a cross sectional study of sexually transmitted infections

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

Dr.M.Selvakumar M.D. D.D.,Associate Professor,Department of DVL

Head of the Department

Dr.P. Nirmaladevi. M.D.,Professor& HOD,

Department of DVLDepartment 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



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

Date:

Dr.VIJAIKUMAR.M.G.Register No.: 201730256

Post graduate in M.D DVL,Department of DVL,

Tirunelveli Medical College,Tirunelveli-627011

ACKNOWLEDGEMENTLanguage 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



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

1

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.

2

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.

3

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.

4

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).

5

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

6

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

7

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

8

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

9

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

10

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.

11

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

12

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

13

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.

14

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.

15

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

16

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

17

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;

18

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.

19

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

20

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

21

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

22

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.

23

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.

24

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

25

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.

26

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

27

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.

28

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

29

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

30

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

31

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

32

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.


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

33

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.

34

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


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.

35

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.

36

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


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

37

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.


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.

38

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

39

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.


Clinically BV can be diagnosed using the Amsel criteria 61

Thin, white, homogeneous discharge.

Clue cells on microscopy

pH of vaginal fluid >4.5

40

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

41

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.

42

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

43

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

44

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

45

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

46


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.

47

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.


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

48

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.

49


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.

50

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


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.

51

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

52

Non candida albicans

women with uncontrolled diabetes mellitus or immunosuppression or

pregnant


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

53

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.


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

54

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.


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,

55

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.

56

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

57

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.

58

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.

59

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.

60

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,

61

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.

62

RESULTS

STATISTICS AMONG HIGH RISK GROUPSThese 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 Percent10-19 3 0.720-39 295 64.140-64 158 34.3>65 4 0.9

Total 460 100.0

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.

0

50

100

150

200

250

300

10-19 20-39 40-64 >65

3

295

158

4

AGE DISTRIBUTION

63

TABLE 2: ANALYSIS OF PATIENT’S GENDER ATTENDING OPD

Gender Frequency PercentMale 351 76.3

Female 69 15.0Transgender 40 8.7

Total 460 100.0

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.

351

69

40

Male

Female

Transgender

64

TABLE 3: LIST OCCUPATION STATUS

Occupation Frequency PercentFEMALE SEX WORKER 28 6.1COOLIE 2 0.4DRIVER 67 14.6HOUSEKEEPING 56 12.2MIGRANTS 33 7.2OTHERS 263 57.2STUDENT 11 2.4Total 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 PercentMarried 366 79.6

Unmarried 93 20.2Widower 1 0.2

Total 460 100.0

Among 460 patients, 79.6% were married, 20.2% were unmarried and 0.2%

were widower.

65

TABLE 5: ANALYSIS OF SEXUAL BEHAVIOUR PROFILE

Sexual Behaviour Frequency Percent

EMC/PMC 263 57.2

MSM 197 42.8

Total 460 100.0

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.

57%43%

EMC/PMC

MSM

66

TABLE 6: LIST OF CONTACT PERSON

Status of contact person Frequency PercentKnown male 108 23.5Known female 48 10.4Unknown male 139 30.2Unknown female 165 35.9Total 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.

67

TABLE 7: MODE OF SEX AMONG HIGH RISK GROUPS

Mode of Sex

Age groupTotal Percent10-19 20-39 40-64 >65

Count Count Count Count

Vaginal route 1 181 76 0258 56.1

Anoreceptive 2 101 66 4173 37.6

Anoinsertive 2 80 44 4130 28.3

Ororeceptive 2 109 78 4193 42.0

Oroinsertive 2 93 59 4158 34.3

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%)

1 2 2 2 2

181

101

80

10993

7666

44

78

59

0 4 4 4 40

20

40

60

80

100

120

140

160

180

200

Age group 10-19

Age group 20-39

Age group 40-64

Age group >65

68

TABLE 8: CONDOM USAGE AMONG HIGHRISK GROUPS

Condom use Frequency PercentProtected 32 7.0Unprotected 428 93.0Total 460 100.0

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.

32

428

PROTECTED

UNPROTECTED

69

TABLE 9: STATUS OF CIRCUMCISION & CASTRATION

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.

2

374

6717

CIRCUMCISED

UNCIRCUMCISED

NONE

CASTRATED

Circumcision Frequency PercentCircumcised 2 0.4

Uncircumcised 374 81.3None 67 14.6

Castrated 17 3.7Total 460 100.0

70

TABLE 10: TOTAL STI’S DIAGNOSED AMONG HIGH RISK GROUPS

Diagnosis Frequency PercentNil 272 59.1STI 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.

71

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%).

72

TABLE 12: ORAL MUCOSA EXAMINATION

ORAL MUCOSA Frequency PercentNORMAL 423 92ORAL CANDIDIASIS 35 7.6ORAL HAIRY LEUKOPLAKIA 1 .2HERPES LABIALIS 1 .2Total 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 HIGHRISK GROUPS

HIV HBV HCVNonreactive 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.

73

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%.

74

STATISTICS AMONG HIGH RISK GROUP WITH STI’SThese statistics comprises of 188 STI cases among 460 high risk

individuals in the study.

TABLE 16: DISTRIBUTION OFAGE GROUP AMONG DISEASED

Age group Frequency Percent20-39 107 56.940-64 80 42.6>65 1 .5Total 188 100.0

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%).

0

20

40

60

80

100

120

20-3940-64

>65

107

80

1

FREQ

UEN

CY

AGE GROUP

75

TABLE 17: ANALYSIS OF GENDER PROFILE

Gender Frequency PercentMale 142 75.5Female 43 22.9Transgender 3 1.6

Total 188 100.0

Among 188 STI cases, 142(75.5%) were males followed by 43(22.9%)

females and 3(1.6%) transgenders.

142

43

3

Male

Female

Transgender

76

TABLE 18: LIST OF OCCUPATION STATUS AMONG STI’S

Occupation Frequency PercentFemale sex worker 26 13.8

Coolie 2 1.1Driver 27 14.4

Housekeeping 24 12.8Migrants 11 5.9Others 88 46.8Student 10 5.3Total 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

Maritalstatus Frequency Percent

Married 140 74.5Unmarried 47 25.0Widower 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.

77

TABLE 20: ANALYSIS OF SEXUAL BEHAVIOUR

Sexualbehaviour Frequency PercentEMC/PMC 144 76.6MSM 44 23.4Total 188 100.0

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%).

144

44

EMC/PMC

MSM

78

TABLE 21: ANALYSIS OF PERIOD OF LAST CONTACT

Last contact Frequency Percent<2WEEK 38 20.2

2WEEEK TO1MONTH 57 30.3

1MONTH TO 1 YEAR 59 31.4>1YEAR 34 18.1

Total 188 100.0

Diagnosis group Last contactTotal<2 weeks 2 weeks to

1 month1 month to

1 year1year

HG-HERPESGENITALIS

11 14 9 5 39

GON-GONORRHOEA 1 1 2 0 4MC-MOLLUSCUMCONTAGIOSUM

1 5 6 1 13

WART 2 8 12 3 25VVC-VULVO

VAGINALCANDIDISIS

8 8 4 1 21

SCABIES 2 1 2 1 6BAL-

BALANOPOSTHITIS9 13 6 15 43

SY 1-PRIMARYSYPHILIS

2 2 1 0 5

SY 2-SECONDARYSYPHILIS

1 2 3 0 6

ELS-EARLY LATENTSYPHILIS

1 0 13 2 16

LLS-LATE LATENTSYPHILIS

0 1 1 5 7

NGU-NON-GONOCOCCAL

URETHRITIS

0 2 0 0 2

HL-HERPESLABIALIS

0 0 0 1 1

Total 38 57 59 34 188

79

TABLE 22: LIST OF CONTACT PERSON

Contactperson Frequency PercentKnown male 43 22.9Known female 22 11.7Unknown male 43 22.9Unknownfemale 80 42.6

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%).

