BACKGROUND:High-quality data are of prime importance in any health survey because survey data are considered as a gold standard for nationally representative data. The quality of data collection largely depends on the design of the questionnaire, training, and skills of the interviewer.OBJECTIVES:In the present study, we tried to evaluate three key components, such as questionnaire design, human resource and training of the field staff for Integrated Biological and Behavioural Surveillance carried out among the HIV high-risk subpopulation.METHODS:A mixed-methods approach was used. Qualitative and quantitative data collection was carried out in the year 2015 with cross-sectional survey design in western states of India. The in-depth interviews of 10 stakeholders, structured interviews of the survey respondents (n = 560), and field investigators (n = 71) were conducted. Data triangulation was used to find out the concurrence of the qualitative and quantitative data.RESULTS:Comprehensive and standardized survey questionnaire, structured training agenda, and strategic preparation for recruiting human resources were the overall strengths of the survey. However, during the implementation of the survey, there were some difficulties reported in data collection process. Overall, the respondents and investigators felt that the questionnaire was long and exhaustive. Difficulties were faced while collecting data on sexual history. The field staffs were not adequately experienced to work with sensitive population.CONCLUSIONS:In order to have accurate, reliable data, especially on sexual behavior; emphasis should be given on simple questionnaire with the use of community-friendly language, skilled and experienced interviewers for data collection, and extensive field training.

Purpose. Emergence of multidrug resistance in Neisseria gonorrhoeae, an STI of public health significance is the biggest challenge to gonorrhoea control. Monitoring for antimicrobial resistance is essential for the early detection of emergent drug resistance patterns. Methodology. One hundred and twenty four N. gonorrhoeae strains were isolated between September 2013-August 2016 [82-New Delhi, 3-Pune, 3-Mumbai, 20-Secunderabad and 16-Hyderabad] to determine antimicrobial susceptibility and to compare the CLSI disc diffusion method with Etest for these strains. The results of the two methods were compared by using kappa statistics. Results. Ninety eight percent [CI: 96.2-100] of isolates were resistant to ciprofloxacin, 52% [CI: 43.2-60.8] to penicillin, 56% [CI: 47.2-64.7] to tetracycline and 5% [CI: 1.2-8.8] to azithromycin. All the strains were susceptible to spectinomycin, ceftriaxone and cefixime except for two strains which showed decreased susceptibility to ceftriaxone and cefixime. Kappa scores for penicillin, azithromycin, ciprofloxacin, ceftriaxone and cefixime showed that the CLSI method had high agreement with Etest while tetracycline had substantial agreement. Conclusion. Our data suggest that the disc diffusion method which is both cost effective and more feasible, can effectively be used routinely for monitoring antibiotic susceptibility in N. gonorrhoeae, in limited resource countries like India. We demonstrate the emergence of decreased susceptibility to ceftriaxone and cefixime and threshold levels of resistance to azithromycin in India. This underscores the importance of maintaining continued surveillance for antibiotic resistance in N. gonorrhoeae and a potential requirement for strategic change in guidelines in the not so distant future.

Introduction The HIV sentinel surveillance [HSS] conducted in 2010-11 among female sex workers [FSW] in the state of Maharashtra, India provided an opportunity to assess characteristics of different types of FSWs and their HIV risk. It is important for India's National AIDS Control Program, to understand the differences in vulnerability among these FSW, in order to define more specific and effective risk reduction intervention strategies. Therefore, we analyzed data from HSS with the objective of understanding the HIV vulnerability among different types of FSW in Maharashtra. Material and methods Cross sectional data collected as a part of HSS among FSWs in year 2010-11 from 21 sentinel sites in the state of Maharashtra were analyzed to understand the vulnerability and characteristics of different types of female sex workers based on their place of solicitation using multinomial logistic regression. Results While the HIV prevalence was 6.6% among all FSWs, it was 9.9% among brothel based [BB], 9% among street based [SB] and 3.1% and 3.7% among home based [HB], and bar based [Bar-B] sex workers respectively. SB FSWs were least likely to be located in HIV low burden districts [ANC] [ARRR: 0.61[95% CI: 0.49, 0.77]], but were 6 times more likely to be recently [<1 year] involved in sex work [ARRR: 6.15 [95% CI: 3.15, 12.0]]. The number of clients of SB FSWs in the preceding week were lower than 11% [ARRR: 0.89 [95% CI: 0.87, 0.90]] as compared to the BB FSWs denoting lesser client load. The duration since last paid sex was shorter [ARRR: 0.94[95% CI: 0.91, 0.96]] as compared to the BB FSWs. Conclusion Street based FSWs have emerged as one of the most vulnerable types of FSW with a high HIV prevalence similar to BB FSWs. Our study reveals that they have more frequent sex acts despite lower client loads, and are more likely to be located in districts highly affected by HIV (ANC prevalence >1%). We identify them as a group to be focused on for prevention interventions and it is likely that they would be easily amenable to novel interventions due to their higher literacy rate as compared to other typologies.

