STD patients reported number, tip of an ice berg
It was in 1952 that the Anti Venereal Disease Campaign was
established in Sri Lanka . Since then the country has gone through 55
years of STD services.
The term 'Venereal disease' has now been replaced with 'sexually
transmitted infections' and even that does not adequately reflect the
real scope of the specialty since venereology covers many conditions
that may have not been transmitted exclusively through sex.
Establishing the Anti Venereal Disease Campaign in 1952 was the
logical result of a variety of activities and developments that occurred
prior to it. I would like to allude to some of the significant moments
of the history prior to establishment of the campaign,
1. Adoption of legislative measures to control venereal diseases by
targeting prostitutes in 1841, 1867 and 1889
2. Starting first free part time venereal disease clinics in 1921
,1931, and 1937 in Colombo, Kandy and Galle respectively
3. Services to control Venereal Diseases in 1938
4. Starting training of medical officers to work in VD clinics in
5. Opening of part time clinics totaling to 23 by 1944
6. Establishment of Venereal Diseases Control Project of WHO in 1951
under Dr S. M. Laired. With the closure of the project the Anti-Venereal
Diseases Campaign was established in 1952. Laboratory facilities were
established in 1968.
In 1985, as a response to the then emerging global epidemic of HIV,
the anti venereal diseases campaign was renamed the National STD/AIDS
Some landmark events in the national response to the HIV epidemic in
1. Establishment of NSACP in 1985
2. Establishment of National Task Force for prevention and control of
AIDS and First HIV sero-survey was conducted in 1986
3. First Sri-Lankan with HIV was detected in 1987
4. Screening of donor blood was started in 1987 by the NSACP in
collaboration with National Blood Transfusion Service
5. Formulation of Combined STD/AIDS control programme in 1988
6. Establishment of HIV sentinel surveillance in 1990
7. external revive in 1993
8. Supply of free ART in December 2004
9. First round of Behavioural Surveillance Survey was conducted in
2006 If I may refer briefly to the structure of NSACP, it has been a
fully devolved programme since 1987 with the introduction of the 13 th
amendment to the constitution.
The central body of NSACP has it's headquarters in Colombo along with
the Central STD clinic and National Reference laboratory.
Presently, there are 29 fulltime STD clinics functioning throughout
the country. Except Galle and Jaffna, all other clinics (26 clinics) are
under the provincial administration.
The availability of antiretroviral therapy (ART) (HAART / CART) free
of charge since December 2004 is undoubtedly a major step in the battle
against HIV in this country. At present ART is provided at the
1. HIV clinic of the Central STD clinic in Colombo
2. STD clinic Kalubowila
3. STD clinic Ragama
4. STD clinic Kandy
5. Infectious Disease Hospital
There have been requests for ART to be provided in all districts and
some appear to be oversimplifying ART management. These requests
indicate a sheer lack of understanding of the gravity of the issue.
At this juncture it would be useful to address some major aspects
that have to be considered before starting ART such as:
1. preparation of patient for ART
2. choosing the best regimen for the patient
3. The necessity of regular monitoring once ART has commenced,
4. assuring adherence to the regimen, a life long process
5. Stopping or/and switching when indicated, Until end of September
2007, there were 400 HIV patients registered for medical care, and 102
patients started on ART, out of an estimated 500 with advanced HIV
Considering the numbers and geographical distribution of known HIV
patients and available expertise to manage ART, the NSACP is providing
those services to the best of its ability. However there is no doubt
that in few years to come the NSACP will be able to provide ART in all
provinces when the newly qualified venereologists assume duties.
It is important to discuss briefly the way antiretroviral drugs work
against the virus. Once ART started,
1. The disease progression will cease in 3 to 4 months
2. Virus undetectability will be possible in 6 to 9 months
3. Immune status will improve (with the increase of CD4 count)
4. Opportunistic infections to disappear gradually
5. There will be less need for hospitalizations
6. Patients reach near normalcy
7. The patient becomes less infectious and therefore less able to
transmit the virus
8. And it will be possible to attract potential HIV positive persons
to access health care
The clinicians have to decide when to start ART in consultation with
the patient. This is not an arbitrary and imposing decision, but an
evidence-based one. The overall clinical picture, the status of the
immune system (which is assessed through the CD4 count) and viral load
(that is the number of viral copies in 1/ml of blood) are the most
important parameters used in making that decision.
