Original Article Frequency of syphilis in female sex workers at red light area of Hyderabad, Pakistan

Ishrat Bibi,1 Bikha Ram Devrajani,2 Syed Zulfiquar Ali Shah,3 Mohammed Hussain Soomro,4 Mumtaz Ali Jatoi5
Medical Services, Green Star Social Marketing,1,4 Department of Medicine, Liaquat University of Medical and Health Sciences (LUMHS), Jamshoro,2,3 Blood Bank, Liaquat University Hospital,5 Hyderabad.

Abstract
Objective: To determine the frequency of syphilis in female sex workers (FSWs) at red light area of Hyderabad. Methods: This study was conducted on female sex workers at red light area of Hyderabad, Pakistan during 2003. All female subjects who were between 17-35 years of age were evaluated and enrolled in the study. All such subjects were screened for Treponema pallidum infection/syphilis by Treponema Pallidum Haemagglutination assay (TPHA). The frequency was determined by identifying the positive Treponema pallidum infected patients. For getting results the data was saved and analyzed in SPSS version 10.00. Results: Total fifty (50) female sex workers were studied; their mean age was 26.22 4.47 years. Syphilis was identified in 22 (44%) females with mean age of 22.68 1.46 years while remaining 28 (56%) with mean age 29.00 4.06 years were free from syphilis (p<0.001). Conclusion: The female sex workers are prone and at risk to acquire sexual transmitted infections (STI), therefore for control and preventive measures, screening programmes should be initialized (JPMA 60:353; 2010).

Introduction
Syphilis has been a major cause of mortality and morbidity for around 500 years. It is caused by the bacterium Treponema pallidum, which is transmitted sexually. The organism enters the body via an abrasion during sexual contact, and there is an incubation period of about 3 weeks.1,2 The disease classically presents in three distinct stages i.e. primary, secondary and tertiary.3

The Sexually transmitted infections (STIs) evolved from the older term Venereal diseases (VDs) are a group of infectious diseases, which are mainly transmitted through sexual intercourse and have been recognized as a major public health problem since years and it is also a common cause of illness in the world.4 The sex workers are at risk to acquire different sexual transmitted infections and they act as a source of transmission of them. In past years, considerable research

has been undertaken on the role of female sex workers (FSWs) in the source and transmission of syphilis and consequently, they have been extensively targeted and counseled to prevent its spread. The female sex workers have high prevalence of sexually transmitted Infections (STIs) and it has been proved by a study conducted on female sex workers in San Francisco, which reported high rate of gonorrhoea (12.4%), chlamydia (6.8%), syphilis (1.8%) and herpes (34.3%). A study of Turkey showed that prevalence of syphilis among female sex workers varies between 8.7% and 31.6%.6 Moreover the prevalence recorded in the related former local studies was syphilis (1.3%), HIV(0.1%), HSV-2 (3.4%), gonorrhoea (0.8%) and chlamydia (no cases), while the city-wise survey showed the highest prevalence to be in Karachi (8.5%), followed by Lahore (5.3%), Quetta (4.3%) Faisalabad (4.0%), Rawalpindi (2.5%) and Peshawar (2.0%) in the study by Mir et al.7 However the prevalence recorded for syphilis among females sex workers in Pakistan is 3.6% (Karachi) and 16.0% in (Lahore).8 Commercial sex work is illegal in Pakistan but sex workers continue their business in all major cities of the county. Due to disorganized and hidden manner of commercial sex profession, the intervention to reduce vulnerability of sexual transmitted infections in this high-risk population (FSWs) is challenging and a difficult task. Therefore by taking such a challenge, the present study is focused on detection of syphilis among female sex workers (FSWs).The diagnostic and treatment approaches in syphilis show wide variations in the management plan.9 However the biochemical parameters i.e. the Rapid Plasma Reagin (RPR) and Venereal Disease Research Laboratory (VDRL), Treponema pallidum haemagglutination assay (TPHA) and Fluorescent Treponemal Antibody Absorption (FTA-ABS) are helpful in the detection of syphilis.10 Therefore, by keeping all specific debate in mind, the present study was conducted at the red light area of Hyderabad city (the second largest city of province Sindh, Pakistan) by focussing on the frequency of syphilis in female sex workers (FSWs). By diagnosing and eradicating Treponema pallidum infection the risk of transmission and progression of the disease can be reduced or inhibited.