Objectives: In India, integrated biological and behavioral surveillance was carried out in 2014–2015 among high-risk key population as a part of second-generation HIV surveillance system. Computer-assisted personal interviewing and integrated information management system were used for the first time in this large national field based survey. We evaluated the strengths and weaknesses of technology use in this survey. Methods: Mixed methods comprising of the key informant's interviews and structured data collected from field interviewers were used to do the strengths, weaknesses, opportunities, and threats analysis with defined attributes. Results: Despite the challenges, the technology use in this survey was a huge success with respect to data coverage, response rates, real-time data, and acceptance by respondents. However, such techniques require more focus on the competency of human resource, training, and concurrent evaluation systems to get better data quality, time adherence, and effective use of technology. Conclusion: The recommendations resulted from this analysis will help for strategic management while designing such systems in field-based community surveys.

Under India's National AIDS Control Program (NACP), WHO recommended strategy of using three rapid tests is adopted for diagnosis of HIV in an asymptomatic individual.Since the NACP has a stringent kit evaluation procedure and due to the availability of newer third generation Rapid Diagnostic Tests (RDTs) it may be possible to adapt two test strategy for HIV diagnosis instead of the recommended three test strategy.The authors reviewed programmatic data on HIV testing to explore whether use of two rapid tests for HIV diagnosis as against three tests could be a feasible approach without compromising the quality and readability of testing.Data on the HIV diagnosis performed on serum specimens collected for the period of one year (2011-12) from 82 Integrated Testing and Counselling Centers (ICTCs) or Prevention of Parent to Child Transmission Centers (PPTCTs) associated with State reference Laboratories (SRLs) was analysed.Out of 654258 results that were analysed 25168 (3.84%) specimens were positives.It was observed that both two and three test algorithms provided similar results for majority (>99%) of the HIV positive specimens.Discordance was observed in labelling of specimen with inconclusive status (N = 21), however the true status of these samples could not be obtained.The analysis indicated that the use of two test algorithm will have programmatic benefits in terms of reduced financial burden to the programme and ease of procurement, shipment and storage before and after distribution without comprising the quality of the testing.The prospective study would confirm this observation.

Introduction: Quality indicators in a clinical laboratory are considered as useful tools for continual improvement of the laboratory services. Aim: The aim of this study was to assess timely performance of the NARI service laboratories in three phases of testing - pre-analytical, analytical and post-analytical, in an effort to improve their performance. Methodology: The study included an assessment of different quality indicators from six laboratories - Clinical Biochemistry, Hematology, Serology, Microbiology, Virology and Immunology at the NARI central laboratory which provide service for the patient care. Results: Data obtained from a total of 39139 clinical samples collected over a period of two years was used in the study. The overall error rate was found to be 2.72%. The commonly observed indicators were revision of the laboratory requisition form (0.49%) and sample rejection (0.31%) during the pre-analytical phase, equipment breakdown (0.12%) and failure of the controls (0.03%) during the analytical phase, turnaround time (1.55%) and revision of the report form (0.15%) during the post- analytical phase. Conclusions: Quality indicators are important tools in improving the quality system in a clinical laboratory and patient care.

