|Year : 2017 | Volume
| Issue : 2 | Page : 274-278
Need for revisiting the role of sexually transmitted disease clinics in government hospitals in India
Madhulekha Bhattacharya, Hema Gogia
Department of Community Health Administration, National Institute of Health and Family Welfare, New Delhi, India
|Date of Web Publication||7-Dec-2017|
Dr. Hema Gogia
115, Vasant Enclave, Palam Marg, New Delhi - 110 057
Source of Support: None, Conflict of Interest: None
Introduction: The Government of India provides treatment for sexually transmitted infections (STIs) through government's sexually transmitted disease (STD) clinics with the mandate of providing curative and preventive services for clients in the context of STIs. However, besides the patients suffering from STDs, other clients with problems related to reproductive and sexual health also attend these clinics. This study aimed to assess the profile and treatment-seeking behavior of clients attending STD clinics in government hospitals in India. Materials and Methods: This multicentric, cross-sectional study with 5098 participants was conducted over 2 months in identified 19 Indian states. Chi–square test was used for statistical analysis. Results: The percentage with STDs (62.98%) was nearly double than those with non-STDs (37.1%). Around 8.2% of patients had an STD and were also HIV positive. Compared to the total STD cases, only 9% of the partners had turned up for screening. Of significance were the non-STD cases who presented with both physical and psychological symptoms including infertility. Among males, it was mainly sexual dysfunction and balanoposthitis, and in females, lower abdominal pain and bacterial vaginosis. Only 27.3% reported that they had come directly to the government facility/clinic. Nearly 38% of males and 30% of females had tried home remedies before coming to the government clinic. Majority (77.9%) of the clients reported that they had never been counseled on any aspect of STD or HIV. Conclusion: The profile of clients in the various clinics across the country indicates that the name “STD Clinic” is a misnomer since the presenting complaints of clients are varied, and related not only to STDs but also to other reproductive tract problems. Furthermore, the average new patient load observed in our study is low and this was attributed to the name “STDs” given to these clinics. Renaming them as “Reproductive Health Clinics” would attract more patients and lead to better utilization.
Keywords: Health-seeking behavior, reproductive health, sexually transmitted diseases, stigma
|How to cite this article:|
Bhattacharya M, Gogia H. Need for revisiting the role of sexually transmitted disease clinics in government hospitals in India. J Family Med Prim Care 2017;6:274-8
|How to cite this URL:|
Bhattacharya M, Gogia H. Need for revisiting the role of sexually transmitted disease clinics in government hospitals in India. J Family Med Prim Care [serial online] 2017 [cited 2019 Jul 22];6:274-8. Available from: http://www.jfmpc.com/text.asp?2017/6/2/274/220011
| Introduction|| |
Sexually transmitted diseases are a major global cause of acute illness, infertility,, long-term disability, and premature death of population worldwide, and more than one million sexually transmitted infections (STIs) are acquired every day across the globe. Sexually transmitted diseases (STDs) are a public health problem in India as well., Studies suggest that every year 5%–6% of the adult population in India is infected with one or more STIs/reproductive tract infections (RTIs)., The 2005 ICMR multicentre rapid assessment survey indicated that 12% of female clients and 6% of male clients attending the outpatient departments had complaints related to STIs/RTIs., Many STDs, such as syphilis, gonorrhea, and chlamydial infections, are easy to diagnose and treat, but still millions of cases are left untreated since many STDs are asymptomatic leading to continued transmission and serious sequelae. Partner treatment is another big challenge which needs to be handled at the STD clinics. Easily accessible clinics will encourage the clients to seek treatment in time.
The Government of India provides STD treatment facilities through STD clinics in hospitals, majority of which are in government hospitals or medical colleges. However, only a minority of people with STD present to public health facilities  due to the stigma attached to the disease. The nomenclature of STD or VD clinic further complicates the matter. Thus, the thrust required for a disease of significance with widespread morbidity hidden in the community is left incomplete. Besides, patients with non-STD reproductive problems also access these clinics for treatment. Thus, to improve the functioning of these clinics, profiling the patients coming to these clinics becomes necessary to assess the situation and suggest steps for intervention.
The study aimed to assess the profile and treatment-seeking behavior of clients attending STD clinics in government hospitals in India.
| Materials and Methods|| |
A cross-sectional, descriptive, multicentric study was conducted in twenty STD clinics, functioning in government hospitals, including medical colleges and district hospitals, in 19 states across the country.
