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Sexually transmitted infections (STIs) are a major public health problem in developing nations. Identification of risk factors can help in formulating effective strategies against them. The present study was conducted in a tertiary care hospital in North India over 1 year to identify the risk factors associated with STIs.
A questionnaire-based cross-sectional case–control survey was conducted where participants answered questions on demographic details, sexual behavior, and awareness of STIs. Cases were patients with STIs whereas controls were randomly selected from healthy individuals accompanying patients with nonvenereal complaints attending our hospital.
There were 106 cases and 64 controls. STI patients had sexual debut 2 years before controls. A higher proportion of STI cases had lower education, multiple sexual partners, lived separately from their partner, had nonregular partners, had protected sex in the last month, had sex under influence of alcohol/illicit drugs, sex in unstructured settings, and engaged in transactional sex, in comparison to controls (P < 0.05). More cases were aware of the symptoms/preventive measures of STIs (P < 0.001). On multivariate analysis, multiple sexual partners, sex under influence of alcohol/illicit drugs with nonregular partner, protected sex in the last month, and knowledge of preventive measures were found to be statistically associated with STIs (P < 0.05).
Our study identifies risk-behavior patterns in patients with STIs, which should be modified to reduce the burden of these diseases. Increasing the knowledge about STIs in these patients can translate into more common condom usage that lends support for strengthening sexual health programs at grass-root levels.
The small size of the study population could have led to decreased power of the study to detect differences between cases and controls. The external validity of our results needs to be tested in different population groups involving larger sample sizes.
Sexually transmitted infections (STIs) continue to remain a major public health problem in developing nations, despite studies showing a gradually declining trend in the number of new cases attending hospitals.[1,2] Patients with STIs are known to exhibit certain behavioral characteristics, which put them at an increased risk of these infections. Identification of these risk factors can help in formulating effective intervention strategies to control their transmission in the community. Like the epidemiology of STIs which varies from country to country, these risk factors may also differ between different population groups. In the absence of good quality data on the risk profiles for STIs in the Indian population, we undertook this study to find the factors associated with STI in patients from North India.
This was a cross-sectional, case–control study conducted at the Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India. The study was conducted prospectively over a period of 1 year (January–December 2012) after approval from the Institutional Ethics Committee (IEC/NP/350-2011). Cases were patients with confirmed STI attending the STI clinic for the first time as well as those on their follow-up visit. Controls were randomly selected from individuals who accompanied patients with nonvenereal complaints, attending the outpatient dermatology department. All the participants were asked to fill a structured questionnaire after an informed consent with the help of a trained female STI counselor, wherever required. The questionnaire consisted of items related to demography, sexual behavior, and STI awareness.
Data for all the controls were analyzed for demographic details and STI awareness, while analysis for sexual behavior was restricted to only sexually active controls. Univariate comparison of cases and controls was done using Chi-square test for dichotomous variables and two-sample t-test for continuous variables. The odds of a variable being associated with a STI were estimated using logistic regression models. Those variables found to have a statistically significant association with STI (P < 0.05) on univariate analysis were selected for multivariate logistic regression analysis. The statistical analysis was performed using Stata 12 software (Stata Statistical Software, Stata Corp., 2011: Release 12, College Station, StataCorp LP, TX, USA).
One hundred and thirty-two patients with STIs and 116 controls were approached for the study, out of which 106 (80.3%) patients and 64 (55.17%) controls agreed to fill the questionnaire. There was no significant difference in age, gender, and employment status between cases and controls. Statistically, more controls had received higher education than STI patients (P = 0.023), while a higher proportion of cases (78/106, 73.6%) were married as compared to controls (38/64, 59.4%), which almost reached statistical significance (P = 0.054). All the cases and 70% (45/64) of the controls admitted to having sex at least once in their lifetime (P < 0.001). STI patients had their sexual debut about 2 years earlier than controls (19.10 ± 2.93 vs. 21.08 ± 3.78 years). The risk for STI decreased by 17% for every year delay in sexual debut (odds ratio 0.83, 95% confidence interval: 0.74–0.93, P = 0.001). A significantly higher proportion of cases (17/106, 16% cases vs. 3/64, 4.7% controls, P = 0.031) was either homosexual (all were men having sex with men: nine cases and three controls) or bisexual (eight cases and no controls). In both men and women, the number of sexual partners was significantly higher in cases as compared to controls (P < 0.001). Around 65% (n = 69/106) of the STI patients and 18% (n = 8/45) of the controls reported having multiple lifetime sexual partners. Compared to 26.7% (n = 12/45) of the controls, about 65% (n = 69/106) of the cases had nonregular sexual partners, and a higher proportion of STI cases (61/106, 57.5% vs. 14/45, 31.1%) did not live with their partner (P < 0.001). Regarding condom usage, no significant difference was observed between cases and controls when compared for the first (31/106, 29.2% cases vs. 14/45, 31.1% controls) and last (59/106, 55.7% cases vs. 20/45, 44.4% controls) sex. Surprisingly, more controls (41/45, 91.1%) had unprotected sex in comparison to cases (77/106, 72.3%) in the last month (P < 0.001). There were statistically significant differences for