Introduction: Cytomegalovirus (CMV) pneumonia is one of the frequent viral pneumonia reported in persons with HIV infection. Knowledge of pulmonary CMV infection is important for deciding appropriate diagnostic strategies. However, there is scanty literature addressing the role of CMV aetiology among HIV positive individuals presenting with Community Acquired Pneumonia (CAP) using Bronchoalveolar Lavage (BAL) samples from India. Aim: To detect CMV in BAL fluid from HIV-positive individuals presenting with CAP. Materials and Methods: This cross-sectional study was conducted using 107 archival BAL samples collected from consecutive HIV-positive patients presenting with CAP as per the Indian Chest Society and National College of Chest Physicians guidelines at the Department of Chest and Tuberculosis, Sassoon General Hospitals, Pune, India. The samples were tested for CMV by Polymerase Chain Reaction (PCR) targeting the IRL11 region at the National AIDS Research Institute, Pune. Results: Of the 107 BAL samples tested, 8 (7.4 %) were positive for CMV, while CMV was the sole pathogen in 5 (4.7%) cases. Co-infection with other pathogens was seen in 3 patients and Mycobacterium tuberculosis, Pneumocystis jiroveci and Streptococcus pneumoniae were the co-pathogens. Five patients had fatal clinical outcome of which three had CMV as the sole pathogen. Conclusion: Ours is the first study to detect Cytomegalovirus (CMV) in bronchoalveolar lavage samples from HIV- positive individuals presenting with community acquired pneumonia from India and indicates the need for further multicentre studies to understand pulmonary CMV infection, which will eventually help in designing appropriate diagnostic strategies and therapeutic interventions.

We utilized computerized record-linkage methods to link HIV and cancer databases with limited unique identifiers in Pune, India, to determine feasibility of linkage and obtain preliminary estimates of cancer risk in persons living with HIV (PLHIV) as compared with the general population.Records of 32,575 PLHIV were linked to 31,754 Pune Cancer Registry records (1996-2008) using a probabilistic-matching algorithm. Cancer risk was estimated by calculating standardized incidence ratios (SIRs) in the early (4-27 months after HIV registration), late (28-60 months), and overall (4-60 months) incidence periods. Cancers diagnosed prior to or within 3 months of HIV registration were considered prevalent.Of 613 linked cancers to PLHIV, 188 were prevalent, 106 early incident, and 319 late incident. Incident cancers comprised 11.5% AIDS-defining cancers (ADCs), including cervical cancer and non-Hodgkin lymphoma (NHL), but not Kaposi sarcoma (KS), and 88.5% non-AIDS-defining cancers (NADCs). Risk for any incident cancer diagnosis in early, late, and combined periods was significantly elevated among PLHIV (SIRs: 5.6 [95% CI 4.6-6.8], 17.7 [95% CI 15.8-19.8], and 11.5 [95% CI 10-12.6], respectively). Cervical cancer risk was elevated in both incidence periods (SIRs: 9.6 [95% CI 4.8-17.2] and 22.6 [95% CI 14.3-33.9], respectively), while NHL risk was elevated only in the late incidence period (SIR: 18.0 [95% CI 9.8-30.20]). Risks for NADCs were dramatically elevated (SIR>100) for eye-orbit, substantially (SIR>20) for all-mouth, esophagus, breast, unspecified-leukemia, colon-rectum-anus, and other/unspecified cancers; moderately elevated (SIR>10) for salivary gland, penis, nasopharynx, and brain-nervous system, and mildly elevated (SIR>5) for stomach. Risks for 6 NADCs (small intestine, testis, lymphocytic leukemia, prostate, ovary, and melanoma) were not elevated and 5 cancers, including multiple myeloma not seen.Our study demonstrates the feasibility of using probabilistic record-linkage to study cancer/other comorbidities among PLHIV in India and provides preliminary population-based estimates of cancer risks in PLHIV in India. Our results, suggesting a potentially substantial burden and slightly different spectrum of cancers among PLHIV in India, support efforts to conduct multicenter linkage studies to obtain precise estimates and to monitor cancer risk in PLHIV in India.