screening based study was taken from Provincial manager of Sindh AIDS Control Programme (SACP). An additional approval was taken from pathologist of referral laboratory SACP, programme manager of NGO, and Blood Bank of Liaquat University Hospital Hyderabad, Sindh. The purpose and rationale of the study was detailed using simple language terminology to the subjects (FSWs). Their participation was entirely voluntarily and they had the right to refuse or withdraw at any stage of the study. In case of refusal during the research, the partially collected data ws immediately destroyed. Further help was sought from six selected outreach workers (peer workers) for providing information to FSWs of that community. They were trained by medical staff/team of the NGO regarding the importance and purpose of the study. Although they were the paid staff of the NGO, they belonged to same area, community and profession. During the survey anonymity and confidentiality was maintained and only selected focal responsible persons of the NGO knew the names and addresses of the participants (FSWs). It was only kept for the purpose of any future correspondence. All the FSWs were given assurance that their identity will never be mentioned in the report of the research. The informed consent was written in clearly understandable Urdu language. All those who could not understand Urdu, information was provided through peer workers in Punjabi language. All protocols and basic parameters of the study were also discussed in detail with the community before the screening of FSWs and complete information regarding syphilis, its transmission and complication was provided to each FSW in a pre-test counseling session. The FSWs were assured that every participant will get her own result of the tests. All the test samples were carefully coded and a number was assigned to each test sent to the laboratory for investigation. The known cases of autoimmune diseases and subjects who refused to participate in the study were considered in the exclusion criteria. We screened 50 subjects because such population (FSWs) is mobile and changes their places due to their profession (sex worker). The Serey Ghatt is a banned area and therefore FSWs went outside the area for their professional activities. Therefore during the study period many female sex workers were not present in the area (Serey Ghatt). Some who were present did not meet the age criteria of the study. Some of the girls were not involved in the sex activities and were limited to dancing and singing only. Regarding ethical justification all the expenses of this study were paid by the valuable cooperation of Sindh AIDS Control Programme team. All the data was kept under lock and key. After the completion of this screening campaign all the collected data

Material and Methods

The study was conducted on the female sex workers at Serey Ghat (the fourth largest red light area of Pakistan), Hyderabad during the month of December 2003 by Sindh AIDS control programme in collaboration with the non government organization NGO (working in the area for awareness regarding sexual transmitted Infections - STIs). All the female sex workers of age 17-35 years were evaluated and enrolled in the study. The approval for this

was entered in SPSS software version 10 for analysis. The frequency and percentage of syphilis in female sex workers was calculated. The mean and standard deviation for age was also calculated. T-test for independent samples was applied between categorical variables at 95% confidence interval and the p-value <0.05 was considered as statistically significant.

Results
A total of fifty female sex workers (FSWs) were screened for syphilis with a mean age of 26.2 4.4 years.
Table-1: Age distribution of female sex workers (FSWs). Age 17 - 20 21 - 25 26 - 30 31 - 35 n = 50 03 27 11 09 % 6 54 22 18

Treponema pallidum haemagglutination (TPHA) method was used as a screening tool for the detection of syphilis in the present study. This is superior in sensitivity and specificity over VDRL, and is consistent with the findings of Saluja et al.21 Another study conducted by Cole et al22 on evaluation of syphilis showed 100% sensitivity by TPHA. The VDRL is interpreted as false positive in many other disorders that include infectious mononucleosis, hepatitis A, HV, lyme disease, certain types of pneumonia, malaria and systemic lupus erythematosus. The female sex workers conceal sex-related diseases until they have serious complications. They also do not seek STIs treatment due to discrimination and unfriendly behaviour. Therefore, there is an urgent need to address the sexual and reproductive health sex workers and STIs service should be made available to the target group (FSWs) in their vicinity. Peer educators involvement in STIs clinic is expected to have appropriate, effective and positive impact on STIs services.