Coded interview schedule prepared at the central level and pretested in a STD clinic was utilized for data collection. Before starting the data collection, all the investigators were trained in the technique of administering the interview schedule to patients. Ethical clearance was obtained from the Ethical Committee of the institute.
All the new clients consecutively attending the clinic in the period of 2 months were included in the study and counted only once. Clinical and syndromic approach was followed for diagnosis. Informed consent from each patient was obtained at the time of data collection. Refusals were noted and it was found that around 156 clients did not give their consent to participate in the study. Data were collated and analyzed using IBM SPSS Statistical software version 23.0. Data entry was made using the coded formats recorded at the various STD clinics by the research teams. Analysis for demographic variables was done in two groups those with a STD according to syndromic approach and the non-STD patients diagnosed based on history and clinical examination. Percentages and Chi-square statistical tests were used to arrive at the results.
| Results|| |
The total number of clinic attendees was only 5098 comprising 3144 males and 1954 females. Considering six working days in a week, the average new patient load in a day per STD clinic was calculated to be around 5–6 patients, thereby reflecting a low new patient influx.
Patients of all ages attended the clinic [Figure 1]. The maximum percentage of clients in both groups was between the ages of 20 and 34 years. Patients with STDs dominated till age 34, but beyond that age, patients with other problems surpassed the ones with STDs. The difference was statistically significant with P = 0.02. Adolescents and fifty plus individuals were also accessing the clinics but in small numbers.
|Figure 1: Age distribution of patients coming for sexually transmitted diseases and other problems|
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Among the patients, majority were males in both the groups [Table 1]. Among the study population, the percentage of those with STDs (62.98%) was nearly double of those with non-STDs (37.1%). Among the patients with STDs, 60.44% were males and the remaining were females (39.55%). The same sex distribution was observed among the patients with non-STDs also. The difference between percentage of males and females attending the STD clinics was found to be statistically significant with P = 0.048 at 95% confidence interval.
|Table 1: Sex-wise distribution of patients coming for sexually transmitted disease problems and other problems|
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Patients came with diverse complaints which comprised those with STDs and non-STDs [Table 2]. Around 8.2% (8% of the male patients and 8.6% of the female patients) of STD clinic attendees had a STD and were also HIV positive. Compared to the total STD cases, only 9% of the partners had turned up for screening, indicating the hesitation and the lack of awareness about the need to rule out the presence of an STD and to get treatment.
|Table 2: Symptoms reported by patients for attending the sexually transmitted disease clinics|
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Of significance are the non-STD cases who presented with both physical and psychological symptoms. The symptoms pertaining to sexual dysfunction, mainly reported by males, were mostly about premature ejaculation, semen wastage, and decreased libido. Infertility emerges as a cause for coming to the STD clinic. Other reproductive tract problems were common and thrice more in males than females. In males, the majority of them had balanoposthitis. Females mostly had fungal infection or bacterial vaginosis [Table 2].
Only 27.3% of the STD clinic attendees reported that they had come directly to the government facility/clinic and females (32%) were more than males (24.4%). Nearly an equal percentage of patients (23%) had gone to a private practitioner before accessing the STD clinic. Almost 38% of males and 30% of females had tried home remedies before coming to the government clinic. Patients, females more than males, had sought advice from quacks/unqualified medical practitioners also [Table 3]. The association between the health facility use and the sexes was found to be statistically significant with P < 0.001.
|Table 3: Health facility accessed by the patients before coming to the sexually transmitted disease clinics|
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Majority (77.9%) of STD clinic attendees reported that they had never been counseled on any aspect of STD or HIV. Of those who had received some counseling on preventive measures related to STDs or HIV/AIDS had been counseled during their visit to Integrated Counseling and Testing Centers (12.5%) and a very small percentage (1.5%) mentioned nongovernment organizations working in target intervention areas as the source of their counseling. About 8.2% of cases mentioned that they had received counseling on STDs or HIV/AIDS from a mixture of sources including friends, peer groups, sex partners, and health facilities [Table 4]. The association between counseled and not counseled was statistically significant (P < 0.001).
|Table 4: Percentage distribution of sexually transmitted disease clinic attendees ever been counseled for sexually transmitted disease/HIV/AIDS|
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| Discussion|| |
The study carried out in various STD clinics across the country highlights the utilization of the STD clinics not only by STD cases (63%) but also by other patients (37%), with symptoms related to reproductive health. The males were observed to report to the STD clinics in larger proportions than the females. Female attendance in low numbers in these clinics is due to several social, economic, and cultural barriers and as a consequence, their STD problem remained neglected and uncared. This factor has been observed in other studies as well.,,,,, The stigma attached to these clinics may be the primary reason for low attendance of females.
