4. ijgmp - epidemiological and clinical study of various sti’s among fsw’s

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EPIDEMIOLOGICAL AND CLINICAL STUDY OF VARIOUS SEXUALLY TRANSMITTED

DISEASES AMONG FEMALE COMMERCIAL SEX WORKERS

REVATHI T. N & CHETAN M

Department of Dermatology, Bangalore Medical College and Research Institute, Fort Road, Bangalore, India

ABSTRACT

A commercial sex workers is defined as a person who provides sexual service for money or other material gains

and includes those who work in brothels or are casual free lance sex workers. Most CSWs from the core/high risk groups.

They are often infected by their clients and subsequently transmit the inspection to other partners. A history of multiple sex

partners and co-infection with other STIs constitute potential risk factors associated for HIV infection among FSWs. This

study was conducted on 100 symptomatic FSWs to recognize various sociodemographic factors associated with their work

and different STIs in them. The mean age group of FSWs in this study is 31.29 that is the adolescent FSWs are vulnerable

to develop STIs.42% of FSWs were married but not living with their husband, 22% were divorced, 17% unmarried and

16% widowed in this study. This study shows about 81% of FSWs had more than 1 partner per day. More number of

sexual partners is responsible for the long exposure to various STIs and acquiring STIs.About 72% of FSWs were aware of

STIs occurring as result of their sex work, their transmission, treatment and prophylaxis. Still the remaining 28% were

partially aware and not aware of STIs. The education and awareness to recognize the symptoms of STIs and health seeking

behaviour of all the FSWs needs to be improved. Personal habits are the important risk factors in acquiring STIs, which

includes alcohol consumption, drug addiction, pan chewing, smoking. In this study 10% FSWs were abused with alcohol.

Majority (78%) of FSWs did not accepted any personal habits. None of them revealed about drug addiction. Under

socioeconomic classification of the CSW’s in this study around 78% belonged to lower middle category, 11% were of

upper lower category, 6% belonged to poor category and 5% of them were of upper middle category. This indicates that

predominantly the lower middle category i.e. the lower socioeconomic population were more leaning towards this

commercial sex activity. The main clinical feature in this study is chronic vaginal discharge (46%) and generalized

symptoms (28%). The genital lesions were observed in 20%.In India in the 1970s and early 1980s, syphilis and chancroid

were the main causes of genital ulcer disease, while viral genital ulcer diseases such as genital herpes were extremely rare.

With the recognition of HIV infection in the 1980s and subsequent behavioural, social and physiological changes, thepattern has shifted from predominantly bacterial to viral STIs. In the present study viral STIs are more compared to

bacterial STIs. HIV infection was 23%, HBV was 8%, genital wart was 8%, molluscum contagiosum 6% and HSV

infection was 2%. Among bacterial STIs was 8%. Vaginal candidiasis was seen in 5%. The present study CSW’s who

always used condoms were found to be 31%, who never used were 13% and 56% revealed that they used it occasionally

and not always. One more parameter studied indicated that around 23% of CSW’s were indulged in unnatural sexual acts

while 77% denied of any such acts.

KEYWORDS: CSW, STI’s, FSW’s, Condoms, Behavioural Parameter

International Journal of General Medicine

and Pharmacy (IJGMP)

ISSN(P): 2319-3999; ISSN(E): 2319-4006

Vol. 4, Issue 1, Jan 2015, 23-36

© IASET


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24 Revathi T. N & Chetan M

Impact Factor (JCC): 2.9545 Index Copernicus Value (ICV): 3.0

INTRODUCTION

A Sexually transmitted infections (STIs) are group of communicable diseases that are predominantly transmitted

by sexual contact. (1) STIs are major public health problem among the woman and Female Sex Workers (FSWs) are at

higher risk for developing countries. These diseases include syphilis, trichomoniasis, gonorrhoea, chlamydial infections,