80

TABLE 23: ANALYSIS OF MODE OF SEX

Mode ofSex

Age group

TOTAL

PERCENT

PVALU

E

10-19 20-39 40-64 >65Coun

tCoun

tCoun

tCoun

t

Vaginalroute

0 54 33 087 46.3%

0.008

Anoreceptive

0 45 36 182 43.6%

Anoinsertive

0 32 24 157 30.3%

Ororeceptive

0 52 45 198 52.1%

Oroinsertive 0 43 33 177 41.0%

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.

0 0 0 0 0

54

45

32

52

43

33 36

24

45

33

0 1 1 1 10

10

20

30

40

50

60

Age group 10-19

Age group 20-39

Age group 40-64

Age group >65

81

TABLE 24: CONDOM USAGE AMONG INFECTED PERSONS

Condom use Frequency PercentProtected

14 7.4

Unprotected174 92.6

Total 188 100.0

In the study of 188 STI cases, p value was >0.05 signifying no association

between condom protection and prevalence of STI’s.

14

174

PROTECTED

UNPROTECTED

82

TABLE 25: STATUS OF CIRCUMCISION / CASTRATION

Circumcision Frequency Percent

Circumcised 2 1.1

Uncircumcised 142 75.5

None 41 21.8Castrated 3 1.6

Total 188 100.0

P value is 0.0001, which shows significance between uncircumcised and

prevalence of STIs which proves increased risk of STI’s among uncircumcised

men.

020406080

100120140160

2

142

41

3

83

TABLE 26: CLINICAL EXAMINATION FINDINGS OF DISEASED

GENITAL ULCER / FISSURE

GENITALULCER/FISSURE Frequency Percent

Painlessindurated ulcer 6 3.2

Painful ulcer 38 20.2Erosions/fissures 43 22.9

Scar 6 3.2None 95 50.5Total 188 100.0

GENITAL DISCHARGE

Genital discharge Frequency PercentUrethral discharge

6 3.2

Curdy white discharge21 11.2

Homogenous paste discharge1 0.5

Sub preputial discharge43 22.9

None 117 62.2Total 188 100.0

84

GENITAL PAPULES

Papules Frequency Percentverrucous papules

26 13.8

Umblicated papules13 6.9

Excoriated papules6 3.2

None 143 76.1Total 188 100.0

LYMPHNODES

Lymph nodes Frequency PercentPresent 51 27.1Absent 137 72.9Total 188 100.0

TABLE 27: STATUS OF HIV, HBV, HCV & DIABETES MELLITUSSTATUS

Frequency PercentHIV 31 16.4

HBsAg 0 0HCV 0 0DM 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.

85

TABLE 28: DISTRIBUTION OF STI’S IN HIV POSITIVE GROUP

Diagnosis group FrequencyHG-HERPES GENITALIS 5GON-GONORRHOEA 1MC-MOLLUSCUM CONTAGIOSUM 1WART 8SCABIES 2BAL-BALANOPOSTHITIS 8SY 1-PRIMARY SYPHILIS 1ELS-EARLY LATENT SYPHILIS 2LLS-LATE LATENT SYPHILIS 2NGU-NON-GONOCOCCAL URETHRITIS 1HL-HERPES LABIALIS 1TOTAL 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.

86

TABLE 29: LIST OF INFECTIONS DIAGNOSED BY CLINICALEXAMINATION AND INVESTIGATIONS AMONG DISEASED.Diagnosis group Frequency PercentHG-HERPES GENITALIS 39 20.7GON-GONORRHOEA 4 2.1MC-MOLLUSCUM CONTAGIOSUM 13 7WART 25 13.3VVC-VULVO VAGINAL CANDIDISIS 21 11.2SCABIES 6 3.2BAL-BALANOPOSTHITIS 43 22.9SY 1-PRIMARY SYPHILIS 5 2.7SY 2-SECONDARY SYPHILIS 6 3.2ELS-EARLY LATENT SYPHILIS 16 8.5LLS-LATE LATENT SYPHILIS 7 3.7NGU-NON-GONOCOCCAL URETHRITIS 2 1.1HL-HERPES LABIALIS 1 0.5Total 188 100.0

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%).

39

4

13

2521

6

43

5 6

16

72 1

05

101520253035404550

TOTA

L CA

SES

87

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

88

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

89

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%

90

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.

91

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.

92

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

93

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.

94

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.

95

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.

96

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

97

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

98

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.

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-GRAM +VE COCCI

PSEUDOHYPHAE & SPORES INKOH

CHROMOGENIC AGAR FOR CANDIDA ALBICANS & NON ALBICANSSPECIES

PINK – CANDIDA KRUSEI

GREEN- CANDIDA ALBICANS

GENITAL SCABIES

RPR - 1:4 DILUTION POSITIVE

TPHA POSITIVITY

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PROFORMA

CASE NO:

1. STI NO: OP NO.

2. DATE:

3. AGE:

4. SEX: M / F / TG

5. OCCUPATION:

6.

COMPLAINTS DURATION

GENITAL ULCER

URETHRALDISCHARGEANORECTALDISCHARGEBURNINGMICTURITION

SUBPREPUCIALDISCHARGEGENITAL PAIN

SORE THROAT

BUBO

VESICLES

ORAL ULCERS

LOWERABDOMINAL PAINOTHERCOMPLAINTS

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 -VeDiplococci

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.N

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1 ARUMUGAM 45 3 M O M 1 2 2 2 1 1 5 1 1 4 N A NR N NR NR NR 3 3 3 2 GON

