Kavitha Ravi

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.

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.

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.

Financial decision making power is associated with moderate to severe anemia: A prospective cohort study among pregnant women in rural South India

OBJECTIVE According to the World Health Organization, about half of all pregnant women in India suffer from some form of anemia. While poor nutrition is the most common cause, social factors, such as gender and religion, also impact anemia status. This study investigates the relationship between anemia and socioeconomic and health-related factors among pregnant women in Mysore, India. DESIGN Prospective cohort study conducted between January 2009 and 2012 SETTING: 144 rural villages ten or more kilometers outside of Mysore City received integrated antenatal care and HIV testing services provided by mobile medical clinic in their communities. PARTICIPANTS 1675 pregnant women from the villages were screened. All women and their infants were then followed up for up to a year after childbirth. METHODS women who provided informed consent underwent an interviewer-administered questionnaire, physical examination by a doctor, and antenatal laboratory investigations including blood test for anemia. Women were followed through pregnancy and 12 months after childbirth to assess mother-infant health outcomes. Anemia was categorised as normal, mild, moderate, and severe, with moderate/severe anemia defined as a hemoglobin concentration of less than 100 g/l. MEASUREMENTS AND FINDINGS two out of three pregnant women were anemic at baseline (1107/1654; 66.9%). Of those women, 32.7% (362) had mild anemia, 64.0% (708) had moderate anemia, and 3.3% (37) had severe anemia. Anemia was associated with lower education among spouses (p = 0.021) and lower household income (p = 0.022). Women living in a household where others had control over household decision-making had lower odds of moderate/severe anemia (Adjusted Odds Ratio: 0.602; 95% Confidence Interval: 0.37-0.97) as compared to women who shared decision-making power with others in the household. CONCLUSION Interventions to reduce anemia should focus on education among men and other household decision makers on the importance of nutrition during pregnancy in India. IMPLICATIONS FOR PRACTICE To our knowledge, this research is one of the first to examine how control of household resources is related to risk for anemia among pregnant women in India. Our data suggests that interventions aimed at reducing anemia may need to address economic factors beyond nutrition and iron status to reduce the burden of anemia among women in developing countries.

Performance of BVBlue rapid test in detecting bacterial vaginosis among women in Mysore, India.

Bacterial vaginosis (BV) is the most common cause of abnormal vaginal discharge in reproductive age women. It is associated with increased susceptibility to HIV/STI and adverse birth outcomes. Diagnosis of BV in resource-poor settings like India is challenging. With little laboratory infrastructure there is a need for objective point-of-care diagnostic tests. Vaginal swabs were collected from women 18 years and older, with a vaginal pH > 4.5 attending a reproductive health clinic. BV was diagnosed with Amsels criteria, Nugent scores, and the OSOM BVBlue test. Study personnel were blinded to test results. There were 347 participants enrolled between August 2009 and January 2010. BV prevalence was 45.1% (95% confidence interval (CI): 41.5%–52.8%) according to Nugent score. When compared with Nugent score, the sensitivity, specificity, positive predictive value, negative predictive value for Amsels criteria and BVBlue were 61.9%, 88.3%, 81.5%, 73.7% and 38.1%, 92.7%, 82.1%, 63.9%, respectively. Combined with a “whiff” test, the performance of BVBlue increased sensitivity to 64.4% and negative predictive value to 73.8%. Despite the good specificity, poor sensitivity limits the usefulness of the BVBlue as a screening test in this population. There is a need to examine the usefulness of this test in other Indian populations.

P3.274 Characterization of Vaginal Lactobacillus Among Non-Pregnant Women with and Without Bacterial Vaginosis in India and US