HIV infections, genital ulcer diseases, candidiasis, bacterial vaginosis and hepatitis B infections. (2). STIs are also among

five leading causes of health problems in developing countries. STIs are also more dynamic than other diseases prevailing

in the community. Their epidemiological profile varies from country to country and from one region to another within a

country, depending upon ethnographic, demographic, socioeconomic and health factors. The clinical pattern is also a result

of the interaction among pathogens, the behaviour that transmit them and the effectiveness of preventive and control

interventions. (3)

STIs including HIV continue to be major health, social and economic problems in the developing world leading to

considerable morbidity, mortality and stigma. Sex workers are one of the core groups for transmission of STIs. It is

necessary to know the prevention of common STIs such as gonococcal infections, vaginal candidiasis; genital ulcers, HIV,

to design effective services. (4). A commercial sex worker (CSW) is a person who provides sexual service for money or

other material gains. In India majority of patients with STIs give history of having visited CSWs. Sexual exposure with

CSWs has been implicated as an important risk factors for Sexually transmitted infections spread because they experience

a higher rate of partner change, longer exposure to infection and poorer access to health care facilities. FSWs represent

important reservoir of STIs including HIV (5). FSWs are at particular risk for STIs and HIV infection. They often are

infected by their client and subsequently transmit the infection to other partners. (6) History of multiple sex partners,

irregular condom use by their clients and co-infection with other STIs constitute potential risk factors associated for HIV

infection among FSWs. (7)

In countries where definitive diagnosis are difficult, “a syndromic approach” to management of STIs is

recommended and practice, yet many STIs have common symptoms or are asymptomatic and therefore they go undetected

and untreated. (8. STIs are transmitted through sexual intercourse; Sexual intercourse is defined as sexual contact including

vaginal intercourse, oral intercourse or rectal intercourse. It can be transmitted between heterosexual or homosexual

partners. The older terminology of “venereal diseases” (VDs) largely has been supressed in the past 50 years by “sexually

transmitted diseases” (STDs) and more recently by “sexually transmitted infections” (STIs)(9). STIs differs from STD in

that STD conventionally includes infections resulting in clinical diseases that may involve the genitalia and other parts of

the body participating in sexual interaction eg., syphilis, gonorrhoea, chancroid, donovansosis, nongonococcal urethritis,

genital warts, herpes genitals, cervicitis, etc. Epidemiology of STIs results from the interactions between STI pathogens;

the behaviours that help transit them and effectiveness of prevention and control interventions. (5). Understanding the path

physiology and epidemiology of STDs is a critical step in developing rational diagnostic, treatment and control strategies.

Keeping in view of all the STIs prevailing in FSWs, this study has been conducted to know the clinicoepidemiology

parameters of STIs among symptomatic FSWs attending the outpatient, occurrence of various sexually transmitted diseases

among high risk population of female sex workers and to know the various risk factors involved, their social and

economical background in acquiring sexually transmitted diseases including human immunodeficiency virus.


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Epidemiological and Clinical Study of Various Sexually Transmitted Diseases among Female Commercial Sex Workers 25


MATERIALS AND METHODS

A total 100 female commercial sex workers attending outpatient /sexually transmitted diseases clinic of Victoria,

Bowring hospitals and also outpatient department clinic of non-government organization working in this field had taken in

this study.

Inclusion Criteria

The study group of FSWs who present with symptoms such as genital soreness, genital discharge, pain, swelling,

growth over genital area. FSWs with chronic constitutional and systemic symptoms and who were willing for clinical

examination and investigation.

Exclusion Criteria

The female sex workers who are not willing for clinical examination and investigation and who did not gave

written consent.

METHODOLOGY

Informed consent was obtained from all FSWS, who were taken for the study. The details of clinical symptoms

were recorded in the proforma. Their socioeconomic and demographic history were also entered which included age, urban

or rural background, education marital status, family conditions, age of first sex, number of clients per day and per month,

personal habits and drug addiction, monthly income, history of unnatural sex acts, use of condoms, recurring symptoms,

treatment history of unnatural sex acts, use of condoms, recurring symptoms, treatment history, awareness about STIs and

IEC activities, The NGO SPAD which is doing continuous work in this field was also involved and they referred or

brought symptomatic FSWs to our OPD for examination and follow up.