2 BHUVAN 21 2 M O M 3 1 3 2 2,3,4,5 2 5 6 2 4 N A R P NR NR NR 3 3 5 2 ELS

3 ANTONY XAVIER 40 3 M O M 3 3 3 2 2,3,4,5, 2 5 6 2 4 N A R P NR NR NR 3 3 5 2 ELS

4 MUTHUKUMAR26 2 M D M 1 3 4 2 1 2 5 1 1 4 N A NR N R NR NR 3 3 3 2 GON

5 MAHARAJA 23 2 M S UN 3 3 3 2 2,3,4,5 2 1 6 1 4 N A R P NR NR NR 3 3 5 2 SY 1

6 POOSAIPANDI 59 3 M H M 1 2 4 2 1 2 5 1 2 4 N A NR N R NR NR 3 3 5 2 NGU

7 SIVA 38 2 M D M 3 1 1 2 2,3,4,5 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

8 GANAPATHY SUNDARAM32 2 M O UN 3 3 1 2 2,3,45 2 5 6 1 4 N A R P R NR NR 3 3 5 2 ELS

9 HEPSI 39 2 F FSW UN 2 2 1 1 1 3 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

10 ESWARAN 32 2 M H UN 3 1 1 1 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

11 GANESAN 33 2 M H UN 3 2 1 1 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

12 MANIKANDAN 28 2 M O UN 3 2 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

13 SINDARAPANDI40 3 M D M 3 2 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

14 MARIE 38 2 F FSW M 1 3 2 2 1 3 5 2 2 4 N A NR N NR NR NR 1 3 1 2 VVC

15 SURESH 30 2 M D M 3 1 1 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

16 VASANTHAKUMAR26 2 M D UN 2 3 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

17 ARCHANA DEV27 2 M O M 3 2 3 2 2,3,4,5 2 5 6 2 1 N A NR N NR NR NR 3 3 5 2 WART

18 MUTHU 34 2 F FSW M 1 2 3 2 1 3 2 6 1 1 N A NR N NR NR NR 3 3 5 1 HG

19 MARIAPPAN 50 3 M D M 3 4 1 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

20 SENTHUR 23 2 M O UN 3 1 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

21 KARTHI 30 2 M D UN 3 2 1 2 2,3 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

22 MUTHAIAH 31 2 M H M 1 2 3 2 1 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

23 GURUNATHAN60 3 M O M 1 2 2 2 1 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

24 PONRAM 33 2 M H UM 3 4 3 2 2,3,4,5 2 3 5 2 4 N A NR N NR NR NR 1 3 1 2 BAL

25 MAHALINGAM 46 3 M H M 1 4 4 2 1 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

S.N

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26 RAJA 30 2 M O UN 3 3 1 2 2,3,4,5 1 5 6 2 1 N A NR N NR NR NR 3 3 5 2 WART

27 BABU 30 2 M O UN 3 3 3 2 2,3,4,5 2 5 6 1 4 N A R P NR NR NR 3 3 5 2 SY 2

28 SUBRAMANI 47 3 M H M 1 2 4 2 1 2 5 6 2 1 N A NR N R NR NR 3 3 5 2 WART

29 JANAKIRAM 37 2 M O M 1 1 4 2 1 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

30 SURESH 40 3 M O M 1 1 2 2 1 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

31 JEEVA 34 2 M O M 3 1 1 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

32 VINOTH 29 2 M O UM 3 3 1 2 2,3,4,5 2 5 6 2 4 N A R P NR NR NR 3 3 5 2 ELS

33 MURUGAN 26 2 M D M 1 3 2 2 1 2 4 6 1 4 N A R P NR NR NR 3 3 5 2 ELS

34 FRANCIS 32 2 M O M 1 4 4 2 1 2 2 6 2 4 N A NR N NR NR NR 3 3 5 1 HG

35 MANIKAM 57 3 M D M 1 3 4 2 1 2 3 5 2 4 OC A NR N R NR NR 1 3 1 2 BAL

36 STEFY 28 2 M O M 3 1 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

37 DEVDASAN 44 3 M D M 1 4 4 2 1 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

38 BALASUBRAMANIAN39 3 M O M 1 3 4 2 1 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

39 MUTHAIAH 48 3 M D M 1 4 2 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

40 BALAKRISHNAN32 3 M D M 1 4 2 2 1 2 5 6 2 4 N A R P NR NR NR 3 3 5 2 LLS

41 KARTHIKETAN43 3 M O M 3 2 1 2 2,3,4,5 2 3 5 2 4 OC A NR N NR NR NR 1 3 1 2 BAL

42 ATHIMUTHU 49 3 M O M 1 3 4 2 1 2 5 6 2 3 N A NR N NR NR NR 3 3 5 2 SCABIES

43 MAHADEVI 24 2 F FSW UM 2 3 3 2 1 3 5 6 2 4 N A R P NR NR NR 3 3 5 2 ELS

44 RAVI 36 2 M D M 1 3 4 2 1 2 5 6 2 3 N A NR N NR NR NR 3 3 5 2 SCABIES

45 POOVARASAN 21 2 M H UM 3 2 3 2 2,3,4,5 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

46 AMUTHA 38 2 F O W 1 2 3 2 1 2 2 6 1 4 OC A NR N R NR NR 3 3 5 1 HG

47 SANKARAN 41 3 M H UM 3 3 3 2 2,3,4,5 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

48 MADASAMY 34 2 M O M 3 3 1 2 4,5 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

49 SIVASUBRAMANIAN28 2 M O UM 3 2 1 2 2,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

50 PERUMAL 42 3 M O M 1 4 2 2 1 2 5 6 2 4 N A R P R NR NR 3 3 5 2 LLS

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51 MURALI 28 2 M D M 1 2 2 2 1 3 5 6 2 1 N A NR N NR NR NR 3 3 5 2 WART

52 VANDIMALAYAN28 2 M O M 1 3 4 2 1 2 5 6 2 1 N A NR N NR NR NR 3 3 5 2 WART

53 KARUPUSAMY 58 3 M O M 1 4 2 2 1 2 3 5 2 4 N A NR N R NR NR 1 3 1 2 BAL

54 MAHARAJAN 21 2 M S UM 2 3 2 2 1 2 5 6 2 2 N A NR N NR NR NR 3 3 5 2 MC

55 PARAMESWARAN48 3 M O M 1 4 4 2 1 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

56 PAULDURAI 27 2 M O UM 1 4 4 2 1 2 5 6 2 3 N A NR N NR NR NR 3 3 5 2 SCABIES

57 ESAKKIMUTHU27 2 M O UM 1 2 4 2 1 2 5 6 2 2 N A NR N NR NR NR 3 3 5 2 MC

58 LAKSHMANARAJ35 2 M O M 1 1 2 2 1 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

59 SUNDARAJAN 35 2 M O M 3 4 2 1 1 2 5 6 2 1 N A NR N NR NR NR 3 3 5 2 WART

60 SUBRAMANIAN37 2 M H M 1 4 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

61 RANI 33 2 F FSW M 1 3 3 2 1 3 5 3 2 4 N A NR N NR NR NR 3 2 2 2 BV

62 AYYADURAI 45 3 M O M 1 4 4 2 1 2 5 6 2 1 OC A NR N R NR NR 3 3 5 2 WART

63 MUTHUKRISHNAN58 3 M O M 1 3 4 2 1 2 5 6 2 1 N A NR N NR NR NR 3 3 5 2 WART

64 KARUPAIAH 65 3 M O M 1 4 2 2 1 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

65 VALIAMAL 50 3 F FSW M 1 2 3 2 1 3 5 2 2 4 N A NR N NR NR NR 1 3 1 2 VVC

66 MADASAMHY 32 2 M O M 3 1 2 2 2,3,4,5 2 5 6 2 1 N A NR N R NR NR 3 3 5 2 WART

67 CHANDRAN 31 2 M D M 1 4 4 2 1 2 5 6 2 4 OHL A NR N R NR NR 3 3 5 2 NIL

68 MARIAMMAL 35 2 F FSW M 1 2 3 2 1 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

69 GANAPATHY 53 3 M D M 1 4 4 2 1 2 3 5 2 4 N P NR N NR NR NR 1 3 1 2 BAL

70 SENTHILKUMAR32 2 M D M 1 4 2 2 1 2 3 5 2 4 N A NR N NR NR NR 1 3 1 2 BAL

71 RAMBA 41 3 TG O UM 3 4 3 2 2,4 4 5 6 2 4 HL P NR N NR NR NR 3 2 5 2 HL

72 SENTHILKUMAR35 2 M O M 3 2 1 1 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

73 DILIP SARKAR 30 2 M O UM 3 2 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

74 THANGAMARIAMMAL36 2 F FSW M 1 3 3 2 1 2 5 6 2 2 N A NR N R NR NR 3 3 5 2 MC

75 KUMAR 39 2 M D M 1 3 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

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76 MADASAMY 43 3 M D M 1 3 4 1 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

