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Editor,—There has been a progressive rise in the prevalence of human immunodeficiency virus (HIV) infection in India, which currently has the largest number of HIV infected people in the world.1 The spread of HIV is predominantly by heterosexual transmission in India.2 Sexually transmitted disease (STD), particularly genital ulcer disease (herpes, syphilis, and chancroid), has an important role in the transmission of HIV, and the two have been observed to be interrelated.3, 4 We conducted a pilot study to assess the relation between syphilis and HIV infection among non-pregnant women attending gynaecology and STD clinics of our hospital.
From June 1998 to July 1999, sera from 281 non-pregnant women were tested for syphilis by VDRL (Serologist, India) and confirmed by TPHA (Immunotrep, Omega Diagnostic Ltd, UK). Sera that tested positive for syphilis were tested for HIV without identifying the patient. Individual informed consent for HIV was not obtained as results were not aimed to be linked to the identity of those tested. Serum was tested first with one ELISA/rapid/simple (ERS) assay, utilising either of the these different enzyme linked immunosorbent assay (UBI, HIV-1/2, United Medical Inc, USA, Recombigens HIV-1/HIV-2, EIA, Cambridge Biotech Galway, Ireland, and HIV spot Genelabs Diagnostic, Singapore). Any reactive sample was retested using a different assay. Samples that were reactive in all the three tests were considered HIV antibody positive. A sample that was non-reactive on the first test was considered HIV negative, as was a sample that was reactive in the first and non-reactive in the next test.5
Of 281 sera tested, 48 (17%) were seropositive for syphilis. HIV antibody was detected in sera of six (12.5%) patients who were seropositive for syphilis (table 1). None of the 233 patients with negative syphilis serology tested positive for HIV antibody. This was highly significant (p<0.001, Fisher's exact test). Presence of HIV antibody was associated with genital ulcer in 23.5% women, followed by genital growth and vaginal discharge in 16.6% and 11.1% respectively.
There is a higher prevalence of STD and HIV infection among men compared with women. HIV seropositivity has been associated with a reactive serological test for syphilis among males. This could be probably due to higher percentage of male attendance in STD clinics.6 We therefore undertook this study to evaluate if some association exists between syphilis and HIV among non-pregnant women attending the gynaecology clinic, as well as the STD clinic. Untreated STDs, especially those with ulcerative disease, can enhance both susceptibility of a person to HIV infection as well as infectivity of HIV positive individual. Breach in the epithelial surface of a genital ulcer may be an important factor in the transmissibility of HIV. This is evident from our results where incidence of positive serology for HIV was highest among women with genital ulcer (23.5%). Our study demonstrates a significant association between positive serology for syphilis and presence of HIV infection. We feel that the diagnosis of syphilis in non-pregnant women may act as a marker to detect the presence of HIV infection.
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