Resistance to azole antifungals is a significant problem in Candida albicans. An understanding of resistance at molecular level is essential for the development of strategies to tackle resistance and rationale design of newer antifungals and target-based molecular approaches. This study presents the first evaluation of molecular mechanisms associated with fluconazole resistance in clinical C.albicans isolates from India. Target site (ERG11) alterations were determined by DNA sequencing, whereas real-time PCRs were performed to quantify target and efflux pump genes (CDR1, CDR2, MDR1) in 87 [Fluconazole susceptible (n = 30), susceptible-dose dependent (n = 30) and resistant (n = 27)] C.albicans isolates. Cross-resistance to fluconazole, ketoconazole and itraconazole was observed in 74.1% isolates. Six amino acid substitutions were identified, including 4 (E116D, F145L, E226D, I437V) previously reported ones and 2 (P406L, Q474H) new ones. CDR1 over-expression was seen in 77.7% resistant isolates. CDR2 was exclusively expressed with CDR1 and their concomitant over-expression was associated with azole cross-resistance. MDR1 and ERG11 over-expression did not seem to be associated with resistance. Our results show that drug efflux mediated by Adenosine-5-triphosphate (ATP)-binding cassette transporters, especially CDR1 is the predominant mechanism of fluconazole resistance and azole cross-resistance in C. albicans and indicate the need for research directed towards developing strategies to tackle efflux mediated resistance to salvage azoles.

In India, the roll out of the free antiretroviral therapy (ART) program completed a decade of its initiation in 2014. The success of first-line ART is influenced by prevalence of HIV pretreatment drug resistance (PDR) in the population. In this cross-sectional study, we sought to determine the prevalence of PDR among adults attending the state-sponsored free ART clinic in Pune in western India. Fifty-two individuals eligible for ART as per national guidelines with median CD4 cell count of 253 cells/mm(3) (inter quartile range: 149-326) were recruited between January 2014 and April 2015. Population-based sequencing of partial pol gene sequences from plasma specimen revealed predominant HIV-1 subtype C infection (96.15%) and presence of single-drug resistance mutations against non-nucleoside reverse transcriptase inhibitor in two sequences. The study supports the need for periodic surveillance, when offering PDR testing at individual level is not feasible.

BACKGROUND:Several studies in recent years have documented the genotype-specific prevalence of HPV infection and wide diversity and multiplicity of HPV genotypes among HIV-seropositive women. Yet, information on changes in HPV genotype-specific incidence and clearance rates over time, and their correlation with clinical or immunologic factors among HIV-seropositive women is scarce. OBJECTIVES:We conducted a prospective study to investigate the incidence and clearance rates of cervical HPV genotypes among HIV-seropositive women in India and expand the evidence base in this area of research. STUDY DESIGN:Cervical samples were collected from n=215 HIV-seropositive women in Pune, India who underwent two screening visits separated by a median of 11-months (interquartile range: 8-18 months). HPV genotypes were determined by Roche Linear Array HPV assay. Individual genotype-specific and carcinogenicity-grouping-specific HPV incidence and clearance rates were calculated and the associations between incidence/clearance and age and HIV-related metrics were explored. RESULTS:Incidence and clearance rates for 'any HPV' and 'carcinogenic HPV' genotypes were 11.1 and 18.3, and 6.7 and 33.8, per 100 person-years, respectively. Incidence and clearance rates for HPV genotypes of alpha-9 species (HPV16, HPV31, HPV33, HPV35, HPV52 and HPV58) and alpha-7 species (HPV18, HPV39, HPV45, HPV59 and HPV68) were 5.8 and 2.04, and 32.1 and 53.5, per 100 person-years, respectively. Clearance of any HPV type was associated with increasing age of participants (odds ratio: 1.08, 95%CI: 1.004-1.17), although the association marginally lost its statistical significance when adjusted for CD4 counts and antiretroviral therapy status. CONCLUSIONS:Genotype-specific clearance rates of HPV were higher than corresponding incidence rates. The suggestion of a positive associations of increasing age with HPV clearance points to the need for etiologic studies on age-related hormonal changes on clearance of cervical HPV infection.

Measurement of C-reactive protein (CRP), a marker of inflammation, in dried blood spots has been increasingly incorporated into community-based social surveys internationally. Although the dried blood spot-based CRP assay protocol has been validated in the United States, it remains unclear whether laboratories in other less-developed countries can generate CRP results of similar quality. We therefore conducted external quality monitoring for dried blood spot-based CRP measurement for the Indonesia Family Life Survey and the Longitudinal Aging Study in India. Our results show that dried blood spot-based CRP results in these two countries have excellent and consistent correlations with serum-based values and dried blood spot-based results from the reference laboratory in the United States. Even though the results from duplicate samples may have fluctuations in absolute values over time, the relative order of C-reactive protein levels remains similar, and the estimates are reasonably precise for population-based studies that investigate the association between socioeconomic factors and health.