Table-2: Frequency of syphilis in female sex workers (FSWs). Syphilis Positive Negative n = 50 22 28 % 44 56 Mean age / (SD) 22.6818 1.4601 29.0000 4.0643 P value < 0.001*

Conclusion
Syphilis is the most common infection among female sex workers. A periodic screening system for STDs should be initialized for high risk subjects like female sex workers. Safe sex practices and counseling must be conveyed to each female sex workers (FSWs).

*p-value is statistically significant.

The frequency, percentage and age range of these subjects is mentioned in Table-1. The results regarding frequency of syphilis in female sex workers (FSWs) is shown in Table-2.

References
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Discussion
The present study revealed that female sex workers were at high risk for acquiring Treponema pallidum infection. However a study conducted during 2000-2001 in Bangladesh showed 19.8% prevalence of syphilis among female sex workers, 11 whereas in the study by Ward et al12 2.3% prevalence of syphilis was observed. In an Indian study the prevalence of syphilis was 29.4% in 124 sex workers.13 The prevalence of syphilis recorded in the present study is 44% which is higher as compared to 22.7%, reported in an Indian study by Desai, et al.14 A low prevalence (8%) of syphilis infection among female sex workers was documented in Colombia.15 The prevalence of syphilis among FSW have been reported in other regions like Veitnam (10.7%),16 China (9.5%),17 and Thailand (9%).18 The possibility of an increase in syphilis and other STIs among such high risk group (sex workers) may be due to their profession (as prostitutes / sex workers) as they tend to have multiple anonymous sexual partners. They are not only difficult to locate but frequently use intravenous (IV) drugs that have high rates of infection with HIV.19,20

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22. Cole M, Perry K. An Evaluation of Newmarket laboratories TPHA 200. (Online) 2005 (Cited 2009 May 9). Available from URL: http://ww w.hpamidas.o r g.u k/documents/reports/Syphil is/Newmarke t %20THA %20200%20v2.pdf.

kontrol dan tindakan pencegahan, program skrining harus diinisialisasi (JPMA 60:353, 2010). PENDAHULUAN Sifilis telah menjadi penyebab utama mortalitas dan morbiditas selama sekitar 500 tahun. Hal ini disebabkan oleh bakteri Treponema pallidum, yang ditularkan secara seksual. Organisme memasuki tubuh melalui abrasi selama kontak seksual, dan ada masa inkubasi sekitar 3 minggu.1, 2Penyakit klasik hadir dalam tiga stadium yang berbeda yaitu primer, sekunder dan tersier.3 Infeksi menular seksual (IMS) berevolusi dari penyakit kelamin jangka lama adalah kelompok penyakit menular, yang terutama ditularkan melalui hubungan seksual dan telah diakui sebagai masalah kesehatan masyarakat yang utama sejak bertahun-tahun dan juga merupakan penyebab umum penyakit di dunia.4 para pekerja seks beresiko untuk mendapatkan infeksi menular seksual yang berbeda dan mereka bertindak sebagai sumber penularan dari mereka. Dalam beberapa tahun terakhir, penelitian yang cukup besar telah dilakukan pada pekerja seks wanita dalam sumber dan penularan sifilis dan akibatnya, mereka telah banyak sasaran dan konseling untuk mencegah penyebarannya. Para pekerja seks wanita memiliki prevalensi tinggi Infeksi menular seksual (IMS) dan telah dibuktikan oleh sebuah penelitian yang dilakukan pada pekerja seks wanita di San Francisco, yang melaporkan tingginya tingkat gonore (12,4%), klamidia (6,8%), sifilis ( 1,8%) dan herpes (34,3%). Sebuah studi Turki menunjukkan bahwa prevalensi sifilis di kalangan pekerja seks wanita bervariasi antara 8,7% dan 31,6% .6 Selain itu prevalensi tercatat dalam studi setempat menunjukkan sifilis (1,3%), HIV (0,1%), HSV-2 (3,4 %), gonore (0,8%) dan klamidia (tidak ada kasus), sedangkan survei city-wise menunjukkan prevalensi tertinggi berada di Karachi (8,5%), diikuti oleh Lahore (5,3%), Quetta (4.3%) Faisalabad (4,0 %),