In our study, only 27.3% belonged to the category who reported directly to the government health facility for treatment of their STDs and this included 24.4% of male attendees and 32.1% of female attendees of STD clinics. These findings are similar to findings of behavior surveillance survey (BSS) 2001 which brought out that only 23% of respondents suffering from an STD sought treatment from government health facilities. The BSS 2006 survey reported this number at only 26%, the increase of 3% (in the number of females getting treatment in a span of 5 years) could be attributed to females getting better care for STD cases under National Rural Health Mission at government health centers in rural areas. Almost one-fourth (23.3%) visited a private practitioner, 5.2% stated that they first sought treatment from an easily approachable unqualified medical practitioner, and 9.5% stated that they tried more than one of the above-mentioned health facilities. Majority sought treatment from private practitioners or unqualified practitioners. According to the last National Integrated Biological and Behavioural Surveillance (IBBS) 2014–2015 for high-risk groups, one-fifth of the female sex workers (FSWs) reported that they sought treatment/advice from a private facility, while 11% reported seeking advice from a private pharmacy and another 13% from some type of alternate practitioners. Similar findings were seen among men having sex with men (MSM), where one-fifth reported visiting private facility (21%), about 13% reported seeking the help of a pharmacy/drug store, and 18% reported seeking advice from some type of traditional healer or AYUSH practitioner. In the National Behavioural Surveillance Survey for youth aged 15–24 years, observation was that treatment for the last episode of STDs was obtained from private clinics/hospitals (32%), followed by government clinics/hospitals (23%) and home-based treatment (22%). Home-based remedies were commonly sought by the patients in our study as well and the practice was more prevalent among males. Over one-fifth of the respondents who suffered from STD during the last 12 months had not sought any treatment.
Other studies regarding health-seeking behavior have also brought out that a large proportion of attendees in STD clinics first tried home remedies or visited a neighborhood quack or private practitioner. In one of the studies, nearly 50% of respondents who ever had an STD had taken treatment from a private practitioner whereas only 5% of respondents had sought treatment at an STD clinic. Another study in Zambia showed similar findings, wherein most of the patients with STD complaints received medication from sources other than the STD clinics. It is therefore important to educate the STD clinic attendees and discourage them from adopting home remedies for reproductive problems.
Low preference for government-run facilities could be due to shyness and stigma attached to accessing the STD clinics in the government hospitals. Studies have shown that perceived STD-related stigma  might be an important barrier to STD-screening behaviors. There is also a stigma related to STDs that is independently associated with lower odds of both males and females getting tested for an STD. Stigma may be a barrier to STD-related care-seeking behavior and should be taken into consideration before designing interventions to improve STD-related care seeking, especially keeping in mind the adolescent and geriatric age group. Increasing knowledge or health-care access alone may not address the barriers posed by STD-related stigma.
In our study, 37% of the STD clinic attendees had problems other than STDs. They reported other issues related to reproductive health such as infertility, burning micturition, lower abdominal pain, menstrual problem, sexual dysfunction, partner having STD, and other reproductive tract problems. This thereby reiterates that STD clinic attendees have a wide range of reproductive tract problems which may or may not be sexually transmitted, reflecting that an ideal clinic should offer and advertise a broad package of health services including STD services to decrease the embarrassment associated with being witnessed accessing services.
In our study, majority (77.9%) of the STD clinic attendees reported that they had never been counseled on any aspect of STD or HIV/AIDS. According to the IBBS 2014–2015, nationally, 63% of FSWs had received counseling for STI and 46% had received referral for HIV testing or other related services and 47% of MSMs reported that they had received counseling for STIs. These figures are high because the high-risk groups have special clinics at the targeted intervention sites. In the STD clinics, it is not only important to provide counseling to the STD clinic attendees but also to ensure that the information imparted is credible and reliable.