Examination and Sample Collection

FSWs were examined clinically with a female doctor and staff nurse. Per speculum examination was conducted

with aseptic precautions. With all aseptic precaution necessary samples were collected for the investigation at the

minor-OT of Vanivilas hospital. Smears were prepared on microscopic glass slides from vaginal discharge and

endocervical swab. Smear samples were sent to Department of Microbiology of Victoria Hospital. Patients were sent in

person to department of pathology Victoria, bowring, and vanivilas hospital, ICTC Victoria and bowring hospitals for

serological investigation.

Investigations Conducted

The necessary investigations were conducted according to the symptoms of the FSWs. These included tests for

HIV by ELISA, VDRL, tests for Hepatitis B-HBSag by ELISA, Tzanck smear, vaginal smear for KOH, clue cells, motile

forms, wet mount, vaginal smear for grams stain, vaginal swab for culture and sensitivity, endocervical smear for grams

stain, endocervical smear for culture and sensitivity.

Treatment Given: Treatment was given based on syndromic management protocol. Patients with chronic

constitutional and systemic symptoms were also sent for physician opinion and follow-up.

I.E.C Activities: The FSWs were also subjected to information, education, councelling activities at our OPD.

Information and advice regarding the disease condition and further care, hygiene, followup were given.


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Statistical Analysis

Descriptive statistical Analysis has been carried out in the present study.

RESULT AND ANALYSIS

In the present study, a total of 100 symptomatic female commercial sex workers (CSW) were examined and

investigated in Out patient department of Dermatology, BMCRI for various sexually transmitted diseases. The following

were the observation made from this study-

Age Distribution of the Cases

More number of STIs were seen in FSWs of the age group between 21-30yrs. The mean age in this study is

31.29yrs.

Table 1: Age Distribution of the CSWs

Sl No Age Group in

Years

No& %

1 11-20 5

2 21-30 47

3 31-40 35

4 41-50 10

5 51-60 3

Total 100

FSWs with age below 11yrs and above 60yrs were not found in this study. 58% of symptomatic FSWs were

married but not living with their husbands, 17% were unmarried, 13% were living with their husband and 12% were

divorced.

Distribution of Personal Habits among the FSWs

78% of FSWs did not reveal any personal habits, 10% revealed that they consume alcohol, 8% revealed pan

chewing as their habits and smoking was noticed in 3% of FSWs. Multiple habits were noticed in 1%.

Table 2: Distribution of Personal Habits of CSWs

Sl No Personal Habits No& %

1 Alcohol 10

2 Smoking 033 Pan chewing 08

4 Drug addiction (0)

5 Smoking & Alcohol consumption 01

6 No habits 78

Total 100

Distribution of Number of Sexual Partners of FSWs

STIs in FSWs were more who had 41-50 (42%) partners per month followed by 31-40partners (39%), 21-30

partners (9%) per month of them had below 21 and above 50 partners per month each.


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Table 3: No. of sexual Partners per Month

Sl No

No. of Sexual

Partners per

Month

%

1 Below 21 52 21-30 9

3 31-40 39

4 41-50 42

5 Above 50 5

Total 100

Table 4: Distribution of Cases According to Socioeconomic Status

Sl No Socioeconomic Status %

1 Upper middle 05

2 Lower middle 11

3 Upper lower 78

4 Poor 06Total 100

Table 5: Awraeness of STDs

Sl No Awareness %

1 Aware 72

2 Partially aware 11

3 Not aware 17

Total 100

In this study 72% of FSWs were aware of various STIs, 17% were totally unaware and 11% of them were

partially aware.

Chronic discharge per vagina was the most common clinical feature found, accounting to 46% followed by

generalized symptoms (28%) and genital lesions (20%).