77 VELUSAMY 75 4 M O M 1 4 4 2 1 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

78 RAJA 30 2 M H M 1 2 4 2 1 2 3 5 2 4 N A NR N NR NR NR 1 3 1 2 BAL

79 SUNDARAJAN 37 2 M D M 1 4 4 2 1 2 3 5 2 4 N A NR N NR NR NR 1 3 1 2 BAL

80 MUTHALAISAMI24 2 M S UM 1 2 4 2 1 2 5 6 2 1 N A NR N NR NR NR 3 3 5 2 WART

81 ULAGANATHAN63 3 M O M 1 2 2 1 1 2 5 6 2 1 N A NR N NR NR NR 3 3 5 2 WART

82 JEEVA 34 2 M O M 3 3 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

83 SARAVANAN 39 2 M O M 1 2 4 2 1 2 3 5 2 4 N A NR N NR NR NR 1 3 1 2 BAL

84 SUNDARAMAHALINGAM36 2 M D M 1 1 4 2 1 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

85 SUBRAMANIAN40 3 M C M 3 1 1 2 2,3,4,5 2 3 5 2 4 OC A NR N R NR NR 1 3 1 2 BAL

86 SIVA 38 2 M O M 3 1 3 2 2,5 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

87 RAMAN 45 3 M D M 3 3 1 2 2,3,4,5 2 3 5 2 4 OC A NR N R NR NR 1 3 1 2 BAL

88 MUTHAIAH 44 3 M O M 3 3 1 2 2,3,4,5 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

89 PARAMESWARI27 2 F FSW M 1 3 3 1 1 3 5 6 2 2 N A NR N NR NR NR 3 3 5 2 MC

90 PONNUSAMI 59 3 M O M 1 4 4 1 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

91 MANIKANDAN 43 3 M D M 1 1 4 2 1 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

92 PETCHIAMMAL43 3 F FSW M 1 3 1 2 1 3 2 6 1 4 N A NR N R NR NR 3 3 5 1 HG

93 MOHAMED KASI20 2 M M UM 2 3 4 2 1 2 5 6 2 2 N A NR N NR NR NR 3 3 5 2 MC

94 MUTHU 34 3 F FSW M 1 2 3 1 1 3 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

95 ESAKKI 55 3 M D M 1 1 4 1 1 2 3 5 2 4 N A NR N NR NR NR 1 3 1 2 BAL

96 KANAMAL 42 3 F FSW M 1 2 3 1 1 3 5 2 2 4 N P NR N NR NR NR 1 3 1 2 VVC

97 RAMAR 45 3 M O M 1 1 4 2 1 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

98 JOSEPH 25 2 M M UM 2 2 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

99 AVINUSH KUMAR35 2 M C M 1 1 4 2 1 2 3 5 2 4 N P NR N NR NR NR 1 3 1 2 BAL

100 AROKIYASAMY50 3 M O M 1 1 4 2 1 2 3 5 2 4 N P NR N NR NR NR 1 3 1 2 BAL

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101 ALPHONSE MARY53 3 F O M 1 3 3 2 1 3 5 2 2 4 N P NR N NR NR NR 1 3 1 2 VVC

102 KANNAN 33 2 M D UM 2 4 4 2 1 2 3 5 2 4 N A NR N NR NR NR 1 3 1 2 BAL

103 MARIAPPAN 42 3 M O M 1 2 4 2 1 2 3 5 2 4 N A NR N NR NR NR 1 3 1 2 BAL

104 VIJAIKUMAR 32 2 M O UM 1 2 4 1 1 2 5 1 2 4 N A NR N NR NR NR 3 3 5 2 NGU

105 SUMAN 28 2 M M M 3 3 3 2 2,3,4,5 2 1 6 1 4 N A R P NR NR NR 3 3 5 2 SY 2

106 MARIAPPAN 31 2 M O M 3 4 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

107 GANESAN 38 2 M D UM 1 1 4 2 1 2 3 5 2 4 N A NR N NR NR NR 1 3 1 2 BAL

108 KALAISELVSN 31 2 M M UM 2 4 4 2 1 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

109 PREMKUMAR 27 2 M D UM 2 3 4 1 1 2 3 5 2 4 N A NR N NR NR NR 1 3 1 2 BAL

110 THANGARAJ 58 3 M O M 3 2 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

111 MARIAPPAN 28 2 M O UM 3 1 1 2 2,3,4,5 2 5 6 2 1 OC A NR N R NR NR 3 3 5 2 WART

112 INDRA 47 3 F M M 1 1 1 1 1 3 5 2 2 4 N A NR N NR NR NR 1 3 1 2 VVC

113 SUBAIAH 55 3 M O M 1 3 2 2 1 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

114 MARIAMMAL 35 3 F FSW M 1 2 3 2 1 3 5 2 2 4 N A NR N NR NR NR 1 3 1 2 VVC

115 HARIHARARAJ36 3 M H M 1 3 2 2 1 2 5 6 2 1 N A NR N R NR NR 3 3 5 2 WART

116 CHANDRAN 29 2 F FSW M 1 2 3 1 1 3 5 6 2 1 N A NR N NR NR NR 3 3 5 2 WART

117 LAKSHMIGANTHAN35 2 M D M 1 3 4 2 1 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

118 SIVANESAN 34 2 M O M 1 3 4 2 1 2 5 6 2 4 N A R P NR NR NR 3 3 5 2 ELS

119 PANDARAPANDIYAN29 2 M M UM 2 2 4 2 1 2 3 5 2 4 N A NR N NR NR NR 1 3 1 2 BAL

120 KARTHI 36 2 M O M 1 2 4 2 1 2 5 6 2 2 N A NR N NR NR NR 3 3 5 2 MC

121 RAMALAKSHMI31 2 F FSW M 1 2 1 2 1 3 5 6 2 2 N A NR N NR NR NR 3 3 5 2 MC

122 SELVI 43 3 F H M 1 2 1 2 1 3 5 6 2 4 N A R P NR NR NR 3 3 5 2 SY 2

123 DHANABAKIYAM32 2 F FSW M 1 1 3 2 1 3 5 2 2 4 N A NR N NR NR NR 1 3 1 2 VVC

124 MOOKAIAH 52 3 M H M 1 4 4 2 1 2 3 5 2 4 N A NR N NR NR NR 1 3 1 2 BAL

125 MARIATHANGAM37 2 F FSW M 1 3 3 2 1 3 5 2 2 4 N A NR N NR NR NR 1 3 1 2 VVC

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126 PONMANI 33 2 M O M 3 4 1 1 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