Frekuensi sifilis pada pekerja seks wanita di daerah lampu merah Hyderabad, Pakistan
Ishrat Bibi,1 Bikha Ram Devrajani,2 Syed Zulfiquar Ali Shah,3 Mohammed Hussain Soomro,4 Mumtaz Ali Jatoi5
Medical Services, Green Star Social Marketing,1,4 Department of Medicine, Liaquat University of Medical and Health Sciences (LUMHS), Jamshoro,2,3 Blood Bank, Liaquat University Hospital,5 Hyderabad

Abstrak Objektif: Untuk menentukan frekuensi sifilis pada pekerja seks wanita di daerah lampu merah Hyderabad. Metode: Penelitian ini dilakukan pada pekerja seks wanita di daerah lampu merah Hyderabad, Pakistan selama tahun 2003. Semua subyek perempuan yang berusia antara 17-35 tahun dievaluasi dan terdaftar dalam penelitian. Semua subjek disaring untuk infeksi Treponema pallidum / sifilis dengan alat Treponema pallidum haemagglutination assay (TPHA). Frekuensi ditentukan dengan mengidentifikasi pasien positif terinfeksi Treponema pallidum. Untuk mendapatkan hasil data yang disimpan dan dianalisis dalam SPSS versi 10.00. Hasil: Jumlah lima puluh (50) pekerja seks wanita yang diteliti, usia rata-rata mereka adalah 26,22 4,47 tahun. Sifilis diidentifikasi pada 22 (44%) perempuan dengan usia rata-rata 22,68 1,46 tahun, namun tetap 28 (56%) dengan usia rata-rata 29.00 4.06 tahun yang bebas dari sifilis (p <0,001). Kesimpulan: Para pekerja seks wanita rentan dan beresiko untuk mendapatkan infeksi menular seksual (IMS), sehingga untuk

Rawalpindi (2,5%) dan Peshawar (2,0%) dalam studi oleh Mir dkk.7 Namun prevalensi tercatat untuk sifilis di kalangan pekerja seks wanita di Pakistan adalah 3,6% (Karachi) dan 16,0% di (Lahore) .8 pekerja seks komersial adalah ilegal di Pakistan, tetapi pekerja seks melanjutkan bisnis mereka di semua kota besar di negara tersebut. Karena pekerja seks komersial berlangsung tanpa organisasi dan tersembunyi, intervensi untuk mengurangi kerentanan dari infeksi menular seksual pada populasi berisiko tinggi adalah menantang dan tugas yang sulit. Oleh karena itu dengan mengambil tantangan tersebut, penelitian ini difokuskan pada deteksi sifilis di kalangan pekerja seks wanita. Pendekatan dalam diagnosis dan pengobatan sifilis menunjukkan variasi yang luas dalam manajemen rencana.9 Namun parameter biokimia yaitu Rapid Plasma Reagin (RPR) dan Venereal Disease Research Laboratory (VDRL), Treponema pallidum haemagglutination assay (TPHA) dan treponemal Fluorescent Antibody Absorption (FTA-ABS) sangat membantu dalam deteksi dari sifilis.10 Oleh karena itu, dengan menjaga semua perdebatan tertentu dalam pikiran, penelitian ini dilakukan di daerah lampu merah kota Hyderabad (kota terbesar kedua di provinsi Sindh, Pakistan) dengan fokus pada frekuensi sifilis pada wanita pekerja seks. . Dengan mendiagnosis dan memberantas Treponema pallidum, infeksi risiko penularan dan perkembangan penyakit dapat dikurangi atau dihambat. Bahan dan Metode Penelitian dilakukan pada pekerja seks wanita di Serey Ghat (terbesar keempat area cahaya merah Pakistan), Hyderabad selama bulan Desember 2003 oleh Sindh AIDS Control Programme bekerjasama dengan organisasi LSM non-Pemerintah (bekerja di daerah untuk kesadaran Infeksi menular seksual mengenai IMS). Semua pekerja seks perempuan usia 1735 tahun dievaluasi dan terdaftar dalam