Partner screening and treatment was low, again indicating the hesitation of patients to visit the STD clinic. This was precipitated by the lack of counseling services as only 4.9% of the total patients or 9% out of the total STD patients had come to the STD clinic since their partner had STD. This is in contrast to the findings in a study on STD partner notification (PN) among African-American adolescent women, where 71% preferred to bring their partner to the clinic for treatment. PN for STIs is an important measure in STI management that interrupts transmission of infections and prevents reinfection and complications., The National Guidelines on Prevention, Management and Control of RTIs and STIs also emphasize on PN and management. It reiterates that both the partners need to be made aware, counseled, and treated, particularly the female partners of male patients with STIs since females often are symptomless and thus may not seek treatment. To overcome this problem, the Centers for Disease Control and Prevention has focused on Expedited Partner Therapy, in which the sex partners are provided with the same treatment as that prescribed to the patients diagnosed to have STD without the health-care provider having examined the partner.
Therefore, it is even more essential to provide a nonstigmatic environment not only to encourage the patients with STD to seek treatment from the government-run STD clinics but also to motivate their partners to seek treatment since STD/HIV risk assessment is not done very commonly in most clinical settings, and stigma of the clinic name compounds the problem.
The male and female sexual health issues are very important as the problems impact the quality of life and there are no formal clinics to attend these needs. Hence, the patients have no alternative choice but to come to a STD clinic. The same was observed in our study. The male patients were in larger numbers than the females. Premature ejaculation, indiscreet wastage of semen through excessive masturbation, wet dreams or excessive sexual desire, and decreased sperm count are all the major causes of sexual problems in males. The few females who came to the STD clinic for sexual dysfunction were courageous women because culturally sexual problems in females are not to be discussed and visiting a STD clinic for the same is stigmatic.
Thus, there is a distinct need for a clinic to address these issues. Changing the name of the STD clinics to “Reproductive Health Clinics” would encourage more patients of both the groups with STDs and non-STDs to make the clinic their first choice and not visit private doctors or quacks or try home remedies and prolong the disease. The clinics with a friendly environment should be a part of all hospitals and health centers. A STD specialist and a clinical psychologist cum counselor should be posted at the clinic to render services in a nonstigmatic environment and ensure optimum utilization of the current STD clinics.
| Conclusion|| |
The profile of clients in the various clinics across the country indicates that the name “STD Clinic” is a misnomer since the presenting complaints of clients are varied and related not only to STDs but also to other reproductive tract problems. Furthermore, the average new patient load observed in our study is low and this was attributed to the name “STDs” given to these clinics.
Therefore, a change in the name of these clinics to “Reproductive Health Clinics” will attract more clients of all ages and also motivate those visiting private or unqualified practitioners to come forward directly for services offered by the government leading to better utilization.
Financial support and sponsorship
This study was funded by the National AIDS Control Organization.
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. Global Incidence and Prevalence of Selected Curable Sexually Transmitted Infections-2008. Geneva: World Health Organization; 2012.
World Health Organization. Sexually Transmitted Infections Fact Sheet. Geneva: World Health Organization; 2015.
National HIV/AIDS Control Organization, Ministry of Health and Family Welfare, Government of India. National STI/RTI Control and Prevention Programme, NACP Phase 3. New Delhi, India: NACO, MoHFW, GoI; 2007.
National AIDS Control Organization. Training of Medical Officers to deliver STI/RTI Services. New Delhi: National AIDS Control Organization; 2011.
World Health Organization. A Rapid Assessment of Health Seeking Behaviour in Relation to Sexually Transmitted Disease. 1995: World Health Organization; 1995.
Ray K. Changing pattern of HIV infection in a tertiary care hospital in New Delhi, India. Int J STD AIDS 2004;15:753-7.
Khandpur S, Agarwal S, Kumar S. Clinico-epidemiological profile and HIV seropositivity of STD patients. Indian J Sex Transm Dis 2001;22:62-5.
Ramasubban R, Rishyasringa B. Treatment Seeking by Women in Mumbai Slums. In Workshop on Reproductive Health in India: New Evidence and Issues; 28 February, 01 March 2000, Pune; 2000.
Jaiswal AK, Bhushan B. Pattern of sexually transmitted diseases in North Eastern India. Indian J Sex Transm Dis 1994;15:19-20.