Table 6: Distribuion of Cases According to Clinical Features

Sl No Clinical Features %

1 Chronic vaginal discharge (CDPV) 46

2 Genital lesions 20

3 Combined clinical features 6

4 Generalised symptoms (fever,

weight loss, fatigue, loose stool,icterus)

28

Total 100

Among combined clinical features, CDPV with pain abdomen and genital lesions were found in 2% of FSWs

each. Genital lesions and body lesions were found in 2% of them.


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Table 7: Distribuion of STIs

SL No STDS %

1 Vaginal candidiasis 05

2 Genital Warts 08

3 Herpes simplex infection 024 Molluscumcontagiosum 06

5 HIV infection 23

6 Hepatitis B virus infection 03

7 Syphilis 08

8 Vaginal candidiasis + bacterial vaginosis 01

9 HIV + co-infections 12

10 Normal commensals 32

Total 100

Genital warts and syphilis seropositivity were seen in 8% of the symptomatic FSWs. Molluscumcontagiosum in

6%, Vaginal candidiasis in 5%, HBV infection in 3%, HSV infection in 2% of FSWs in this study. Both Vaginal

candidiasis and bacterial vaginosis was seen one case.HIV seroprevelance was seen in 23%. Of 12 HIV seropositives, 4

were positive for HBV, 2 had positive serology for syphilis, 2 had HSV infection, 2 had candidiasis, 1 had genital wart.

One FSW had molluscumcontagiosum and HBV coinfection with HIV infection.Gonorrhea, genital Chlamydial infections,

bacterial vaginosis cases were not found in this study.In 32% of the symptomatic cases were concluded as normal

commensals. Among them 31 had chronic vaginal discharge and 1 had pain abdomen.In this study 23% of FSW’s practised

unnatural and 77% practised penovaginal sex.

Table 8: Data of Use of Condoms

Serial No Use of Condoms Total Number Percentage

1 Always yes 31 31%

2 Not always 56 56%

3 Never used 13 13%

31% of FSW’s always used condoms, 13% of them never used and 56% used condoms irregularly during

intercourse.

DISCUSSION

Prostitution, or sex work, has a very long history in India; the topic was discussed in texts written as for back as

the third century BC. (11) FSWs represent an important reservoir of STIs, including HIV. The mean age of FSWs in this

study is 31.29yrs which correlates with other studies conducted in India. Panchanadeswaran S et al found the mean age of

FSWs in their study on 100 CSWs n Chennai in 2010, was 32.3, 62% were in the age group of 30-39yrs and 28% wee in

20-29yrs group. 10% were in the >40 age group. Total 42% of FSWs were married but not living with their husband, 22%

were divorced, 17% unmarried and 16% widowed in this study. This may be due to, some women, given limited options,

choose sex work as a means to support their families after being widowed, divorced, or abandoned by their husbands.

While 76% of the FSWs were currently married and living with spouse, 8% were widowed, 6% were deserted and 10%

were unmarried in a study conducted by Panchanadeswaran S et al., at Chennai in 2010. (14). In a study conducted in

China by Cai et al in 2010 on 324 FSWs, 50% were unmarried (22)


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Distribution of Personal Habits

72% of FSWs did not reveal any habit which requires further enquiry. With remaining FSWs 10% showed alcohol

abuse, 8% pan chewing and 3% smoking. These habits especially alcohol abuse increases the high risk sexual behaviours

by adopting abnormal sexual practices, unprotected sex and also violent behaviour. Similar observations were also made

by other studies. 39% of the FSWs were reported consuming alcohol before meeting their clients by Panchanadeswaran S

et al at Chennai in 2010 (21). 867 FSWs had more than one habit but commonest were betel nut chewing (67.59%) and

alcohol consumption either alone or with the clients (61.1%) reported in Kolkota. Drug abuse was not agreed by any of the

sex workers.(43) Though the drug abuse among FSWs is the major risk behaviour in acquiring STIs, none of the FSWs in

this study revealed this habit.

