|Ahead of print publication
Seroprevalence of Sexually Transmitted Infections (Hepatitis B Virus Hepatitis C Syphilis, and HIV) in Pregnant Women and Evaluation of Sociodemographic Characteristics and Awareness Regarding STIs in North Indian Population
Ruby Bhatia, Girisha Mehta, Sukhbir Pal Kaur Sidhu, Trisha Arora, Renuka Raina
Department of Obstetrics and Gynaecology, MMIMSR (Deemed to be University), Mullana, Haryana, India
|Date of Submission||04-Sep-2021|
|Date of Acceptance||04-Apr-2022|
|Date of Web Publication||08-Aug-2022|
Department of Obstetrics and Gynaecology, Professor and Head of Department, MMIMSR (Deemed to be University), Mullana, Haryana, India. Postal address: 56, Lata Green enclave, Near radio station road, Patiala-147002
Source of Support: None, Conflict of Interest: None
Abstract Context: Sexually transmitted infections (STIs) are a problem of increasing concern among men and women. They can affect fertility, increase maternal and neonatal morbidity, and can become a burden on both physical and emotional health. Owing to lack of awareness and partly due to the social stigma attached, couples do not come forward for screening. Antenatal testing for STIs is an effective strategy recommended to detect STIs in this subset of the population. Aims: To estimate the seroprevalence of four STIs (hepatitis B, hepatitis C virus, HIV, and syphilis) in pregnant women, to evaluate its correlation with sociodemographic characteristics and sexual behavior, and to check awareness regarding STIs. Settings and Design: It was an observational study on 500 pregnant women attending an antenatal clinic at a tertiary care hospital in rural Haryana, India. Methods and Material: Pregnant women were screened for four STIs – hepatitis B, hepatitis C virus, HIV, and syphilis. Statistical Analysis Used: The sample size was calculated considering the mean reported seroprevalence of infections in pregnant women in previous studies. The power of the study was kept 80% and the alpha error was 0.05. Results: Seroprevalence for STIs in pregnancy was 5.2% – hepatitis C virus (2.6%), hepatitis B (2.4%), and syphilis (0.4%). Conclusions: Viral STIs are more prevalent among pregnant women. Antenatal screening is an effective strategy for the detection of STIs in pregnant women.
Keywords: Antenatal screening, mother to child transmission, seroprevalence, sexually transmitted infections
Key Messages: There is a pressing need for improvising awareness and screening of STIs in the periconceptional period. Screening in pregnancy is an effective tool for the detection of STIs in this subset of the population. Viral STIs are more prevalent in pregnant women. New patients with STIs detected in pregnancy can get the benefit of starting treatment and hence prevent the transmission of dise
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Bhatia R, Mehta G, Sidhu SK, Arora T, Raina R. Seroprevalence of Sexually Transmitted Infections (Hepatitis B Virus Hepatitis C Syphilis, and HIV) in Pregnant Women and Evaluation of Sociodemographic Characteristics and Awareness Regarding STIs in North Indian Population. MAMC J Med Sci [Epub ahead of print] [cited 2022 Nov 26]. Available from: https://www.mamcjms.in/preprintarticle.asp?id=353660
| Introduction|| |
Sexually transmitted infections (STIs) are a major public health concern with more than one million curable STIs occurring each day globally., Almost 80% of curable STIs occur in developing countries like India. STIs are more common in the reproductive age group and if left undetected or untreated can lead to long-term sequelae, that is, chronic infection, infertility, and chronic pelvic pain. In pregnancy, it can lead to poor neonatal outcomes by contributing to preterm births, low birth weight, congenital malformations, developmental delays, and stillbirths. The social stigma attached to diagnosis, lack of awareness, and costs involved are some of the major factors hindering the screening and treatment of STIs.