reasons of using and not using condom between the two groups. The most common reason for using condom was contraception in both the groups (47/106, 44.3% cases and 28/45, 62.2% controls), while a higher proportion of STI patients (19/106, 17.9% cases as compared to 1/45, 2.2% controls) reported condom use to prevent sexually transmitted diseases. More than half the cases (47/92, 51.1%) who did not use condom did so due to dislike as compared to 8 (14.8%) controls. Less than 10% of the participants in both the groups (6/92, 6.5% cases and 5/54, 9.3% controls) reported desire for pregnancy as the reason for not using condom. A significantly higher proportion of cases liked to take alcohol/illicit drugs while having sex (46/106, 43.4% cases vs. 6/45, 13.3% controls, P < 0.001). About 55% (n = 58/106) of the cases had sex in an unstructured setting (brothels, travel/vacations, etc.) as opposed to 20% of the (n = 9/45) controls (P < 0.001). A higher proportion of cases had sex in exchange for money or gift (52/106, 49% cases vs 4/45, 8.9% controls, P < 0.001). Although more cases (76.9%, 40 of 52 cases who had transactional sex, vs 50%, 2/4 controls) used condom while engaging in transactional sex, the difference between the two groups was not statistically significant (P = 0.231). Significantly, more STI patients were knowledgeable regarding the STI symptoms (genital ulcer, discharge, itching, swelling, dyspareunia, and painful micturition) and preventive measures (sexual abstinence, protected sex, and partner notification) as compared to controls (P < 0.001). Around 80% of the cases were aware of the symptoms (n = 85/106) and knew at least one method to prevent STIs (n = 83/106) in contrast to only 50% (n = 32/64) and 19% (n = 12/64) controls, respectively [Table 1].
Step-wise multivariate logistic regression analysis revealed the following variables to be significantly associated with STIs: multiple lifetime sexual partners, use of alcohol/illicit drugs while having sex with a nonregular partner, use of condom in the last 30 days, and knowledge of methods of STI prevention [Table 2].
Multiple sexual partners and sex under the influence of alcohol/illicit drugs are well-established risk factors for STIs.[4,5,6,7,8,9,10,11,12] Our finding of earlier age of sexual debut being associated with a higher risk of STIs is also consistent with the previous results.[7,13] We found the STI risk to decrease by about 17% for every year by which the sexual debut was delayed. In addition, variables such as lower education status, homosexual/bisexual orientation, having a nonregular sexual partner, staying away from partner, engaging in transactional sex, and having sex in unstructured settings were associated with STIs on univariate analysis but not in multivariate analysis in our study, probably due to the small number of controls. Instead of dismissing these factors, they may be better viewed as showing a trend for STI risk.
Two interesting findings have emerged from our study. First, the awareness regarding STI prevention was higher among STI patients, and second, more frequent condom use was reported by STI patients as compared to controls. These findings appear to be contrary to conventional belief: knowledge of preventive measures should exert a protective effect against STIs, and condom use has been demonstrated to be associated with a lower risk of infection in many studies.[5,6,7,8,14] However, the increased awareness among STI cases in our study could be attributed to the counseling imparted to them regarding safe sexual practices during their visits to the clinic. Since no efforts were made in our study to recruit only the first-time attendees, many of our cases were on their follow-up visits at the time of study participation and had already been counseled at our STI clinic (which is a tertiary- care center) or other centers. The more consistent condom use among the STI patients probably reflects the effect of this counseling, and it is encouraging to see it being translated into a safer sexual practice. More than half of the STI cases used condom in their last sex, an increase from roughly 30% who used it at their first sex. Diclemente et al. also noted that a past STI diagnosis was associated with an increased knowledge of STI prevention among the African-American female adolescents, however that was not associated with higher rates of condom use. Of course, the other explanation for our finding could be that the risk due to unprotected sex in the controls is offset by a higher proportion of monogamous relationships, lack of transactional sex, and use of contraceptive measures other than condom in a relationship with a trusted partner. It seems that the health education being imparted to patients with STIs is focused predominantly on condom promotion, as other high-risk behaviors (such as polygamy, having sex under the influence of alcohol/illicit drugs or in unstructured settings, and engaging in transactional sex) were still more prevalent in these patients as compared to controls. One worrisome finding was the lack of STI-related knowledge in our study participants: about 45% of the study population was not aware of precautions to prevent transmission of the infection, and about one-third was not aware of STI symptoms. The fact that these knowledge gaps were more apparent in the controls as compared to cases suggests that health education is being imparted only to the patients, instead of general population. Thus, our observations lend support for sexual health education, long considered a “taboo” in our country, to be made a part of school curricula.
Our study has certain limitations. The sample size of our study population, especially the controls, is small, which could have led to decreased power of the study. Recruiting controls from the community, instead of hospitals, could have helped us gather data from a larger population. The low response rate could bias our results, as it is possible that only a certain type of controls, for example, those who considered their behavior “correct,” may have answered the questionnaire. As the study population belonged to North India, our results cannot be generalized to the whole country.
Our study provides insight to the risk behavior profile of patients with STIs in North India. The results of this study have implications for preventing the spread of STIs in North India.
There are no conflicts of interest.