penelitian. . Persetujuan dari skrining berbasis penelitian ini diambil dari manajer Sindh AIDS Control Programme (SACP). Persetujuan tambahan diambil dari ahli patologi dari laboratorium rujukan SACP, manajer program LSM, dan Bank Darah Liaquat University Hospital Hyderabad, Sindh. Tujuan dan dasar pemikiran dari penelitian ini dirinci menggunakan terminologi sederhana untuk subjek. Partisipasi mereka adalah sepenuhnya sukarela dan mereka memiliki hak untuk menolak atau mundur pada setiap tahap penelitian. Dalam kasus penolakan selama penelitian, data yang dikumpulkan sebagian segera dihapuskan. Bantuan lebih lanjut dicari dari enam petugas penjangkauan yang dipilih (rekan pekerja) untuk memberikan informasi kepada pekerja seks wanita dari komunitas tersebut. Mereka dilatih oleh staf medis / tim dari LSM tentang pentingnya dan tujuan penelitian. Meskipun mereka adalah staf dibayar dari LSM, mereka milik daerah yang sama, masyarakat dan profesi. Selama survei anonimitas dan kerahasiaan dipertahankan dan hanya memilih orang-orang yang khusus bertanggung jawab untuk LSM diketahui nama dan alamat dari para peserta. Itu hanya disimpan untuk tujuan dari setiap korespondensi masa depan. Semua pekerja seks wanita diberi jaminan bahwa identitas mereka tidak akan disebutkan dalam laporan penelitian. Informed consent ditulis dalam bahasa Urdu dengan jelas dan dimengerti. Semua orang yang tidak bisa memahami bahasa Urdu, informasi yang diberikan melalui rekan pekerja dalam bahasa Punjabi. Semua protokol dan parameter dasar dari penelitian itu juga dibahas secara rinci dengan masyarakat sebelum screening pekerja seks wanita dan informasi yang lengkap mengenai sifilis, transmisi dan komplikasi diberikan kepada masing-masing pekerja seks wanita dalam sesi tes pra-konseling. Para pekerja seks wanita yakin bahwa setiap peserta akan mendapatkan hasil sendiri dari tes. Semua

sampel tes diberi kode dengan hati-hati dan nomor yang ditandai untuk setiap tes dikirim ke laboratorium untuk diinvestigasi. Yang diketahui dari kasus penyakit autoimun dan subjek yang menolak untuk berpartisipasi dalam penelitian ini dipertimbangkan dalam kriteria eksklusi. Kami menyaring 50 subjek karena pekerja seks wanita mobile dan tempat mereka berpindah-pindah karena profesi mereka (pekerja seks). The Ghatt Serey adalah daerah yang dilarang dan karena itu pekerja seks wanita pergi ke luar daerah untuk kegiatan profesional mereka. Oleh karena itu selama masa studi banyak pekerja seks perempuan tidak hadir di daerah (Serey Ghatt). Beberapa yang hadir tidak memenuhi kriteria usia penelitian. Beberapa gadis-gadis itu tidak terlibat dalam kegiatan seks dan terbatas pada menari dan menyanyi saja. Mengenai pembenaran etis semua biaya penelitian ini dibayar oleh kerjasama berharga dari Sindh AIDS Control Programme Team. Semua data disimpan dan dikunci. Setelah selesainya skrining semua data yang dikumpulkan dimasukkan dalam software SPSS versi 10 untuk dianalisis. Frekuensi dan persentase sifilis pada perempuan pekerja seks dihitung. Mean dan standar deviasi untuk usia juga dihitung. T-test untuk sampel independen diterapkan antara variabel kategori pada tingkat kepercayaan 95% dan nilai p <0,05 dianggap sebagai signifikan secara statistik. Hasil Sebanyak lima puluh pekerja seks wanita diskrining untuk sifilis dengan usia rata-rata 26,2 4,4 tahun. Tabel-1: Usia distribusi pekerja seks wanita (FSWs).
Age 17 - 20 21 - 25 26 - 30 31 - 35 n = 50 03 27 11 09 % 6 54 22 18