127 ARUNACHALAM56 3 M O M 1 2 4 2 1 2 2 6 1 4 N P NR N NR NR NR 3 3 5 1 HG

128 RAMALAKSHMI29 2 F H M 1 1 1 1 1 3 5 2 2 4 N A NR N NR NR NR 1 3 1 2 VVC

129 ARUMUGANAINAR42 3 M H M 1 4 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

130 KITTU 51 3 M O M 3 2 3 1 3,4,5 2 3 5 2 4 N P NR N NR NR NR 1 3 1 2 BAL

131 SORNAMMUDI 29 2 M M UM 2 2 4 2 1 2 5 6 2 3 N A NR N R NR NR 3 3 5 2 SCABIES

132 SRINIVASAN 33 2 M H M 1 1 4 2 1 2 3 5 2 4 N A NR N NR NR NR 1 3 1 2 BAL

133 RADHAKRISHNAN55 3 M O M 1 4 4 2 1 2 5 6 2 4 N A R P NR NR NR 3 3 5 2 LLS

134 MANIKANDA PRABHU25 2 M H UM 3 2 1 2 2,3,4,5 2 1 6 1 4 N A R P NR NR NR 3 3 5 2 SY 1

135 KASI 46 3 M D M 1 4 4 2 1 2 5 6 2 4 N A R P NR NR NR 3 3 5 2 LLS

136 RAMACHANDRAN53 3 M O M 1 4 4 2 1 2 3 5 2 4 N P NR N NR NR NR 1 3 1 2 BAL

137 MATHIVANAN 42 3 M H M 1 4 4 2 1 2 3 5 2 4 N A NR N R NR NR 1 3 1 2 BAL

138 KARPAGAM 30 2 F FSW M 1 1 3 2 1 3 5 2 2 4 N A NR N NR NR NR 1 3 1 2 VVC

139 MARIAPPAN 41 3 M M M 1 2 4 2 1 2 3 5 2 4 N A NR N NR NR NR 1 3 1 2 BAL

140 ANDIAPAN 28 2 M D UM 2 2 4 2 1 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

141 MURUGESWARI37 2 F O M 1 1 3 2 1 3 5 2 2 4 N A NR N NR NR NR 1 3 1 2 VVC

142 PERUMAL 45 3 M D M 3 1 1 2 2,3,4,5 2 2 6 1 4 OC A NR N NR NR NR 3 3 5 1 HG

143 SHANMUGAPANDIAN54 3 M O M 1 3 4 1 1 2 3 5 2 4 N P NR N NR NR NR 1 3 1 2 BAL

144 MARIAMMAL 42 3 F H M 1 3 1 1 1 3 5 6 2 1 N A NR N NR NR NR 3 3 5 2 WART

145 MASOOD 23 2 F O M 1 1 3 2 1 3 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

146 MARIA STEPHEN52 3 M O M 1 2 4 2 1 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

147 RAMANATHAN54 3 M D M 1 4 2 2 1 2 3 5 2 4 N P NR N NR NR NR 1 3 1 2 BAL

148 THANGAM 43 3 F FSW M 1 1 1 2 1 3 5 2 2 4 N A NR N NR NR NR 1 3 1 2 VVC

149 GOMATHI 45 3 F FSW M 1 1 1 2 1 3 5 2 2 4 N A NR N NR NR NR 1 3 1 2 VVC

150 PALANIVEL 28 2 M O M 1 1 4 2 1 2 3 5 2 4 N A NR N NR NR NR 1 3 1 2 BAL

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151 DURAIRAJ 41 3 M M M 1 1 4 2 1 2 3 5 2 4 N P NR N NR NR NR 1 3 1 2 BAL

152 KRISHNAN 65 3 M O M 1 1 4 2 1 2 3 5 2 4 N P NR N NR NR NR 1 3 1 2 BAL

153 COLUMBUS 25 2 M O UM 2 2 4 2 1 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

154 MANI 51 3 M O M 1 2 4 2 1 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

155 SATHISH 28 2 M D UM 2 3 4 2 1 2 5 6 2 2 N A NR N NR NR NR 3 3 5 2 MC

156 MUTHUKUMAR39 2 M O M 1 3 4 2 1 2 5 6 2 2 N A NR N NR NR NR 3 3 5 2 MC

157 PREETHI 36 2 TG O UM 3 1 1 2 2,3,4,5 4 5 6 2 2 N A NR N NR NR NR 3 3 5 2 MC

158 SIVASHANKAR31 2 M O UM 3 3 3 2 2,3,4,5 2 5 6 2 1 N A NR N NR NR NR 3 3 5 2 WART

159 MARAGATHAM44 3 F FSW M 1 2 3 2 1 3 5 2 2 4 N A NR N NR NR NR 1 3 1 2 VVC

160 KANAGARAJ 51 3 M H M 1 3 4 2 1 2 5 6 2 1 N A NR N R NR NR 3 3 5 2 WART

161 MANI 63 3 M H M 1 3 4 2 1 2 3 5 2 4 OC P NR N R NR NR 1 3 1 2 BAL

162 SORNALAKSHMI27 2 F FSW M 1 2 3 2 1 3 5 2 2 4 N A NR N NR NR NR 1 3 1 2 VVC

163 SAKTHIVEL 29 2 M M M 1 4 4 2 2 2 5 6 2 2 N A NR N NR NR NR 3 3 5 2 MC

164 SIVASAKTHI 29 2 M H UM 2 3 4 2 1 2 5 1 1 4 N A NR N NR NR NR 3 3 3 2 GON

165 ESAKKI 43 3 M O M 3 2 3 2 2,3,4,5 2 3 5 2 4 N P NR N NR NR NR 1 3 1 2 BAL

166 HASSAN 32 2 M M M 3 1 1 2 2,3,4,5 2 5 1 1 4 N A NR N NR NR NR 3 3 3 2 GON

167 SUBRAMANIAN33 2 M O M 1 1 4 2 1 2 1 6 1 4 N A R P NR NR NR 3 3 5 2 SY 1

168 RAMAKRISHNAN47 3 M O M 1 3 4 2 1 2 5 6 2 4 N A R P R NR NR 3 3 5 2 ELS

169 KUMAR 26 2 M H UM 3 1 1 2 2,3,4,5 2 1 6 1 4 N A R P NR NR NR 3 3 5 2 SY 1

170 SURESH 24 2 M O UM 3 1 3 2 2,3,4,5 2 5 6 2 4 N A R P NR NR NR 3 3 5 2 SY 2

171 MURUGAN 43 3 M O M 1 4 4 2 1 2 5 2 2 4 N A NR N NR NR NR 1 3 1 2 VVC

172 PETHCIAMMAL21 2 F S UM 2 2 1 2 1 3 5 2 2 4 N A NR N NR NR NR 1 3 1 2 VVC

173 SHANMUGAM 26 2 M O UM 3 1 3 2 2,3,4,5 2 5 6 2 3 N A NR N R NR NR 3 3 5 2 SCABIES

174 THALAVAI 54 3 M H M 3 2 3 2 2,3,4,5 2 3 5 2 4 N P NR N NR NR NR 1 3 1 2 BAL

175 MANIKANDAN 24 2 M O M 1 4 4 2 1 2 5 6 2 1 OC A NR N R NR NR 3 3 5 2 WART

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176 MUTHUSELVI 41 3 F FSW M 1 3 3 2 1 3 5 2 2 4 N A NR N NR NR NR 1 3 1 2 VVC