BACKGROUND:Although HIV incidence has declined in India, men and transgender women who have sex with men (MSM) continue to have high rates of HIV and sexually transmitted disease (STD). Indian MSM face substantial pressures to marry and have families, but the HIV/STD burden among married Indian MSM is not well characterized.METHODS:A diverse sample of Indian MSM were recruited through respondent-driven sampling. Independent variables that produced a P value of 0.10 or less were then added to a multivariable logistic regression model.RESULTS:Most of the 307 MSM (95 married and 212 unmarried) recruited into the study were younger than 30 years, and less than one-third had more than a high school education. Almost two-thirds of the married men had children, compared with 1.4% of the unmarried men (P < 0.001). The numbers of condomless anal sex acts did not differ by marriage status. Although unmarried MSM more often identified themselves as "kothi" (receptive role), their rates of HIV or bacterial STD were similar to married MSM, with 14.3% being HIV infected. The respondent-driven sampling-adjusted prevalence of any bacterial STD was 18.3% for married MSM and 20% for unmarried MSM (not significant). Participants reported high levels of psychological distress, with 27.4% of married and 20.1% of unmarried MSM reporting depressive symptoms (not significant).CONCLUSIONS:Men who have sex with men in Mumbai had high rates of HIV, STD, and behavioral health concerns. Clinicians need to become more comfortable in eliciting sexual histories so that they can identify MSM who need HIV/STD treatment and/or prevention services.

The present study was undertaken to detect Pneumocystis jirovecii infection among HIV-positive patients presenting with symptoms of lower respiratory tract infection and analyze the associated dihydropteroate synthase (DHPS) and dihydrofolate reductase (DHFR) mutations. P. jirovecii infection was detected in 12.6 % cases. We did not find DHPS gene mutations at the commonest positions of codon 55 and 57; however, mutation at codon 171 was detected in two cases. No mutations in DHFR gene were detected. The results indicate low prevalence of DHPS and DHFR mutations in Indian P. jirovecii isolates, suggesting that the selective pressure of sulfa drugs on the local strains has probably not reached the levels found in developed nations.

BACKGROUND AND OBJECTIVES:Emergence of multi-drug resistant Neisseria gonorrhoeae resulting from new genetic mutation is a serious threat in controlling gonorrhea. This study was undertaken to identify and characterise mutations in the mtrR genes in N.gonorrhoeae isolates resistant to six different antibiotics in the quinolone group.MATERIALS AND METHODS:The Minimum inhibitory concentrations (MIC) of five quinolones for 64 N.gonorrhoeae isolates isolated during Jan 2007-Jun 2009 were determined by E-test method. Mutations in MtrR loci were examined by deoxyribonucleic acid (DNA) sequencing.RESULTS:The proportion of N.gonorrhoeae strains resistant to anti-microbials was 98.4% for norfloxacin and ofloxacin, 96.8% for enoxacin and ciprofloxacin, 95.3% for lomefloxacin. Thirty-one (48.4%) strains showed mutation (single/multiple) in mtrR gene. Ten different mutations were observed and Gly-45 → Asp, Tyr-105 → His being the most common observed mutation.CONCLUSION:This is the first report from India on quinolone resistance mutations in MtrRCDE efflux system in N.gonorrhoeae. In conclusion, the high level of resistance to quinolone and single or multiple mutations in mtrR gene could limit the drug choices for gonorrhoea.

There has been a reduction in the most severe cases of HIV-associated neurocognitive disorders (HAND) with advances in antiretroviral treatment (ART). But the prevalence of milder forms of HAND still remains high. Data from systematically conducted studies on the effects of ART on cognition are scanty in India, where HIV-1 clade C is prevalent. The purpose of the present study was to assess the effect of antiretroviral therapy in HIV-seropositive (HIV+) individuals ( n = 92) with CD4 cell counts <200 cells/mm 3 . The overall and domain-specific levels of cognitive functioning were determined using a locally recruited normative sample, and a change in neurocognitive functioning at the 1-year follow-up visit was analyzed. Results revealed cognitive impairment in 44.6 % of the HIV+ group at baseline. At the 1-year follow-up, the group showed significant improvement in the Learning domain ( p < 0.05). HIV+ individuals showing improvement in the global cognitive scores had a significantly lower baseline CD4 cell count compared to others. Overall, the degree of improvement associated with the magnitude of rise in CD4 suggests the possibility that early, mild subclinical deficits may also benefit from treatment.

