Anjali Arun

Prevalence of Trichomonas vaginalis infection among young reproductive age women in India: implications for treatment and prevention.

BACKGROUND Trichomonas vaginalis infection is the most common curable sexually transmissible infection (STI) worldwide. The present study describes the burden and correlates of T. vaginalis infection among young reproductive age women in Mysore, India. METHODS Between November 2005 and March 2006, sexually active women aged 15-30 years were recruited from low-income peri-urban and rural neighbourhoods of Mysore, India. Participants were interviewed and offered a physical examination and testing for T. vaginalis, bacterial vaginosis, vaginal candidiasis, Neisseria gonorrheoea and herpes simplex virus type-2 antibodies. RESULTS Of the 898 participating women, 76 had a T. vaginalis infection (8.5%, 95% confidence interval [95% CI]: 6.7-10.5%). Nearly all (98%) participants were married and most reported their spouse as their main sex partner. The mean age at marriage was 16.9 years (s.d. 2.9 years) and two-thirds of the sample reported having first sexual intercourse before the age of 19 years. Risk factors independently associated with T. vaginalis infection included early age at first intercourse (adjusted odds ratio [OR] 2.09; 95% CI: 1.09-4.00), concurrent bacterial vaginosis (OR 8.21; 95% CI: 4.30-15.66), vaginal candidiasis (OR 2.40; 95% CI: 1.48-3.89) and herpes simplex virus type-2 infection (OR 3.44; 95% CI: 1.97-6.02). CONCLUSION The burden of T. vaginalis infection at 8.5% is relatively high among a community sample of young reproductive aged women. Because this infection increases the risk of HIV transmission and is associated with adverse pregnancy outcomes, there is a need for increased screening and treatment of this easily curable sexually transmissible infection in India.

Bacterial Vaginosis and Risk for trichomonas vaginalis Infection: A Longitudinal Analysis

Background: Bacterial vaginosis (BV) and Trichomonas vaginalis (TV) have been estimated to affect one-quarter to one-third of sexually active women worldwide, and are often found concurrently. Few studies have examined this relationship longitudinally to better understand the direction and temporality of this association. Methods: Between 2005 and 2006, a cohort of 853 young, sexually active women was followed in Mysore, India; participants were interviewed and tested for BV and TV at baseline, and at 3- and 6-month visit. Generalized estimating equations were used to estimate how changes in vaginal flora between consecutive visits—as defined by Nugent diagnostic criteria for BV—were related to the risk of TV infection at the latter visit, adjusted for sociodemographic and behavioral covariates. Treatment was offered to women with TV and/or symptomatic BV. Results: After adjustment for covariates, participants with abnormal vaginal flora at 2 consecutive visits had 9 times higher risk of TV (95% CI: 4.1, 20.0) at the latter visit, relative to those with persistently normal flora. An increased risk of TV was also observed for participants whose flora status changed from normal to abnormal (adjusted risk ratio: 7.11, 95% CI: 2.8, 18.2) and from abnormal to normal (adjusted risk ratio: 4.50, 95% CI: 1.7, 11.8). Conclusions: Women experiencing abnormal flora during a 3-month span appear to have significantly increased risk of acquiring TV infection. Women of reproductive age in low-resource settings found to have abnormal vaginal flora should be assessed for TV.

Increasing Antenatal Care and HIV Testing among Rural Pregnant Women with Conditional Cash Transfers to Self-Help Groups: An Evaluation Study in Rural Mysore, India