Background Lactobacillus is an integral part of vaginal microbiota that maintains healthy environment and plays an important role in preventing sexually transmitted infections and HIV. We profile the Lactobacillus species present when the women are healthy or have Bacterial Vaginosis among women in US and India. Method Between February 2010 and November 2011, a sample of 75 women attending Prerana Women’s Health Clinic in India or San Francisco City Clinic in USA were sampled and diagnosed for BV based on Amsel’s Criteria. In addition, Gram stained smears of vaginal fluid were Nugent scored. Vaginal swabs were then cultured in MRS broth. Gram positive Lactobacilli generating about 600–800bp amplicon by16SrDNA PCR with 16S primers were further characterised by sequencing. Result Vaginal samples were obtained from 75 women. According to Amsel criteria, 34 women were healthy and 41 women had BV. Lactobacilli were isolated from 22 healthy Indian and 10 healthy US women. Lactobacilli were also isolated from 4 Indian and 5 US women with BV. Eleven Lactobacillus species were isolated from 26 Indian women and 9 species were identified from 15 US women. The common Lactobacilli species found in Indian women included L. Crispatus (24.3%), L. Gasseri (24.3%), and L. Jensenii (13.5%), while L. Crispatus (32.0%), L. Jensenii (20.0%), and L. Coleohominis (12.0%) were common in US women. L. crispatus was cultured from 44% of healthy and 4.9% of women with BV. L. jensenii, L. gasseri, and L. acidophilus were cultured from 25.6%, 23.5% and 2.9% of healthy women; and 2.4%, 4.9% and 0.0% of BV women, respectively. Conclusion Our findings showed lactobacilli species present in healthy vagina of women in India do not differ from those reported from other countries. This information is useful to development of microbicides for HIV prevention.

P2.003 Feasibility and Acceptability of Self-Collected Vaginal Swabs For Diagnosis of Bacterial Vaginosis Among Pregnant Women in a Community Setting in Rural Mysore, India

Background Bacterial vaginosis (BV) is a common cause of adverse birth outcomes. Its association with other obstetric and gynecologic complications and HIV are increasingly recognised. This study examined the acceptability and feasibility of using self-collected vaginal swabs (SVS) for screening of BV in a community setting among rural pregnant women in Mysore Taluk, India. Methods A community based cross-sectional study was carried out between June 2007 and December 2010. Mobile medical clinics offered antenatal care and HIV testing in all 144 rural villages in Mysore Taluk. Women were also screened for BV using SVS and asked about their experience with the collecting process. Gram-stain evaluation of vaginal samples using Nugent score (NS) was conducted by two trained laboratory personnel. Results Among the 1675 women attending the mobile medical clinics from the 144 villages, 1541(92%) were included in the analyses. 1639 agreed to provide vaginal swabs (97.8% response rate). The quality of the swabs was satisfactory in 1545 of the cases. There were 134 non-interpretable slides owing to poor quality. The median age of women was 20 years (range 14 to 40 years). Majority (98.7%) reported themselves as Hindus and 1634 (97.5%) were housewives. The prevalence of BV was 9.9% with a NS of 7–10 and 14.9% of women had intermediate flora on Nugent score of 4–6. While 212 women (12.9%) reported collecting the vaginal swab as being ‘very easy’, 1402 (85%) found it ‘easy’ and 22 (1.3%) reported it as ‘difficult’. Only 12 women were unable to collect the swab for various reasons. Conclusion These study results support the use of self-collected vaginal swabs for diagnosing BV. Self-collected swabs to detect BV were well accepted by most of rural pregnant women in this region, and the quality of the swabs seemed to be satisfactory.

P3-S7.02 Performance of a point-of-care diagnostic for Bacterial Vaginosis among young reproductive age women in Mysore, India

Background Bacterial vaginosis (BV) remains the most common cause of abnormal vaginal discharge in Indian women of reproductive age and is associated with increased susceptibility to HIV/STI and preterm delivery. Diagnosis of BV in resource-poor settings is often overlooked; there is a need for cheap, rapid, objective point-of-care diagnostic test. Methods Vaginal swabs were collected from women attending a womens health clinic. Women over the age of 18 with a pH of over 4.5 were invited to participate in the study. BV was diagnosed on the basis of the Nugent score, the Amsel clinical criteria, and results of OSOM BVBlue test independently by study clinician and laboratory personnel who were blinded to the results of the other tests. Results From August 2009 to May 2010, 313 participants were enrolled. BV prevalence was 45.1% (95% CI 41.5% to 52.8%) according to Nugent score. When compared with the Nugent score, the sensitivity, specificity, positive predictive value, negative predictive value for Amsel clinical criteria was 61.9%, 88.3%, 81.5%, 73.7%; and for BVBlue it was 38.1%, 92.7%, 82.1%, 63.9% respectively. The performance of BVBlue can be increased if it is combined with “Whiff test where the sensitivity increases to 64.4%, sensitivity 85.6%, PPV 79.3% and NPV 73.8%”. Conclusions These results highlight the importance of systematic evaluation of rapid test kits as a low-cost alternative to laboratory diagnosis in resource-constrained settings. The BVBlue test is a simple, rapid, and objective test for the diagnosis of BV and has the potential to facilitate prompt diagnosis and appropriate treatment of BV in the absence of microscopy.