Once ART is started, the viral load probably is the most important
parameter to monitor the status of the infection. If there is treatment
failure, changes in the viral load would be the first parameter to
reflect that situation. Therefore, in my view, uninterrupted facilities
for viral load investigation is very important.
Because of the low prevalence of HIV in the country, limiting the
viral load testing to the National Reference laboratory would be
Sexually Transmitted Diseases services STD attendance
2004 2005 2006 Male 35836 30839 38422 Female 41773 42250 42927 Total
77609 73089 81349
Total number of visits recorded by STD clinics
In 2004, 2005 and 2006 were 77609, 73089 and 81349 respectively. here
have been 10,153 new episodes of sexually transmitted infections
diagnosed in 2005 and 10,268 new episodes in 2006 throughout the
We are aware that the patients seen in the STD clinics reflect only
the tip of the ice berg. The annual estimates of new episodes of STIs
are around 60,000 to 200,000. These figures are a clear indication of
the extent of risky behaviours that people engage in.
On the other hand, the data on STI also indicate the vulnerability of
Sri Lanka to an explosion of the HIV epidemic.
That is why the control and prevention of STDs is being regarded as a
fundamental strategy for control and prevention of HIV all over the
world. Very often, some look for reasons for low prevalence of HIV in
Non Gonococcal Urethritis (NGU) NGU is primarily a sexually acquired
condition. It is due to inflammation of the urethra which is
characterized by discharge and/or dysuria. Patient may also be
Causes of NGU
1. chlamydia trachomatis 30-50%
2. mycoplasma genitalium 10-20%
3. ureaplasma urealyticum 10-20%
4. trichomonasis vaginalis 1-17%
5. other bacteria (eg. bacterial vaginosis associated) 2-10%
6. HSV, candida species, bacterial UTIs, urethral strictures, foreign
bodies 10% Causative factor not identified 20-30% There are
complications that can be developed due to NGU and they are
1. chronic NGU
3. sexually acquired reactive arthritis Chronic NGU could be either
persistent or recurrent. There is no consensus of opinion in either
diagnosis or management of persistent or recurrent NGU.
What is important is that persistent or recurrent NGU can occur in
20-60% of men treated for acute NGU. I don't want to go any further on
discussing NGU but would like to stress that management of NGU could be
Genital Herpes: Herpes is known to all of us and it is caused by HSV
type 1 and 11. The infection usually causes multiple, superficial and
painful lesions in the affected area.
Following primary HSV infection, cell mediated immunity clears
actively replicating virus from the body. But some virus remain in a
virtually inactive state within neuronal tissues lifelong and may
activate any time causing genital ulcers.
Probability Average number of episodes Type 1 40-50% 1/year Type 11
Though it is not my intention to discuss HSV, we must not forget that
HSV facilitates both transmission and acquisition of HIV and herpes in
pregnancy may be associated with serious outcomes.
My concern is that recurrent genital herpes affects
1. quality of life
2. psychological functioning
3. sexual functioning
5. behaviour and its management poses a challenge to the
venereologist Pelvic Inflammatory Disease (PID) Pelvic inflammatory
disease is the result of ascending infection from the endocervix causing
endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abcess
and pelvic peritonitis. Most episodes of PID are polymicrobial. Symptoms
and signs of PID symptoms and signs of PID are
1. Intermenstrual spotting
2. post-coital bleeding
3. recent onset menorrhaagia
4. vaginal discharge
5. deep dyspareunia
6. lower abdominal pain
7. pain in right upper quadrant of abdomen
As there are no diagnostic clinical criteria for PID, a high degree
of suspicion warrants treatment. If the condition is left untreated or
treatment is delayed, recurrent attacks may result in serious
complications and sequelae such as chronic pelvic pain, ectopic
pregnancy, infertility and dyspareunia.
These are associated with considerable psychological morbidity and
are costly to treat in terms of time and money. These sequelae are
potentially preventable and we should work towards this objective.
Bacterial vaginosis BV is the commonest cause of abnormal vaginal
discharge in women of childbearing age.
Its characteristic signs are:
1. increased vaginal discharge which is thin, homogenous and adherent
2. pH above 4.5.