Sir, The identification of Neisseria gonorrhoeae by sensitive, precise, and rapid technique is important for the correct diagnosis and appropriate treatment of patients with gonorrhoea. For decades, the standard method of identification of the pathogen has been acid production from cystine tryptic agar (CTA) medium containing carbohydrates1. For a more rapid identification of this pathogen a variety of immunological and biochemical commercial kits have now become available. An ideal test should have high sensitivity and specificity, should be easier to perform and cheap. An attempt was made in this study to identify such a test by comparing four available tests on 71 N. gonorrhoeae isolates. The three most widely used immunological kits are the MicroTrak N. gonorrhoeae culture confirmation test (an immunofluoresence test; Trinity Biotech PIC, Ireland), the Phadebact Monoclonal GC test (a coagglutination test; MKL Diagnostics AB, Kung Hans Vag, Sollentuna, Sweden) and GonoGen II (a membrane immunoassay; New Horizons Diagnostics, USA), all of which employ monoclonal antibodies (mAbs) developed against specific epitopes on the two types of the major outer membrane protein, protein I A and B (PIA and PIB)2. Interpretation of the MicroTrak test is less subjective but requires a fluorescence light microscope whereas Phadebact monoclonal test is easier to perform and can be used by most small laboratories2,3. GonoGen II is a colorimetric test and does not require heat treatment step of the coagglutination test. This test eliminates the reading of agglutination; instead, the mixture of antigen-antibody complex is passed through a filtration unit. The appearance of a red dot on the filter indicates a positive reaction2. Though the specificity of these kits for detection of N. gonorrhoeae is high, both false-positive (cross-reactions with other Neisseria species such as N. meningitidis, N. lactamica, N. cinerea and Kingella denitrificans) and false-negative results have also been reported4. The biochemical kits widely used are the Neisseria Preformed Enzyme Test (PET), Gonochek II, RapID NH, Neisstrip, API-NH and Rapid carbohydrate utilization test (RCUT)3,4,5. These tests are based on the presence of preformed chromogenic enzyme in the culture, and thus require a heavy inoculum of the organism grown on selective medium to permit rapid speciation of isolates. The enzymes that are detected by these systems include beta-galactosidase, gamma-glutamylaminopeptidase and prolyl-hydroxyprolyl aminopeptidase2. The Neisseria PET and Gonochek II are both single-use tubes containing chromogenic substrates that detect the presence of three preformed enzymes, each of which is indicative of a pathogenic Neisseria species, namely N. lactamica, N. meningitidis and N. gonorrhoeae. In Gonochek II, after incubation a red colour change (hydrolysis of L-proline 4-methoxynapthylamide) is observed2,3. The API-NH and RapID NH kits employ a battery of tests, combining carbohydrate utilization and preformed enzymes. These two tests detect the change in prolyl iminopeptidase (PIP) enzyme activity due to the mutation in the pip gene. Not all isolates of N. gonorrhoeae possess PIP activity6,7. In RCUT, preformed enzyme is measured by adding a suspension of the overnight growth of the suspect organism to a buffered (non-nutrient) solution containing the sugar to be tested and a pH indicator. A yellow colour change indicated a positive reaction and orange red colour as negative reaction8. As taxonomic differences between members of the Neisseria genus remain small, the identification of this pathogen can be problematic. Of the several commercial kits used worldwide for identification of N. gonorrhoeae, only four commercial kits, RCUT, API-NH, Gonochek II and Phadebact GC system were available in India. The purpose of this study was to compare the performance of these four commercial biochemical methods to identify pathogenic N. gonorrhoeae and to assess the cost effectiveness and utility in the clinical laboratory. A total of 71 Neisseria isolates were included in the study carried out at the National AIDS Research Institute (NARI), Pune, India, during January 2007 to June 2009. Of these, 64 isolates of N. gonorrhoeae were obtained from patients attending STD clinics of NARI, Pune (n=16), Safdarjang hospital, New