Parmar J, Raval RC, Bilimoria FE. Clinical profile of STDs at civil hospital Ahmedabad. Indian J Sex Transm Dis 2001;22:14-6.
Ranganayakulu B, Ravi Kumar GP, Bhaskar GV. Patterns of STDs at Karnool. Indian J Sex Transm Dis 1998;19:117-21.
National AIDS Control Organization-Ministry of Health and Family Welfare (Government of India); New Delhi; India. National Baseline General Population Behavioural Surveillance Survey Report; 2001.
National AIDS Control Organization-Ministry of Health and Family Welfare (Government of India); New Delhi, India. National Endline Behaviour Surveillance Survey; 2006.
National AIDS Control Organization-Ministry of Health and Family Welfare (Government of India); New Delhi, India. National Integrated Biological and Behacioural Surveillance (IBBS) 2014-15 – High Risk Groups; 2014-15.
National AIDS Control Organization-Ministry of Health and Family Welfare (Government of India); New Delhi, India. National Behavioural Surveillance Survey(BSS) 2006-Youth(15-24 years); 2006.
Balamurugan S, Bendigeri N. Health care-seeking behaviour of women with symptoms of reproductive tract infections in urban field practice area, Hubli, Karnataka. Natl J Res Community Med 2012;1:123-77.
Brackbill RM, Sternberg MR, Fishbein M. Where do people go for treatment of sexually transmitted diseases? Fam Plann Perspect 1999;31:10-5.
Faxelid E, Ahlberg BM, Ndulo J, Krantz I. Health-seeking behaviour of patients with sexually transmitted diseases in Zambia. East Afr Med J 1998;75:232-6.
Prasad JH, Abraham S, Kurz KM, George V, Lalitha MK, John R, et al.
Reproductive tract infections among young married women in Tamil Nadu, India. Int Fam Plan Perspect 2005;31:73-82.
Cunningham SD, Kerrigan DL, Jennings JM, Ellen JM. Relationships between perceived STD-related stigma, STD-related shame and STD screening among a household sample of adolescents. Perspect Sex Reprod Health 2009;41:225-30.
Fortenberry JD, McFarlane M, Bleakley A, Bull S, Fishbein M, Grimley DM, et al.
Relationships of stigma and shame to gonorrhea and HIV screening. Am J Public Health 2002;92:378-81.
Dennis FJ, Mary M, Amy B, Sheana B, Martin F, Diane GM, Kevin MC. Bradley SP. Relationships of Stigma and Shame to Gonorrhea and HIV Screening. Am J Public Health 2002; 92;379.
Tilson EC, Sanchez V, Ford CL, Smurzynski M, Leone PA, Fox KK, et al.
Barriers to asymptomatic screening and other STD services for adolescents and young adults: Focus group discussions. BMC Public Health 2004;4:21.
Buchsbaum A, Gallo MF, Whiteman MK, Cwiak C, Goedken P, Kraft JM, et al.
Sexually transmitted disease partner notification among African-American, adolescent women. Infect Dis Obstet Gynecol 2014;2014:619632.
Potterat JJ, Meheus A, Gallwey J. Partner notification: Operational considerations. Int J STD AIDS 1991;2:411-5.
Low N, Broutet N, Adu-Sarkodie Y, Barton P, Hossain M, Hawkes S. Global control of sexually transmitted infections. Lancet 2006;368:2001-16.
Volmink J, Siegfried N, van der ML, Brocklehurst P. Antiretrovirals for reducing the risk of mother-to-child transmission of HIV infection. Cochrane Database of Systematic Reviews: Reviews. Cochrane Database of Systematic Reviews. Chichester (UK): John Wiley & Sons, Ltd; 2007.
Workowski KA, Bolan GA. Morbidity and Mortality Weekly Report. Centres for Disease Control and Prevention; 2015.
Centres for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines; 2015.
McMahon CG. Premature ejaculation. Indian J Urol 2007;23:97-108.
] [Full text]
Verma RK, Rangaiyan G, Singh R, Sharma S, Pertti J. A study of male sexual health problems in a Mumbai slum population. Culture, Health & Sexuality 2001;3:339-52. Taylor & Francis Ltd (ISSN 1369-1058).
[Table 1], [Table 2], [Table 3], [Table 4]