Distribution of Number of Sexual Partners

In this study about 81% of FSWs had more than 1 partner per day. This result compares well with other studies

conducted in other parts of India. Khan MA and Sehgal A in 2010 found about 68% of CSWs entertain >3 clients per day

in Delhi. (44=18) Studies and longitudinal behavioural surveillance survey (BSS) data reported that CSWs see on average

three clients a day in India (11).The average no of clients visiting 867 CSWs in Kolkota studied by Raut DK et al in 2003

was 2.67 per day. (43). In a data published by Buzdugan R et al in 2010 about FSWs in Karnataka, HIV prevalence was

30% and other STIs were 27% seen in street and lodge based workers. They had relatively high client volume of 51 clients

per month(45). Cai et al in China studied 324 CSWs among which 41% had an average no of 3 sexual partners per day (22).This shows their more exposure to different sexual partners and the more chances of

getting STIs in FSWs

Distribution of Awareness among FSWs

FSWs lacking self-protection consciousness are at an extremely high risk of acquiring STIs. In this study 72% of

FSWs are aware about various STIs and their prevention in this region. Where other studies showed quite lower percentage

of awareness. Raut DK found the knowledge of STIs was quite low, 49.48% of CSWs had heard about STIs and around

49.6% knew that these infections could be prevented by condom use. (45) Cai et al in 2010 reported 60.8% of FSWs had

knowledge about STIs in China. (22)

Distribution of Socioeconomic Status of FSWs

Driven by extreme poverty faced by their families and lure of relatively large incomes, some women choose this

profession. Most of the sex workers had less education level which was also reported by other workers. (6, 22). They also

had less monthly income like other studies. (22),

Distribution of Clinical Features

The most common symptom among 100 FSWs was chronic vaginal discharge (46%) followed by generalized

symptoms (28%). 20% of them had genital lesions.Talsania et al in their study from Ahmedbad, vaginal discharge was the

major compliant followed by genital ulcer (4.9%), pain during intercourse (4.3%), burning micturation and lower

abdominal pain. (1)Desai VK found vaginal discharge in 51.7%, pain in lower abdomen in 19.5%, genital ulcer in 5.9%

out of 118 FSWs in Surat. (4)


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Distribution of STIs in FSWs

India has multiple epidemics of HIV in different geographical settings and among people with different types of

risk. FSWs were the main group among these.

Table 25: Comparison of STIs (%) in Different Studies Conducted (4,2&)

Sl

NoSTIs

DESAI VK 2003,

SURAT

SHETHWALA

ND 2009 Surat

TALSANIA NJ

2007,

Ahmedabad

Present

Study

1 Vaginal candidiasis 10.33 5

2 Genital Warts 8

3 Herpes simplex infection 0 2

4 Molluscumcontagiosum 6

5 HIV infection 43.2 11.6 3.2 2.3

6 Hepatitis B virus infection 3.33 3

7 Syphilis 22.7 6.66 3.7 8

8 Gonorrhoea 16.9 0 09 Genital Chlamydia 8.5 0 0

Bacterial vaginosis 13.33 1

10 Trichimoniasis 14.4 2 0

Figure 1


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Figure 4

Figure 5


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Among the genital lesions syphilis and genital warts accounted for 8% each, molluscumcontagiosum for 6%.

Dhawan J and Khandpur S observed an increase in cases of molluscumcontagiosum in South India. (24)Number of syphilis

cases in this study is higher when compared to a 10 months study in Bangalore in 2010 3.7% had RPR titre>1:8. (46)

HBV infection (3%) was found to be similar to other studies. HbsAgseroprevalence in FSWs was 24% in

Tirupathi.HSV seroprevalence in this study is 2%, lower compared to reports, 38% from Chennai and 57.2% from Goa in

2007. (24)Bacterial STIs, gonorrhoea, genital chlamydial infection and bacterial vaginosis were not found.

Trichomonalvaginalis infection was also not found. Vaginal candidiasis was associated with bacterial vaginosis in one

case.