*nilai P- secara statistik signifikan. Rentang frekuensi, persentase dan usia dari subjek disebutkan dalam Tabel-1. Hasil mengenai frekuensi sifilis pada pekerja seks wanita ditunjukkan pada Tabel-2. Diskusi Penelitian ini mengungkapkan bahwa pekerja seks wanita berada pada risiko tinggi untuk tertular infeksi Treponema pallidum. Namun sebuah penelitian yang dilakukan selama 2000-2001 di Bangladesh menunjukkan prevalensi 19,8% dari sifilis di kalangan pekerja seks wanita, 11 sedangkan dalam studi oleh Ward dkk12 prevalensi 2,3% dari sifilis diamati. Dalam sebuah studi di India prevalensi sifilis adalah 29,4% dalam 124 pekerja seks.13 Prevalensi sifilis tercatat dalam penelitian ini adalah 44% yang lebih tinggi dibandingkan dengan 22,7%, dilaporkan dalam studi India oleh Desai dkk.14 Prevalensi rendah (8%) dari infeksi sifilis di kalangan pekerja seks wanita yang didokumentasikan di Colombia.15 Prevalensi sifilis di kalangan pekerja seks wanita telah dilaporkan di daerah lain seperti veitnam ( 10,7%), 16 China (9,5%), dan Thailand 17 (9%) .18 Kemungkinan peningkatan sifilis dan PMS lainnya di antara kelompok berisiko tinggi seperti (pekerja seks) mungkin karena profesi mereka (sebagai pelacur / pekerja seks) karena mereka cenderung memiliki banyak pasangan seksual anonim. Mereka tidak hanya sulit untuk menemukan tapi sering menggunakan obat intravena (IV) yang memiliki tingkat tinggi infeksi HIV.19, 20 Treponema pallidum haemagglutination (TPHA) metode yang digunakan sebagai alat

Tabel-2: Frekuensi sifilis pada pekerja seks wanita (FSWs).

skrining untuk mendeteksi sifilis dalam penelitian ini. Hal ini unggul dalam sensitivitas dan spesifisitas lebih dari VDRL, dan konsisten dengan temuan Saluja dkk.21 Penelitian lain dilakukan oleh Cole dkk22 pada evaluasi sifilis menunjukkan sensitivitas 100% oleh TPHA. VDRL ini ditafsirkan sebagai positif palsu pada gangguan lain yang termasuk infeksi mononukleosis, hepatitis A, HV, penyakit lyme, beberapa jenis pneumonia, malaria dan sistemik lupus eritematosus. Para pekerja seks wanita menyembunyikan penyakit seks sampai mereka memiliki komplikasi yang serius. Mereka juga tidak mencari pengobatan IMS akibat diskriminasi dan perilaku tidak ramah. Oleh karena itu, ada kebutuhan mendesak untuk mengatasi pekerja seks dan kesehatan reproduksi dan IMS layanan harus dibuat tersedia bagi kelompok target(pekerja seks wanita) di sekitar mereka. Keterlibatan pendidik sebaya dalam klinik IMS diharapkan memiliki dampak yang tepat, efektif dan positif pada layanan IMS. Kesimpulan Sifilis adalah infeksi yang paling umum di antara pekerja seks wanita. Sebuah sistem skrining periodik untuk PMS harus diinisialisasi untuk subjek yang berisiko tinggi seperti pekerja seks wanita. Penerapan seks aman dan konseling harus disampaikan kepada masing-masing pekerja seks wanita (FSWs).