177 RAJA 31 2 M O UM 3 3 1 2 2,3,4,5 2 5 6 2 1 N A NR N NR NR NR 3 3 5 2 WART

178 SUBRAMANIAN47 3 M H M 1 2 4 2 1 2 5 6 2 1 N A NR N R NR NR 3 3 5 2 WART

179 MURUGAN 46 3 M O M 3 4 1 2 2,3 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

180 RAJAKUMARI 38 2 F FSW M 1 1 1 1 1 3 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

181 KUTRALAM 72 4 M O M 1 4 2 2 1 2 3 5 2 4 N P NR N NR NR NR 1 3 1 2 BAL

182 PAPANASAM 38 2 M O M 1 1 2 2 1 2 5 6 2 3 N A NR N NR NR NR 3 3 5 2 SCABIES

183 KALIRAJ 28 2 M H UM 2 3 4 2 1 2 5 6 2 4 N A R P NR NR NR 3 3 5 2 ELS

184 PRABAKARAN 28 2 M D UM 2 3 4 2 1 2 4 6 1 4 N A R P NR NR NR 3 3 5 2 ELS

185 SUDALAIMUTHU32 2 M O M 3 3 3 2 2,3,4,5 2 4 6 2 4 N A R P NR NR NR 3 3 5 2 ELS

186 ARUL 28 2 M O M 1 3 4 2 1 2 5 6 2 4 N A R P NR NR NR 3 3 5 2 LLS

187 KATHIRAVAN 36 2 M O M 1 4 4 2 1 2 3 5 2 4 O A NR N R NR NR 1 3 1 2 BAL

188 PRIYA 23 2 F S UM 2 3 1 2 1 3 5 6 2 1 N A NR N NR NR NR 3 3 5 2 WART

189 MARIAANTONY39 2 M O M 1 4 4 2 1 2 3 5 2 4 N P NR N NR NR NR 1 3 1 2 BAL

190 CHELLADURAI58 3 M O M 1 4 2 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

191 PALANIAPPAN 32 2 M H M 1 4 4 2 1 2 3 5 2 4 N A NR N NR NR NR 1 3 1 2 BAL

192 PATTAMMAL 22 2 TG M UM 3 1 1 2 2,3,4,5 4 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

193 MAHARAJAN 33 2 M H M 3 4 3 2 2,3,4,5 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

194 KARUTHAPANDI59 3 M O M 1 3 2 2 1 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

195 SARAVANAN 41 3 M D M 3 3 3 2 2,3,4,5 2 3 5 2 4 N A NR N NR NR NR 1 3 1 2 BAL

196 MURUGAN 50 3 M O M 1 3 2 2 1 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

197 VASANTHI 30 2 F FSW M 1 2 1 2 1 3 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

198 PARTHIBAN 21 2 M S UM 3 3 1 2 2,3,4,5 2 5 6 2 4 N A R P NR NR NR 3 3 5 2 SY 2

199 ROHINI 22 2 F S UM 2 2 1 2 1 3 5 2 2 4 N A NR N NR NR NR 1 3 1 2 VVC

200 KANNAMMAL 42 3 F FSW M 1 2 1 2 1 3 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

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201 MAHARASI 33 2 F FSW UM 2 2 1 2 1 3 5 6 2 2 N A NR N NR NR NR 3 3 5 2 MC

202 AMALRAJ 40 3 M D M 1 1 4 2 1 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

203 NAMBIRAJAN 24 2 M O UM 3 3 3 2 2,3,4,5 2 5 6 2 1 N A NR N NR NR NR 3 3 5 2 WART

204 MUTHU 53 3 M O M 1 3 4 2 1 2 2 6 1 4 N A NR N NR NR NR 3 3 5 1 HG

205 ESAKKI 58 3 F O M 1 4 1 2 1 3 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

206 MANONMANI 47 3 F O M 1 4 1 2 1 3 5 6 2 4 N A R P NR NR NR 3 3 5 2 ELS

207 VIJAYALAKSHMI22 2 F S UM 2 3 1 2 1 3 5 6 2 4 N A R P NR NR NR 3 3 5 2 ELS

208 SENTHILKUMAR29 2 M O UM 2 3 1 2 1 2 4 6 2 4 N A R P NR NR NR 3 3 5 2 ELS

209 SUMATHI 45 3 F FSW M 1 2 3 2 1 3 5 6 2 4 N A R P NR NR NR 3 3 5 2 LLS

210 MURUGAN 39 3 M O M 3 2 1 2 2,3,4,5 2 1 6 1 4 N A R P R NR NR 3 3 5 2 SY 1

211 KARUPUSAMY 48 3 M O M 1 3 4 2 1 2 2 6 1 4 N A NR N R NR NR 3 3 5 1 HG

212 THANGAVEL 38 3 M O M 1 2 4 2 1 2 3 5 2 4 N P NR N NR NR NR 1 3 1 2 BAL

213 KAVITHA 28 2 F O M 1 2 1 2 1 3 5 2 2 4 N A NR N NR NR NR 1 3 1 2 VVC

214 SANYASI 39 2 M O M 1 2 4 2 1 2 3 5 2 4 N P NR N NR NR NR 1 3 1 2 BAL

215 RAJINI 36 3 M O M 1 2 4 2 1 2 5 6 2 2 N A NR R NR NR NR 3 3 5 2 MC

216 SUBRAMANI 44 3 M O M 1 2 4 2 1 2 3 5 2 4 N A NR N R NR NR 1 3 1 2 BAL

217 GUNASEELAN 22 2 M S UM 3 3 1 2 2,3,4,5 2 5 6 2 1 N A NR N NR NR NR 3 3 5 2 WART

218 SARANYA 23 2 F S UM 2 2 1 2 1 3 5 6 2 1 N A NR N NR NR NR 3 3 5 2 WART

219 MARIAMMAL 30 2 F O M 1 1 1 2 1 3 5 2 2 4 N A NR N NR NR NR 1 3 1 2 VVC

220 TAMILSELVAN42 3 M O M 3 4 1 2 2,3,4,5 2 4 6 2 4 N A R P NR NR NR 3 3 5 2 ELS

221 SASIKALA 31 2 F O M 1 3 1 2 1 3 4 6 2 4 N A R P NR NR NR 3 3 5 2 ELS

222 NAGAMUTHU 32 2 M O M 3 2 1 2 2,3,4,5 2 5 6 2 4 N A R P NR NR NR 3 3 5 2 SY 2

223 ASWIN RAJ 28 2 M O UM 3 3 1 2 2,3,4,5 2 5 6 2 1 N A NR N NR NR NR 3 3 5 2 WART

224 MANI 50 3 M O M 1 2 4 2 1 2 2 6 1 4 N A NR N R NR NR 3 3 5 1 HG

225 GANESAN 40 3 M O M 3 3 1 2 2,3,4,5 2 2 6 1 4 OC A NR N R NR NR 3 3 5 1 HG

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226 MURUGAIAH 36 2 M D M 1 4 4 2 2 2 3 5 2 4 N A NR N NR NR NR 1 3 1 2 BAL

227 GANESAN 55 3 M O M 1 2 4 2 1 2 3 5 2 4 N A NR N NR NR NR 1 3 1 2 BAL

228 RAJ 48 3 M O M 1 4 4 2 1 2 5 6 2 4 OC A R P R NR NR 3 3 5 2 LLS

229 AROKYASUDHAN30 2 M O M 3 2 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR R NR 3 3 5 2 NIL

230 KANCHANA 34 2 TG O UM 3 2 1 2 2,4 4 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

231 NAGURAMMAL48 3 F H M 1 3 3 2 1 3 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

232 RAJA 33 2 M D M 1 1 4 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

233 ZAHIR APPAS 29 2 M D M 1 3 4 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

234 MUTU 31 2 M H M 1 4 2 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

235 MURUGAN 23 2 M O M 3 2 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

236 ESAKKIAMMAL43 3 M O M 1 3 4 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

237 BEER 39 2 M O M 3 4 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

238 GURUSAMY 28 2 M O UM 3 2 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

239 GANGA 29 2 TG M UM 3 3 3 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

240 VELAMMAL 43 3 F H M 1 1 1 2 1 3 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

241 PARAMASIVAM44 3 M D M 3 3 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

242 PRIYA 33 2 TG M UM 3 4 1 2 2,4 4 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

243 RAMYA 23 2 TG O UM 3 3 1 2 2,4 4 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

244 JOTHISWARAN29 2 M O M 3 3 4 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

245 RAM 28 2 M O M 2 4 2 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

246 MOHAMMED ALI54 3 M O M 3 3 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

247 VICTOR JEROME28 2 M O M 3 4 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

248 VINO 23 2 TG O UM 3 4 1 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

249 JAMUNA 25 2 TG O UM 3 2 3 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

250 NANDHINI 33 2 TG O UM 3 4 1 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

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251 HARINI 23 2 TG M UM 3 2 3 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