3. production of amines resulting in a fishy odour
4. presence of 'clue' cells
BV is an important condition which has to be managed properly due to
1. adverse pregnancy outcomes such as premature rupture of membrane,
pre-term delivery and low birth weight
2. non-pregnancy complications of BV such as it's association with
PID, infertility and NGU, BV is nota trivial condition. When recurrent
episodes develop, extra care is needed to manage these patients.
Vulvovaginal Candidiasis (VVC) or thrush Vulvovaginal candidiasis is
most often caused by candida albicans. Nearly 75% of women will
experience at least one episode in the life-time and up to 5-10% of them
will have more than one attack.
Attacks of candidal infection may be precipitated by the use of
antibiotics, diabetes mellitus, immunosuppression and pregnancy. But
most of the times no cause can be found.
The frequent symptoms of VVC are vulval itching, vulval soreness
vaginal discharge, Superficial dyspareunia and sometimes external
dysuria. Erythema, oedema, fissuring and satellite lesions are some of
the signs of VVC.
Though easily diagnosed and treated in recurrent VVC often
constitutes a management problem, and considerably disabling for
Special clinics have been to look into set up male and female problem
conducted by senior registrars and /or consultants in the specialty to
deal with these patients. This is likely to renew confidence in
treatment among patients, provide relief and reduce costs of care.
Dedicated clinic for sex-workers: When we think of people who seek
STD services, sex-workers naturally come to mind. Epidemiologically,
sex-workers are considered as the source and reservoir of STD/HIV /AIDS
in all countries and considered as one of the groups most vulnerable to
infection. Thousands of visits by sex-workers have been recorded in STD
clinics and this is probably.
The tip of the iceberg and the majority are unlikely to be benefiting
by services that STD clinics can offer. We are familiar with the
experience of Thailand , Brazil and Kampuchea that achieved 100% condom
use among sex-workers.
Female sex-worker attendance
2004, 2005, 2006 Newly registered sex-workers for the year 890, 692,
597 Newly registered sex-workers with STDs 502, 457, 358 Total number of
visits recorded by sex-workers 2117, 2429, 2117.
The External Review of the national response to sexually transmitted
infections and HIV/AIDS in Sri Lanka in 2006, identified strategic
priorities for the National STD/AIDS Control Programme (NSACP).
These included. The need to map sex-workers and develop an essential
service package including clinical services for STIs and promotion of
condom use. These have now being incorporated in the National Strategic
Plan 2007, 2011 and is expected to increase the accessibility of STD
services for sex workers.
How are we to achieve the target set in the national strategic plan?
One viable Option would be to establish Dedicated clinics for
sex-workers starting at the Central STD clinic in Colombo.
Emergency contraceptive services as a provider of sexual health
services, we also need to address the issue of contraception, including
emergency contraception available at STD clinics.
Available data indicates that about 150,000 to 175,000 induced
abortions take place annually in this country and about 10% of these are
among unmarried women. Abortion is not legalized in Sri Lanka and may be
performed only on medical concurrence to save the life of the mother.
As above mentioned facts reveal up-to 10% abortion seekers are
unmarried and they are unmarried females having unprotected sex. Even if
we go by the lowest figures of all estimates the number of unmarried
females seeking abortions a year is more than 15,000.
When we consider the possible health consequences, these women may be
potentially vulnerable to STDs as well as HIV infection.
We should be able to attract these women to our services by offering
them emergency contraceptive services and same time STD care under one
roof as in many other countries.
Another area that is important but rarely addressed is that of sexual
dysfunctions. It is a matter of concern that these services are still
not formalized within our state services.
Few men and women pass through life without experiencing some
concerns and difficulties with their sexual life. Sri Lankans are no
exceptions though culture is often a formidable barrier to surmount in
seeking relief for these conditions.
Sexual dysfunction may be the result of organic or psychological
The common problems experienced by men include erectile failure
disorder, premature ejaculation and performance anxiety. Among women,
primary vaginismus leading to nonconsummation deserves attention, other
common complaints being dyspareunia and a lack of sexual desire.
Sexual dysfunctions - Attendance at Ragama STD clinic / 2006 Problem
No. patients Erectile dysfunction 13, Premature ejaculation 09, Reduced
libido 01 Total 23 I think you may agree with me that the confidential
atmosphere in a STD clinic would be appropriate and comfortable for
people with sexual dysfunctions to seek relief.