Question
How well do STI syndrome guidelines for the general population of women in India perform compared to standard etiological diagnosis of STIs by laboratory methods for the diagnosis and treatment of STIs in female sex workers in Surat, India?

Design
This article describes a cross-sectional study comparing the performance of syndromic case management (Indian guidelines) with laboratory detection for the diagnosis of STIs in female sex workers in India.

Participants
One hundred eighteen out of 500 to 600 female sex workers in the Surat, India, red light area completed all aspects of the study and were included in the analyses. The age ranged from 16 to 50 years (mean age = 28.5 years), the mean number of sex partners per day was five, and 94.9% reported consistent condom use with clients.

Description of Tests and Diagnostic Standard
Each participant was administered a structured questionnaire, a physical examination, and specimen collection. STIs were diagnosed by laboratory tests including RPR (Spinreact Reactivos, Spinreact, Spain) and TPHA (Human, Human Gesellschaft fur Biochemica and Diagnostics mbH, Germany) on serum for the presence of active syphilis infection, culture of modified Thayer-Martin medium (Himedia, Himedia Laboratories Ltd., Mumbai, India), Gram stain, and Pace2 GC assay (Gen-probe Inc., San Diego, CA) on endocervical swabs for the diagnosis of gonorrhea, Pace2 CT assay (Gen-probe) on endocervical swabs for diagnosis of chlamydial infection, wet mount and culture of Whittington media (Himedia) on vaginal fluid for detection of T. vaginalis, and two ELISA assays (Biosign, Princeton BioMeditech Corp for Premier Medial Corp, USA and Lab Systems, Helsinki, Finland) on serum for detection of HIV antibodies.

Main Outcome Measures
The sensitivity, specificity, and positive predictive values (PPV) of STI syndromic management were calculated compared to laboratory detection for the diagnosis of STIs.

Main Results
Forty-nine (41.5%) of 118 women reported symptoms related to STDs. Syndromic diagnoses included abnormal vaginal discharge in 51.7%, lower abdominal pain in 19.5%, enlarged inguinal lymph nodes in 11.9%, and genital ulcers in 5.9%. The prevalence of STIs based on laboratory screening was 22.9% for active syphilis, 16.9% for culture-positive gonorrhea, 8.5% for chlamydial infection, 14.4% for trichomoniasis, and 43.2% for HIV. The sensitivity, specificity, and PPV of vaginal discharge and genital ulcer syndromic management for the diagnosis of laboratory detected STIs are shown in the table.

Authors’ Conclusions
The performance of Indian recommended treatment guidelines for vaginal discharge syndrome and genital ulcer syndrome compared to laboratory diagnosis was poor. Syndromic case management missed a large number of asymptomatic cases and provided treatment in the absence of infection.

Source of funding:  Partner in Sexual Health, DFID, UK.

For correspondence:  Vikas Desai, Community Medicine Department, Government Medical College, Surat, Majura gate, Surat, Gujarat, India.

psmvikas@hotmail.com.