Low HIV and high STIs among CSWs in brothel was found in Bangladesh in 1998. (47)

In India, HIV seroprevalence rates among sex workers have ranged from 50-90% in Bombay, Delhi and Chennai.

(18)HIV prevalence among sex workers in South India ranges from less than one percent in some districts of Kerala and

Tamil Nadu to more than 30% in districts of Maharashtra and Karnataka. (24) In this study HIV infection was observed in

23%. This low infectivity may be due to greater awareness of FSWs about STIs and their prevention.In this study 32 cases

of CDPV showed normal commensals by microbiological investigations. The factors that can be attributed to this were,

these patients had chronic and recurrent symptoms and had history of being treated for the same at different occasions.

Also some of the symptoms could have been cases of physiological discharge.

HIV and Co-Infection

STIs have been found to increase the transmission of HIV. HIV and HBV share a common mode of transmission

– sexual, parenteral and perinatal. The presence of genital ulcers because of syphilis can facilitate the transmission of HIV

and increase the risk of acquiring HIV. (20)In this study HBV and Syphilis co-infection with HIV were found 4% and 2%

(1 was secondary syphilis) respectively, less compared to other studies conducted in other parts of India. In Surat the HIV

and HBV co-infection was 5.27% and HIV and syphilis 14.28% (2). In Raipur, Chattisgarh area in 2005 the prevalence

rate of HIV and HBV was 5% in CSWs. 23.3% of CSWs showed positive VDRL test for Syphilis. (42) vaginal candidiasis

in HIV infected FSWs is observed in 5% where as a higher percentage (17.4%) was observed in a study by Shwetala in

Surat (2).Silverman JG found 74 (30.1%) positive for HIV antibodies from 204 sex trafficked women and girls from

Nepal. Syphilis and HBV infection among HIV infected sex workers were 31% and 9.1% respectively. (23)

CONCLUSIONS

The continuous surveillance, early diagnosis, appropriate treatment and rigorous follow up is of utmost

importance in limiting the transmission of STIs. The average age group of CSWs which is around 31 years shows CSWs

are more active in their prime reproductive age and forms one of the easy routes of earning when compared to the more

aged to meet their financial needs, to meet their two ends and to support their dependents. This shows these FSWs had

adapted sex work as their occupation for their money and to support their family.

In this study people who were away from family life such as living single, separated from husbands, divorced,

widowed were found to be more involved in commercial sex work focussing various aspects of society and economic

needs. Out of 32 cases chronic discharge per vagina majority of the investigation showed normal commensals

microbiologically. This may be explained by the fact these CSWs were chronic patients and on many occasions they were


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treated according to the syndromic management by the NGO SPAD where they were enrolled. Many of CSW in this study

who presented with chronic generalized constitutional and systemic symptoms also were found to be retropositive. Also in

our study co infections were found in quite a number of patients and most of the co infections were of viral origin

indicating a trend that shows a gradual shift of infections from bacterial to predominantly viral infections in the era of HIV.In this study the number of CSW’s having awareness about STI’s was significantly high but a number of CSW’s who used

condoms always did not match with the awareness criteria. The percentage of CSW’s who followed unnatural methods of

sexual act was far less when compared to natural methods of sexual act which may correlate with their awareness levels.

The socioeconomic criteria lower socioeconomic groups were found to be more indulged in commercial sex activities.

These diseases can be controlled by promoting strategies to reduce high risk behaviour, encouraging condom use,

strengthening STI clinics and family health awareness programs, adolescent health clinics, mass health campaigns in areas

of preventive, curative and also measures for overall betterment of such group.More extensive developmental work aimed

at betterment of living conditions of CSWs is required for effective HIV/STIs prevention in the form of education for their

children, employment opportunities, self-help groups, erasing the social stigma faced by such population and allowing

them to lead a respectable life in the main stream of society.

ACKNOWLEDGEMENTS

The author acknowledge the Dean and Professor and head, Department of Dermatology and Venerology, BMCRI,

Fort Road, Bangalore

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