Prevalence of STIs may be more in pregnant women when compared to the general population as they tend to use less of condoms as compared to those who are nonpregnant, which could increase STI incidence. Alterations in immune function and physiological changes in the cervix during pregnancy are also the potential biological pathways of increased risk. Routine screening in antenatal care settings have shown high prevalence of common STI's.,
Viral infections contribute substantially to the global burden of STIs. According to a WHO report on global STI surveillance (2018), chronic Hepatitis C Virus (HCV) infection is present in approximately 71 million people. The estimated prevalence of HCV infection in India varies from 0.5% to 1.5%., HCV can be transmitted through unsafe injection practices, unsafe IV drug use, unscreened blood and blood products transfusion, unprotected sexual practices, and vertical transmission. Antiviral medications can cure more than 95% of those infected with the hepatitis C virus. Centers for Disease Control & Prevention (CDC) recommends screening for all pregnant patients during each pregnancy, except in places where the prevalence of HCV by HCV RNA positivity is less than 0.1%.
An estimated 257 million people are living with chronic hepatitis B globally. Hepatitis B can pass from the mother to the baby during intrapartum period. Steps taken to prevent mother to child transmission (MTCT) of Hepatitis B Virus (HBV) infection start with the screening of the mother for Hepatitis B virus (HBsAg). Antiviral treatment in the antenatal period given to women with HBV vaccination and hepatitis B immunoglobulin given to high-risk infants can further decrease the MTCT risk of HBV.
Globally, the second leading cause of stillbirths is syphilis in pregnancy. The prevalence of syphilis among females aged 15 to 49 years is 0.5%. There are an estimated one million active cases of syphilis in pregnancy. Treponema pallidum can cross the placenta and infect the baby in utero and result in preterm birth, low birth weight, stillbirth, neonatal death, and infections in newborns. The rate of syphilis testing in India is still low. Only 33.9% of antenatal care attendees were tested for syphilis in India in 2019 leaving a high percentage of antenatal women untested, undetected, and hence untreated for syphilis posing a greater risk of fetuses born with congenital syphilis.
In developing countries, Human Immunodeficiency Virus (HIV) is a major health problem. Globally, around 38 million people are living with HIV. Although the incidence of HIV has reduced by twofold in the last decade due to various HIV/AIDS control programs, it still poses a major public health problem due to its magnitude. In pregnancy, HIV can be transmitted vertically via the transplacental route or during delivery. Early detection and antiretroviral therapy can decrease Mother to Child Transmission (MTCT) of HIV to a significant extent.
Vertical transmission of HIV, HCV, and HBV can lead to neonatal infection. Congenital syphilis can lead to various debilitating and life-threatening sequelae in newborns. Prevention and control of infections in the prenatal and antenatal periods is an imperative and effective strategy to prevent sequelae related to these infections.
During pregnancy, routine antenatal visits and testing present an excellent opportunity for screening this subset of the population for STIs.
Thus, the present study was planned to estimate the seroprevalence of four STIs (hepatitis B, hepatitis C virus, HIV, syphilis) in pregnant women, to evaluate their correlation with sociodemographic characteristics and sexual behavior, and to check awareness regarding STIs.
| Subjects and Methods|| |
It was an observational prospective study involving pregnant women attending the Antenatal Clinic from January 2019 to June 2019 in the Department of Obstetrics & Gynaecology in a tertiary care hospital in Northern India. A total of 500 pregnant females in the age group of 15 to 49 years were included in the study after written informed consent.
Detailed information regarding sociodemographic profile, personal history, and high-risk sexual behavior (multiple sex partners/unsafe sexual practices) of pregnant females along with their spouses/partners was noted. A complete general and physical examination followed by obstetrical and per speculum examination was done in all cases. Pregnant women attending the antenatal clinic were included in the study and seropositive pregnant women were referred to respective specialty clinics for further counseling and treatment. Women not willing to participate in the study were excluded from the study.
All routine antenatal investigations were done including ABO/Rh typing, complete hemogram, urine routine, and culture. All pregnant women included in the study were referred to the Integrated counselling and testing centre (ICTC) for counseling and testing for HIV as per the National AIDS Control Organization (NACO) guideline. HIV screening was done with a HIV1+2 immunodot test kit. For screening syphilis, a Venereal disease research Lab (VDRL) test was done and those who were found positive were offered further confirmatory test (TPHA) and management including partner testing and treatment were commenced. Screening for hepatitis B was done by testing HBsAg by rapid hepacard test. HCV screening was done with an HCV tridot kit to see for anti-HCV antibodies. Partners of seropositive females were also screened and were referred for further management and counseled regarding future protective measures.