Background. We describe a one-year evaluation study comparing SCIL intervention of mobile provision of integrated ANC/ HIV testing with an enhanced (SCIL+) intervention of community mobilization strategy providing conditional cash transfers (CCT) to womens SHG for identifying and accompanying pregnant women to mobile clinics. Methods. Twenty pairs of villages matched on population, socioeconomic status, access to medical facilities, and distance from Mysore city were divided between SCIL and SCIL+ interventions. The primary study outcome was the proportion of total pregnancies in these villages who received ANC and HIV testing. Results. Between April 2011 and March 2012, 552 pregnant women participated in SCIL or SCIL+ interventions. Among women who were pregnant at the time of intervention delivery, 181 of 418 (43.3%) women pregnant at the time of intervention delivery received ANC in the SCIL arm, while 371 of 512 (72.5%) received ANC in the SCIL+ arm (P < 0.001); 175 (97%) in the SCIL and 366 (98.6%) in the SCIL+ arm consented to HIV testing (P < 0.001). HIV prevalence of 0.6% was detected among SCIL clinic, and 0.9% among attending SCIL+ clinic attendees. Conclusion. Provision of CCT to womens microeconomic SHG appears to significantly increase uptake of ANC/HIV testing services in rural Mysore villages.

Characterization of culturable vaginal Lactobacillus species among women with and without bacterial vaginosis from the United States and India: a cross-sectional study.

Lactobacillus species play an integral part in the health of the vaginal microbiota. We compared vaginal Lactobacillus species in women from India and the USA with and without bacterial vaginosis (BV). Between July 2009 and November 2010, a cross-sectional study was conducted among 40 women attending a womens health clinic in Mysore, India, and a sexually transmitted diseases clinic in San Francisco, USA. Women were diagnosed with BV using Amsels criteria and the Nugent score. Lactobacillus 16S rDNA was sequenced to speciate the cultured isolates. Ten Indian and 10 US women without BV were compared with an equal number of women with BV. Lactobacilli were isolated from all healthy women, but from only 10% of Indian and 50% of US women with BV. 16S rDNA from 164 Lactobacillus colonies was sequenced from healthy women (126 colonies) and women with BV (38 colonies). Seven cultivable Lactobacillus species were isolated from 11 Indian women and nine species from 15 US women. The majority of Lactobacillus species among Indian women were L. crispatus (25.0%), L. jensenii (25.0%) and L. reuteri (16.7%). Among US women, L. crispatus (32.0%), L. jensenii (20.0%) and L. coleohominis (12.0%) predominated. L. jensenii and L. crispatus dominated the vaginal flora of healthy Indian and US women. Indian women appeared to have a higher percentage of obligate heterofermentative species, suggesting the need for a larger degree of metabolic flexibility and a more challenging vaginal environment.

Performance of the OSOM Trichomonas Rapid Test for diagnosis of Trichomonas vaginalis infection among women in Mysore, India

UNLABELLED Background Trichomonas vaginalis is the worlds most common treatable sexually transmissible infection. Currently, wet mount microscopy and syndromic management based on vaginal discharge are the most widely used methods for diagnosing and treating trichomoniasis in resource-constrained settings. Wet mount microscopy requires equipment and trained technicians, who are in short supply. We examined the diagnostic accuracy of the OSOM Trichomonas Rapid Test for detecting T. vaginalis vaginal infection among women in Mysore, India. METHODS During July 2009-August 2010, 450 sexually active women over 18 years seeking care at an urban reproductive health clinic were enrolled in the study. Clinician-collected vaginal swabs were evaluated for trichomonads using wet mount microscopy, InPouch culture and the OSOM test. RESULTS Of the 418 samples included in the analyses, culture detected 68 (16.3%) positive samples, wet mount microscopy detected 56 of the culture-positive samples and four false positive samples. The OSOM test detected 60 of the culture-positive samples plus two false positive cases. Using the composite reference standard (CRS), defined as wet mount- or culture-positive, the sensitivities of wet mount, the OSOM test and culture were 83.3%, 86.1% and 94.4%, respectively. The positive and negative predictive values of the OSOM test were 100% and 97.1% respectively. The Cohens kappa agreement between the OSOM test and the CRS was excellent (κ=0.94). CONCLUSION The OSOM test has high sensitivity, excellent specificity, and excellent positive and negative predictive value compared to a CRS. This simple test can improve screening and diagnosis of T. vaginalis infection in resource-constrained settings where microscopy and culture are unavailable.

Comparison of Culture-dependent and Culture-Independent Molecular Methods for Characterisation of Vaginal Microflora.