252 ANJALI 27 2 TG O UM 3 1 1 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

253 SAMBAVI 23 2 TG O M 3 3 3 2 2,4 4 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

254 VITHIYASHREE21 2 TG O UM 3 2 3 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

255 STELLA 29 2 TG O UM 3 3 3 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

256 HASINI 23 2 TG O UM 3 4 1 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

257 SOWMYA 33 2 TG M UM 3 2 1 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

258 RAJA 35 2 M O M 3 1 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

259 ALAGESAN 38 2 M O M 1 3 2 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

260 SWATHI 24 2 TG O M 3 2 3 2 2,3,4,5 4 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

261 KATHIRESAN 25 2 M H M 1 4 1 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

262 RASHEEQ 44 3 M H M 3 4 1 1 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

263 SNEHA 28 2 F O M 1 3 1 2 1 3 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

264 NIRMALADEVI 44 3 F O M 1 3 1 2 1 3 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

265 RAJA 27 2 M D M 3 4 3 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

266 ESWARAN 27 2 M O M 3 4 3 2 2,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

267 MUTHURAMALINGAM44 3 M O M 3 2 1 2 3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

268 MARIAPPAN 27 2 M O UM 2 3 2 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

269 SANKAR GANESH21 2 M O M 3 1 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

270 KANNAN 27 2 M O M 3 3 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

271 VINOD 25 2 M O UM 2 2 2 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

272 SAMEER 25 2 M O M 3 3 1 2 2,3 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

273 KANNAM 27 2 M O M 3 4 3 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

274 MURUGAN 54 3 M O M 1 2 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

275 PERIYARAJ 37 2 M D UM 2 3 2 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

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276 NAMBI 34 2 M H UM 2 3 2 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

277 MARY 37 2 F O M 1 2 4 1 1 3 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

278 INDRA 48 3 F M M 1 3 4 2 1 3 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

279 KRISHNAMOORTHY29 2 M O M 1 4 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

280 SUNDARI 39 2 F O M 1 2 4 2 1 3 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

281 RAJAN 40 3 M O M 3 1 3 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

282 MARY 38 2 F O M 1 3 4 2 1 3 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

283 GANESAN 30 2 M D M 3 4 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

284 VEDAMUTHU 63 3 M O M 1 2 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

285 ALAGENDRAN 23 2 M O UM 2 3 2 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

286 MALAIRAJAN 50 3 M O M 1 2 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

287 PRABU 22 2 M O M 3 3 3 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

288 MANOHAR 25 2 M O M 3 4 3 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

289 RAMESH 37 2 M O M 3 2 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

290 LAKSHMI 33 2 F O M 1 3 4 2 1 3 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

291 MUTHUGANESH26 2 M O M 3 2 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

292 TEJASWINI 24 2 TG M M 3 3 3 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

293 SWAPNA 28 2 TG M M 3 2 3 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

294 UMAYAL 29 2 TG M M 3 2 3 2 2,4 4 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

295 ARULPARAI 30 3 M O M 3 3 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

296 MANIKANDAN 24 2 M O M 3 4 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

297 NISHI 34 2 M O M 3 3 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

298 VIGNESH 34 2 M O M 3 4 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

299 THANGAM 32 2 F O M 1 2 4 2 1 3 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

300 ISAC 44 3 M O M 1 3 2 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

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301 GANESAN 28 2 M O M 3 1 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

302 VINOTH 25 2 M O M 3 2 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

303 ELANGOMANI 36 2 M O M 1 3 4 2 1 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

304 VELMURUGAN34 2 M O M 3 3 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

305 SUNDAR 58 3 M D M 1 4 2 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

306 SABRUDEEN 48 3 M D M 2 4 2 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

307 BARATH 24 2 M O M 3 4 3 2 2,3 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

308 MANIKANDAN 38 2 M O M 1 3 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

309 SUNDARRAJ 28 2 M H M 1 2 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

310 MUTHUPANDI 29 2 M O M 1 3 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

311 SELVASANTHANAM35 2 M O M 1 3 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

312 RAJA 32 2 M O M 1 4 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

313 SANKAR 29 2 M O M 3 3 3 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

314 JOHN PETER 61 3 M H M 3 2 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

315 MAHEEB 35 2 M D M 1 4 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

316 MURUGAN 47 3 M H M 1 2 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

317 SANKARAN 27 2 M O M 3 4 3 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

318 DANIEL 26 2 M O M 3 4 3 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

319 ISMAIL 29 2 M O M 3 4 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

320 VIKY 27 2 M O M 3 3 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

321 KARTHI 29 2 M D M 3 2 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

322 MARIMUTHU 25 2 M O M 3 2 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

323 AVUDAIAPPAN29 2 M D M 3 3 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

324 SABARIRAJ 40 3 M D M 1 3 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

325 RAJA 21 2 M D M 3 4 3 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

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326 PRAKASH 34 2 M H M 3 4 3 2 3,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

327 KRISHNAN 25 2 M H M 3 2 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

328 SENTHILKUMAR26 2 M O M 3 2 3 1 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

329 BALA 23 2 M O M 3 2 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

330 GANESAN 39 2 M O M 3 3 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

331 GANESAN 29 2 M O M 3 4 3 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

332 RAMKUMAR 26 2 M O M 3 4 3 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

333 AJMAL 22 2 M H M 3 3 3 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

334 MURUGAN 33 2 M D M 1 4 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

335 KULANTHAIPANDI62 3 M D M 1 3 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

336 MANMATHARAJ31 2 M H M 1 4 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

337 AMMU 38 2 M H M 1 3 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

338 DAS 32 2 M O M 3 4 1 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

339 VELMURUGAN39 2 M O M 1 2 4 1 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

340 AMMU 36 2 M O M 1 2 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

341 MAHI 27 2 M O M 3 1 1 2 3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL


343 NARAYANAMOORTHI33 2 M O M 2 4 2 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

344 SELVAM 31 2 M O M 3 2 3 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

345 SANTOSH 30 2 M H M 3 3 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

346 RAM 24 2 M S UM 3 4 3 2 2,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

347 VICTOR 45 3 M M M 1 3 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

348 KAMARAJ 45 3 M O M 3 4 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

349 CHARULATHA 25 2 TG O M 3 2 3 2 2,3,4,5 4 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

350 MUTHAIYAH 47 3 M O M 1 2 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

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351 ESAKIRAJA 22 2 M D M 3 3 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