The sample size was calculated considering the mean seroprevalence of hepatitis B virus, hepatitis C virus, syphilis, and HIV in pregnant women, reported in India in previous studies, as 3% ± 1.5. The power of the study was kept at 80% and alpha error as 0.05 and the sample size was calculated as 441. Results obtained were compared and analyzed statistically.
This study was carried out in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Approval from the institutional ethical committee was taken before the commencement of the study.
| Results|| |
A total of 500 pregnant women were screened for STIs during the study period. The median age group of the study population was 26 years. Twenty-six (5.2%) women were found to be seropositive for STIs (HIV/HBV/HCV/syphilis). The sociodemographic details of the women under study were noted [Table 1].
Seropositive cases of different STIs (HCV, HBsAg, syphilis, and HIV) detected in screening tests in pregnant women and their spouses were compared [Table 2].
|Table 2 Seroprevalence of STIs in pregnant women (n = 500) and sero-concordance for STIs in spouses of seropositive women|
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The maximum number of pregnant women with seropositivity for infections was found in the hepatitis C virus group with a prevalence of 2.6% constituting half of the STIs recorded in our study. This was closely followed by HBsAg with a prevalence of 2.4% and the prevalence of syphilis was 0.4%. No case was found positive for HIV in our study. Seropositivity for STI among spouses of seropositive women was found in 34.61% of cases and 88.89% of these were sero-concordant (for the same STI).
Among women detected seropositive for infections, the majority were found in the 21 to 30 years age group (21/26) (80.76%), and the majority were positive for HBsAg (11/21) (52.38%), followed by HCV (9/21) (42.86%). One patient was found to be positive for both HBsAg and HCV. Two cases of syphilis were found in this group (2/21) (9.52%).
In the 31 to 40 years age group, 15.38% (4/26) of cases were found and all were HCV positive. At extremes of age, the number of pregnant women was less and so was the seropositivity rate. Only one case was found to be positive for HBsAg below 20 years of age and no women reported pregnancy at age more than 40 years, and so this age group was excluded from the final analysis.
Most of the women seropositive for STIs were from a rural background (18/26) (69.2%) and the majority were found to be positive for HCV (11/18) (61.1%). The most commonly found STI among the urban group was HBsAg (5/8) (62.5%).
Seroprevalence of infections was highest among women from low socioeconomic status (21/26) (80.76%) when compared with middle (4/26) (15.38%) and upper class (1/26) (3.84%). The majority of cases among low socioeconomic cases were positive for HBsAg (10/21) (47.61%) and HCV (9/21) (42.85%). Both cases of syphilis were from this group (2/21) (9.52%).
Seropositivity for STIs was higher in men and women with high-risk sexual behavior among the study population. The majority of women with high-risk sexual behavior (4/6) (66.6%) were among seropositive cases and 74.07% (20/27) of women with spouses with multiple sexual partners belonged to the seropositive group. It was observed that 83.3% (5/6) women and 77.7% (14/18) spouses with a history of unprotected oral and anal sex were seropositive for STIs.
Awareness regarding STIs, safe sexual practices, and utilization of available STI services was lower among couples screened seropositive for STIs population [Table 3]. Awareness regarding HIV/AIDS infection was higher (75.8%) than awareness of any other infections screened in the study population [Table 4].
|Table 3 Awareness among couples regarding STIs, STI services, and utilization of STI services|
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| Discussion|| |
The burden of STIs is increasing and its implications on pregnancy and childbirth necessitate the strong implementation of preventive and control measures. WHO’s global health sector strategy on STIs (2016–2021) acknowledges STIs as a major public health concern and has established it as its goal to end the STI epidemic. STI prevention and control is an important initiative to achieve Sustainable Development Goals for combating the AIDS epidemic and other communicable diseases among adults. It is also vital for preventing mortality among newborns and under five-year-old children. Surveillance is needed to assess the disease burden in a given area and the WHO recommends countries to assess the prevalence of STIs routinely (every 2–3 years).