Purpose. To date, molecular methods that circumvent the limitations of traditional culture methods have not been used to describe the vaginal microflora in India. Here, we compared culture and culture‐independent molecular methods in characterizing the vaginal microbiota in Indian women. Methodology. Culture methods involved traditional cultivation on Rogosa and sheep blood agar, whereas culture‐independent methods bypassed a culturing step by performing broadrange 16S rDNA PCR on DNA isolated directly from vaginal swabs. Results. A total of 13 women were included in the study, of which five were characterized as healthy, two were bacterial vaginosis intermediate and six were bacterial vaginosis positive according to Nugent scoring. Lactobacillus jensenii was detected most frequently when using culture methods. On the other hand, Lactobacillus iners, which was not detected by culture methods, was the most common Lactobacillus sp. detected using cultivation‐independent methods. Conclusion. We found little overlap between the species found using cultivation‐dependent and cultivation‐independent methods. Rather, culture‐dependent and culture‐independent methods were found to be complementary in describing the vaginal microflora among South Indian women. Culture‐independent methods were found to be superior in detecting clinically relevant vaginal flora.To date, molecular methods that circumvent the limitations of traditional culture methods have not been used to describe the vaginal microflora in India. Here, we compared culture and culture-independent molecular methods in characterising the vaginal microbiota in Indian women. Culture methods involved traditional cultivation on Rogosa and sheep-blood agar, whereas culture-independent methods bypassed a culturing step by performing broad-range 16S rDNA PCR on DNA isolated directly from vaginal swabs. A total of 13 women were included in the study, of which five were characterised as healthy, two were BV-intermediate and six were BV-positive according to Nugent scoring. Lactobacillus jensenii was detected most frequently when using culture methods. On the other hand, Lactobacillus iners, which was not detected by culture methods, was the most common lactobacillus species detected using cultivation-independent methods. We found little overlap between the species found using cultivation-dependent and cultivation-independent methods. Culture-independent methods were found to be superior in detecting clinically relevant vaginal flora.

Birth preparedness and place of birth in rural Mysore, India: A prospective cohort study.

BACKGROUND India accounts for almost a third of the global deaths among newborns on their first day of birth. In spite of making significant progress in increasing institutional births, large numbers of rural Indian women are still electing to give birth at home. The aim of this study was to identify factors associated with place of birth among women who had recently given birth in rural Mysore, India. METHODS Between January 2009 and 2011, 1675 rural pregnant women enrolled in a prospective cohort study in Mysore District completed interviewer-administered questionnaires on maternity care services. Ethical approval of the original study was obtained from the Institutional Review Boards of Vikram Hospital and Florida International University. Logistic regression analyses were conducted to identify factors associated with place of birth among the 1654 (99%) women that were successfully followed up after childbirth. FINDINGS The median age of the women was 20 years; the majority were educated (87%), low-income (52%), and multiparous (56%). The prevalence of home births was low (4%). Half of the women giving birth at home did not adequately plan for transportation (55%), finances (48%), or birthing with a skilled provider (55%). Multiparous women had greater odds of giving birth at home compared to public (adjusted odds ratio [AOR]=7.83, p<0.001) and private institutions (AOR=7.05, p<0.001). Women attending ≥4 antenatal consultations had greater odds of giving birth at public (AOR=2.53, p=0.036) and private institutions (AOR=3.58, p=0.010). Those with higher scores of birth preparedness also had greater odds of giving birth at public (AOR=2.53, p<0.001) and private institutions (AOR=3.00, p<0.001). CONCLUSIONS AND IMPLICATIONS As a means to reduce newborn mortality, maternal health interventions in India and similar populations should focus on increasing birth preparedness and institutional births among rural women, particularly among those from lower socio-economic status.