352 ROHINI 30 2 TG M M 3 4 3 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

353 BANU 17 1 F O UM 2 2 4 2 1 3 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

354 EDWIN 49 3 M H M 3 3 3 1 2,3,4,5 2 5 6 2 4 N A NR N NR NR R 3 3 5 2 NIL

355 VENKAR 26 2 M O M 3 4 3 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

356 STALIN 38 2 M O M 3 3 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

357 GHANARAJ 27 2 M O M 3 2 1 2 2,5 2 5 6 2 4 N A NR N NR R NR 3 3 5 2 NIL

358 VELLADURAI 56 3 M O M 1 4 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

359 PONNUPANDIYAN55 3 M O M 3 3 3 2 2,3,4,5 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

360 KUMAR 28 2 M O M 3 2 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

361 JEYASRI 31 2 TG M M 3 3 3 2 2,4 4 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

362 SIVASANKARAN23 2 M H M 3 4 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

363 SUDHA 37 2 F O M 1 3 4 2 1 3 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

364 NASRUDEEN 32 2 M M M 3 2 3 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

365 THANGARAJ 38 2 M O M 3 2 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

366 INDARAAJ 64 3 M O M 1 1 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

367 OVIYA 30 2 TG M M 3 2 1 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

368 TAMIL 29 2 M O M 1 3 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

369 MURUGESAN 28 2 M O M 3 4 3 2 2,4,5 2 5 6 2 4 N A NR N NR R NR 3 3 5 2 NIL

370 HAKKINRAJA 31 2 M O M 3 2 3 2 2,3,4,5 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

371 VIGNESH 25 2 M O M 1 3 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

372 RAJA 42 3 M O M 3 2 3 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

373 RAJAGOPAL 35 2 M O M 3 3 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

374 SARAVANAMUTHU30 2 M O M 3 2 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

375 DEIVENDRAN 31 2 M O M 3 3 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

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376 MUTHUPANDI 23 2 M D M 3 3 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

377 NITHYA 34 2 TG M M 3 4 3 1 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

378 KARTHIKETAN19 1 M O M 3 4 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

279 VIJAYASUBBURAJ39 2 M O UM 2 3 2 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

380 VINOTH 30 2 M O M 1 4 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

381 RAJAMANI 54 3 F O M 1 3 4 2 1 3 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

382 PONKALA 35 2 TG M M 3 4 3 2 2,4 4 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

383 AIYSHA 30 2 TG O M 3 3 3 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

384 KIRTHIKA 22 2 TG O M 3 2 3 2 2,4 4 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

385 NAKSHTRA 27 2 TG O M 3 3 1 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

386 JINCHANA 19 1 TG M M 3 4 3 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

387 AVANTHIKA 21 2 TG O M 3 3 3 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

388 CHIPPU 36 2 M O M 3 4 3 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

389 MANIARASAN 50 3 M O M 3 2 3 2 2,3,4,5 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

390 MANIKANDAN 24 2 M O UM 2 3 2 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

391 MURUGAN 65 4 M D M 1 4 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

392 MANIKAM 38 2 M D M 3 2 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

393 ARUMUGAM2727 2 M H M 3 4 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

394 PATTURAJAN 22 2 M O UM 2 3 2 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

395 MANIKANDAN 26 2 M O M 3 2 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

396 MAHESHWARI 42 3 F O M 1 4 4 2 1 3 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

397 UIKATTAN 45 3 M O UM 2 2 2 2 1 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

398 KARUPPAN 67 4 M O M 1 4 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

399 ARUN 23 2 M O M 3 3 3 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

400 MAHESHWARI 37 2 F O M 1 3 4 2 1 3 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

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401 CHANDRAN 54 3 M O M 1 3 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

402 SANSIYA 38 2 TG M UM 3 4 3 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

403 SUDALAIMUTHU58 3 M O M 1 2 4 2 1 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

404 ELAVARASI 27 2 F O M 1 3 4 2 1 3 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

405 KUMAR 60 3 M D M 1 2 4 2 1 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

406 JEYARAMAN 28 2 M H M 3 3 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

407 SUNDAR 30 2 M M M 1 3 2 2 1 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

408 MEERAN 44 3 M O M 1 4 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

409 CHANDRALEKAN52 3 M O M 1 2 4 2 1 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

410 VIJAYALAKSHMI29 2 TG O UM 3 4 3 2 2,4 4 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

411 THANGADURAI40 3 M O M 1 2 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

412 VIJAYAN 37 2 M O M 1 4 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

413 SIVAPNDI 59 3 M O M 1 3 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

414 SANKARAMMAL58 3 F O M 1 1 4 2 1 3 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

415 VIJAYASANKARAN34 2 M D M 3 4 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

416 NARAYANAN 51 3 M H M 1 3 4 2 1 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

417 LAKSHMI 41 3 F D M 1 4 4 2 1 3 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

418 MANIVEL 44 3 M M M 1 2 4 2 1 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

419 NAGOORAMMAL40 3 F O M 1 4 4 2 1 3 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

420 SELVAM 47 3 M O M 3 3 3 2 2,3,4,5 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

421 KANNAN 35 2 M O M 2 2 2 2 1 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

422 ANTONY 48 3 M O M 2 1 4 2 1 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

423 PERUIYASAMY41 3 M O M 1 2 4 2 1 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

424 NARAYANAN 38 2 M O M 1 4 2 2 1 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL


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426 AMUDHA 35 2 TG M M 3 4 3 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

427 DHANIYA 25 2 TG O UM 3 3 1 2 2,4 4 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

428 VINOSRI 25 2 TG M UM 3 3 1 2 2,4 4 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

429 VINO 26 2 TG O UM 3 3 1 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

430 MAYA 26 2 TG O UM 3 4 1 2 2,4 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

431 MADASAMY 55 3 M O M 1 2 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

432 ARUMUGAPANDI34 2 M D M 1 3 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

432 KUMAR 40 3 M H M 1 4 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

434 MAHABOOB 47 3 M D M 1 3 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

435 SAMUEL 20 2 M D UM 3 4 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

436 ALI 47 3 M D M 2 3 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

437 DEEPSINGH 64 3 M H M 1 2 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

438 KUMAR 40 3 M H M 2 4 2 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

439 VIJAY VITTAL 25 2 M O M 2 3 2 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

440 SUNDARRAJ 40 3 M O M 3 2 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

441 ESAKIAMMAL 44 3 F O M 1 3 4 2 1 3 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

442 MOTHILAL 32 2 M O M 1 4 4 2 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

443 PRIYA 28 2 F H M 1 3 4 2 1 3 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

444 MICHEAL 48 3 M D M 1 4 4 2 1 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

445 PERUMAL 34 2 M D M 1 3 3 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

446 SABARIRAJ 28 2 M H M 3 2 3 1 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

447 MUTHU 24 2 M O M 3 4 3 2 4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

448 ARUMUGAVADIVU34 2 F O M 1 3 2 2 1 3 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

449 SINDHUKUMAR22 2 M O M 3 2 1 2 2,3,4,5 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

450 RAGHU 45 3 M O M 3 3 1 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

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451 RAJESHKUMAR41 3 M O M 2 2 2 1 1 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

452 MANIKANDAN 26 2 M H M 3 3 3 2 2,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

453 RAJANDRA PRASAD44 3 M D M 1 4 4 2 1 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

454 RAJAIYA 49 3 M D M 1 3 4 2 1 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

455 SUSAIYAPPAN 42 3 M H M 3 4 3 2 2,3,4,5 2 5 6 2 4 OC A NR N R NR NR 3 3 5 2 NIL

456 VIGNESH 24 2 M O UM 3 3 3 1 2,3,4,5 2 5 6 2 4 N A NR N R NR NR 3 3 5 2 NIL

457 SHEIKMOHAMMED34 2 M O M 3 2 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

458 VINOSHRI 24 2 TG O UM 3 4 3 2 2,4 4 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

459 SUNDARI 31 2 F O M 1 3 4 2 1 3 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

460 RAJA 24 2 M O UM 3 2 3 2 2,3,4,5 2 5 6 2 4 N A NR N NR NR NR 3 3 5 2 NIL

a cross sectional study of sexually transmitted infections

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Transcript of a cross sectional study of sexually transmitted infections