Pregnant women form a subset of the population that needs evaluation as targeting this population can help control these infections and their transmission in the antenatal, intrapartum, and postpartum periods.
A number of factors determine the seroprevalence of STIs in different areas, the most important being the awareness regarding STIs among couples. It also depends on knowledge regarding the prevention of STIs, control measures available, and utilization of STI services. In the present study, a total of 26 (5.2%) antenatal women were found seropositive for STIs. Seroprevalence of STIs in studies from different regions of India has been reported to vary from as low as 1.5% by Maheshwari et al from Haryana to as high as 22.5% by Kaur et al from Punjab. As some of the infections are also transmitted via blood, infected syringes and instruments, infected blood products, and sharing of needles as in IV drug users, many factors are influencing the prevalence and spread of these infections with some areas having a very high prevalence than others.
The seroprevalence of HCV in the present study was 2.6%. The global prevalence of HCV in 2015 was estimated to be 1%. In India, the prevalence of HCV infection in pregnancy varies in different regions and has been reported from as low as 0.13% to as high as 9%.
Hepatitis C MTCT occurs at a rate of 5% to 15%. HCV guidance panel (AASLD) recommends that hepatitis C testing should be done in the preconceptional period and those tested positive should receive treatment in prepregnancy. Women should be counseled regarding the benefits of treatment for themselves and for their future pregnancies and uptake of treatment should be encouraged to prevent MTCT of HCV infection.
Seroprevalence of hepatitis B virus infection in our study was found in 2.4% of pregnant women, which is comparable to a study from Faridkot (Punjab) with a prevalence of 2.8%. The global prevalence of hepatitis B virus infection is 3.5% and it is the commonest cause of chronic hepatitis. In endemic areas, MTCT during pregnancy is the leading cause of transmission and it can be prevented by early identification of infection via screening. India lies in intermediate prevalence countries for hepatitis B infection (2–7%). WHO recommends testing all pregnant women in areas where the seroprevalence of HBsAg exceeds from 2% to 5% range. Hepatitis B testing is recommended in pregnancy in India. Knowledge of hepatitis B status in pregnancy can help plan delivery and neonatal care more effectively addressing the antenatal, intrapartum, and postpartum management and prevention of transmission to newborns.
Seroprevalence of syphilis is observed in 0.4% of the population in our study. The estimated global prevalence of maternal syphilis was 0.69% in 2016. In a 5-year study from a prenatal screening center in India (2011–2015), the prevalence of syphilis was found to be less than 1%. It has been observed that cases of congenital syphilis have been decreasing with better preventive measures coming into action over time. The global health sector strategy on STI (2016–2021) has a goal to decrease the cases of congenital syphilis to less than 50 cases per 100,000 in 80% of countries by the end of 2030. In 2017, there were an estimated 18 million cases of syphilis. The introduction of elimination of MTCT HIV and syphilis program (since 2007) has upscaled the screening of syphilis at the first antenatal visit and, hence, timely detection and treatment of syphilis.
A decreasing trend in new HIV infections has been observed (a fall by 39%) largely due to increasing awareness regarding prevention through AIDS control programs. In India, the adult prevalence of HIV is 0.3% with adult female HIV prevalence of 0.29%. The presence of other STIs increases the chances of HIV acquisition by 4% to 10%.
We did not find any cases of HIV in our study population. Different studies across India and abroad have observed seroprevalence of HIV as 0.7%, 6.8%, and 5.5%. WHO has recommended lifelong treatment with antiretroviral drugs for people with HIV irrespective of their CD4 count or stage of the disease. Approximately 85% of pregnant and breastfeeding women with HIV have received ARV treatment to prevent MTCT in 2019.