The Epidemiology of Herpes Simplex Virus Type-2 Infection among Pregnant Women in Rural Mysore Taluk, India

Objectives. To assess the prevalence and determinants of herpes simplex virus type 2 (HSV-2) infections among pregnant women attending mobile antenatal health clinic in rural villages in Mysore Taluk, India. Methods. Between January and September 2009, 487 women from 52 villages participated in this study. Each participant consented to provide a blood sample for HSV-2 and HIV testing and underwent an interviewer-administered questionnaire. Results. HSV-2 prevalence was 6.7% (95% confidence interval (CI) 4.4–9.0), and one woman tested positive for HIV. The median age of women was 20 years and 99% of women reported having a single lifetime sex partner. Women whose sex partner traveled away from home had 2.68 (CI: 1.13–6.34) times the odds of being HSV-2 seropositive compared to women whose sex partner did not travel. Having experienced genital lesions was also associated with HSV-2 infection (P value = 0.08). Conclusion. The 6.7% HSV-2 prevalence was similar to results obtained in studies among pregnant women in other parts of India. It appeared that most women in this study contracted HSV-2 from their spouses and few regularly used condoms. This finding highlights the need for public health policies to increase awareness and education about prevention methods among women and men living in rural India.

Implementing community-based cervical cancer screening programs using visual inspection with acetic acid in India: A systematic review

The objective of this review was to systematically appraise the existing published literature about community-based cervical cancer screening programs that have used visual inspection methods using acetic acid (VIA) in India. All peer reviewed journal articles till December 2015 were searched per PRISMA guidelines. Articles reporting results from cervical cancer screening programs in community-based settings, conducted in India, and using VIA were included in this review. The search resulted in 20 articles to be included in the review with a total of 313,553 women at 12 unique urban and rural sites across India. Seventeen (85%) studies were cross-sectional and three studies were randomized controlled trials; most studies compared accuracy of VIA with other screening tests such as visual inspection using Lugols Iodine (VILI), HPV DNA, and cytology. Of studies that reported test accuracy for CIN Grade 2+, the VIA sensitivity values ranged from 16.6-82.6% and specificity ranged from 82.1-96.8%. Women between age groups of 30-59 years were recruited using motivational one-on-one counseling and local support staff. All studies conducted diagnostic follow-up using colposcopy and guided biopsies, when necessary. Three major themes were identified that facilitated implementation of screening programs in a community-based setting: standardized training that maintained competency of test providers; collaborations with community-based organizations that used health education for recruitment of participants; and employing the screen-and-treat method to reduce loss to follow-up. Summarized evidence presented in this review could substantially influence future implementation and sustainment of cervical cancer screening programs at a national level.

Incidence of herpes simplex virus type 2 in young reproductive age women in Mysore, India

CONTEXT There are sparse data on herpes simplex virus type 2 (HSV-2) infection in India. HSV-2 is one of the most common sexually transmitted infections and the primary cause of genital ulcer disease worldwide. AIM The aim of this study is to describe the incidence of HSV-2 infection among young reproductive age women in Mysore, India. SETTING AND DESIGN Between October 2005 and April 2006, 898 women were enrolled into a prospective cohort study in Mysore, India, and followed quarterly for 6 months. MATERIALS AND METHODS An interviewer administered questionnaire was used to collect demographic and social risk factors, and physical examination was conducted for collection of biological specimens to screen for reproductive tract infections at each visit. Serologic testing was conducted for the presence of HSV-2 antibodies using HerpeSelect HSV-2 enzyme-linked immunosorbent assay. STATISTICAL ANALYSIS USED Data were analyzed using R. Incidence density rates were calculated using Poisson distributions with person-time of follow-up as denominator. Person-time was calculated as time from enrollment until time of first positive HSV-2 test. RESULTS There were 107 women with HSV-2 antibodies leaving 700 women with negative results at enrollment. The analysis included 696 out of which, there were 36 HSV-2 seroconversions during the study period. The study cohort accumulated roughly 348 woman-years of follow-up, yielding an HSV-2 acquisition rate of 10.4 cases/100 woman-years. All detected infections were asymptomatic. CONCLUSIONS HSV-2 incidence is moderate in this community sample of young reproductive age monogamous women. More research is needed to establish incidence estimates in different Indian settings.