%).16
Our rates fall within the lower end of these ranges, perhaps reflecting the relatively lower levels of social disadvantage in this community compared to other communities in India.9
A similar study from the Gambia reported very low rates of NG (as low as 0%) and comparable rates of CT.15
On the other hand, a study from Peru showed much higher rates of all RTIs (70.4%), and CT (6.8%).17
Rates of RTIs/STI are not consistently higher in studies of women attending health centres with the complaint of vaginal discharge; for example, while in a New Delhi study,18
rates were high (12.2% CT; 10% TV), a similar study in primary care in Bangladesh reported rates comparable to our study.19
The higher New Delhi study rates possibly reflect the low income urban demographic characteristics of the sample.
Gender disadvantage, particularly spousal violence, was consistently associated with BV; this may reflect the lack of control women have over their hygiene and possible effects of stress on vaginal flora. Low social integration and concern about a husband's extramarital relationships, a potential indicator of sexual risk, were associated with STI; however, other indicators of gender disadvantage were not associated with STI. We are not aware of other studies that report on risk of gender disadvantage and there are inconsistent findings regarding other risk factors; in west African studies with health centre attenders, older age, marital status, or having a new sexual partner in the previous 3 months were associated with CT/NG.20
Younger age, unemployment, and lack of financial support were associated with STIs in South Africa.21
After adjustment for socioeconomic factors, STI were less common among women who had been pregnant and who had had abortions, perhaps reflecting the role of chlamydia on fertility. The use of contraception, particularly oral contraceptives and condoms, was associated with a reduced risk for BV. These associations have been seen in previous studies.22,23
The reduced risk of BV among women using oral contraceptives may result from oestrogens stimulating vaginal epithelial cells to produce more glycogen.24,25
This creates a more favourable environment for lactobacilli and thus may prevent colonisation by anaerobes. The increased risk among women not using condoms may be another marker of gender disadvantage in our setting; condom use is rare among men and is attributed to the lack of control women have over their sexual health. Sterilisation was associated with higher risk for STI, perhaps owing to the fact that women who have been sterilised are less likely to engage in protected sexual intercourse because of the absence of risk of an unwanted pregnancy. With regard to clinical symptoms, only a non‐white vaginal discharge showed a significant association with STI and BV. Presence of any genital symptom was significantly associated with BV.
Thus, rates and risk factors for RTI/STI are likely to be highly dependent on local contextual factors, such as poverty, gender disadvantage, and contraceptive use, and findings from one study cannot be generalised to any other population. We confirm the role of gender disadvantage for the risk of RTI, though this is most marked only for BV. The risk factors for STIs indicated that disadvantaged women were likely to be infected by their husbands; thus, women who were older, less educated, married and poorer, who had concerns regarding their husband's extramarital relationships, whose husbands also had a genital discharge, and who were socially isolated had higher risks. It is often clinically easier and more effective to diagnose and treat men with STIs than women in resource poor settings and this may prove to be an effective strategy in controlling the spread of STIs, and reducing the burden in women.26
Women who have had a sterilisation operation should be informed that the risk for STI is not reduced through this intervention. Although the population prevalence of RTIs is high, the bulk of the burden comprises endogenous infections for which treatment is not always necessary for asymptomatic women.27,28
The feasibility of self administered swabs10
and relatively cheap and simple diagnostic tests for endogenous infections may make this a reasonable way of identifying infections in symptomatic women.
- The prevalence of RTI among women aged 18–50 years living in a relatively stable community in a relatively well developed region of India is high. An STI (gonorrhoea, chlamydia, or trichomoniasis) was detected in 4.2% of the sample
- Socioeconomic deprivation and gender disadvantage were associated with raised risk for BV while the use of oral contraceptives or condoms was associated with reduced risk
- The risk for STI was greatest in poorer, socially isolated, older, married women whose husbands were engaged in extramarital relationships and had a genital discharge
- Women's gynaecological complaints had little association with either infection