The majority of seropositive pregnant women in our study were from low socioeconomic status (80.76%), rural background (65.38%), illiterate (61.54%), and were homemakers (61.53%). Jindal et al. reported 89.4% of the seropositive population from low socioeconomic status and 87.3% with a low level of education in a community-based study. Higher seroprevalence among the rural population and lower socioeconomic status has been reported by many other studies.,
High-risk sexual behavior was observed in 5.4% of spouses and 1.2% of pregnant women in the study population. 74.07% of women with spouses with multiple sexual partners and 66.6% of women with a history of multiple sexual partners were seropositive for STIs. A higher incidence of STIs in spouses (17.3%) and pregnant women (5.4%) with high-risk sexual behaviors was reported by Kaur et al. Partner screening and treatment is an essential step in management to prevent infection and reinfection among spouses. Sero-concordance rate of STIs was high (88.89%) in spouses who were tested positive among spouses of seropositive pregnant women in the present study. This further emphasizes the importance of screening and treatment of partners.
Among the total pregnant population under study, 75.8% had awareness regarding HIV/AIDS while only 26.92% of the seropositive population were aware of HIV/AIDS. Awareness regarding STIs and knowledge of their mode of spread in a population plays an important role in enabling people to follow control measures and prevent the further spread of infections. Knowledge regarding HCV infection was lower in the seropositive population (19.23%) as compared to the total population (42.6%) in the present study. Knowledge regarding syphilis in the seropositive population was very low (3.85%). National Family Health Survey 4 (NFHS-4 Haryana) reports awareness about HIV/AIDS in 71.6% of women and 87.7% of men in the general population.
Availability of STI services was known to 62.4% of the study population. Only 39.2% had a positive attitude toward the utilization of these services in the present study. Kaur et al and Sandgren et al. reported 68.44% and 96% awareness and 57.33% and 45% positive attitude toward utilization of available STI services, respectively.,
Seroprevalence of STIs may be on increase but the decreasing trend in seroprevalence of HIV infections and syphilis has been observed among the pregnant population owing to robust HIV and syphilis control programs. Increased prevalence of STIs has been observed among the age group of 21 to 30 years, homemakers, uneducated group, women from low socioeconomic status, rural backgrounds, and couples with high-risk sexual behavior.
Lack of knowledge regarding STIs and poor utilization of available STI services may lead to an increase in seroprevalence of STIs. To prevent MTCT, it is important to screen asymptomatic pregnant women for STIs and to spread awareness and a positive attitude toward the utilization of STI/RTI services, which is a key program strategy for the prevention and control of STIs.
| Limitations and strengths|| |
This was a hospital-based study. Only cases referred to our tertiary-care center were recruited. Hence, the results may not be generalizable to the general population. A community-based study may be more suitable for this. Certain physiological changes in pregnancy and altered immune responses may predispose pregnant women to infections and increase the incidence of STIs as compared to the general population.
Our study had a large sample size of 500 cases. The design of the observational prospective study is another strength as it is helpful to know the current trends of seroprevalence.
| Conclusions|| |
Viral STIs are more prevalent among pregnant women. Antenatal screening is an effective strategy for the detection of STIs in pregnant women. There is a need for imparting more awareness with emphasis on preventive measures and screening in the preconceptional period to prevent transmission and spread of STIs that may affect both mother and child in pregnancy.
The present study shows an increasing trend of seroprevalence of hepatitis B and C (2.4 and 2.6%, respectively) in pregnant women, with a high prevalence of concordant infections in partners. The majority of cases were young (21–30 years of age), illiterate, from a rural background, with unprotected high-risk behavior with multiple sexual partners. Lack of awareness regarding STIs and non-utilization of STI services had a significant impact on seropositivity. Strong implementation of preventive and control measures to end STIs and their impact on pregnancy, childbirth, and neonate is the need of the millennium. Hence, seroprevalence of STIs must be evaluated every 2 to 3 years as per WHO recommendations. Pregnancy provides an opportunity to screen for STIs, which may otherwise remain unchecked. Partner screening and treatment is an essential step in the management and prevention of reinfection.
Financial support and sponsorship
Nil.Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]