Delhi (n=35) and 13 collected under STI-Operations Research project conducted at NARI (Mumbai-6, Hyderabad-6 and Nagpur-1). Patients attending STD clinics with complaints of urethral/cervical discharge were included in the study. Seven non gonococcal Neisseria strains, N. sicca (n=2), N. cinerea (n=2) and N. lactamica (n=3) recovered from clinical specimens from patients attending NARI clinics were also included. All the strains were tested by API-NH (Bio Merieux SA, France), Gonochek II (E-Y Laboratories, CA, USA), Phadebact monoclonal GC OMNI test (Boule Diagnostics AB, Sweden) according to manufacturers’ instructions, and by Rcut8. N. gonorrhoeae ATCC 49226 (β-lactamase negative) and WHO strains A, G H, E and O (received under WHO Gonococcal Antimicrobial Surveillance Programme from WHO GASP South East Asia Region Reference Laboratory, New Delhi) (β-lactamase positive) were used as quality control in each test run. The cost per test for each identification method was calculated considering the cost of media, reagents, ancillary supplies and time required to perform identification by each test method. All isolates of N. gonorrhoeae were correctly identified with RCUT system and Phadebact monoclonal GC OMNI system (Table). Gonochek II test correctly identified in 68 (95.3%) of N. gonorrhoeae isolates. The low sensitivity of this test has also been reported earlier. API-NH system correctly identified 51 (79.6%) of N. gonorrhoeae isolates. Thirteen (20.3%) N. gonorrhoeae isolates did not show any reaction for PIP enzyme in the API-NH system, which could be done to the lack of enzyme in these isolates. Specificity of these tests was evaluated based on their ability to give negative results on the seven non gonococcal strains. RCUT system correctly identified N. cinerea, N. sicca strains and one of the three N. lactamica strains as non gonococcal strains. Similar findings were observed by Young and Moyes9. API-NH system correctly identified both N. cinerea strains, one of the two N. sicca strains and one of the three N. lactamica strains as non gonococcal strains. Gonochek II test correctly identified one of the three N. lactamica strains as non gonococcal. Other studies have also reported similar findings in identifying N. gonorrhoeae, N. lactamica and N. sicca strains5,10. The Phadebact monoclonal GC OMNI system correctly identified both N. cinerea strains, two of the three N. lactamica strains and one of the two N. sicca strains. The sensitivity and specificity of Phadebact monoclonal GC OMNI system in our study was similar to that reported earlier5. Thus, RUCT appeared to be the most specific (6/7) followed by Phadebact OMNI system (5/7), and API-NH (4/7). Gonochek II test showed lowest specificity by identifying six of the 7 non gonococcal strains as N. gonorrhoeae. RCUT was found to be the cheapest among all tests (Table). Table Comparison of four test systems for the identification of N. gonorrhoeae isolates The Phadebact monoclonal GC OMNI system was rapid, simple to perform, accurate and provided results in 2-3 min. However, it showed moderate specificity and was more expensive than other methods. The colours generated in the Gonochek II system incubated at 30°C for 30 min were distinct, easy to read, stable and easy to handle in the clinical laboratory. However, it had low sensitivity (95.3%) in identification of N. gonorrhoeae. Additionally, it appeared to have low specificity since six of the seven non gonococcal strains were identified as gonococcal strains. API-NH system showed low sensitivity and specificity in identification of N. gonorrhoeae. This may be due to the lack of enzyme PIP in these isolates which have also been reported in other studies4,5,6,7. We found that the RCUT gave reliable results within 4 h, and identified 100 per cent of N.gonorrhoeae isolates as reported earlier by Yong and Moyes9. Additionally, it appeared to be highly specific since only one of seven non gonococcal strains was wrongly identified as gonococcal strain. Considering the performance, rapidity and cost, RCUT appeared to be the best among the four methods studied for confirmatory identification of N.gonorrhoeae. RCUT can be used routinely as it is cheaper and easily available but the reagents used for RCUT should be evaluated with the known control strain before being used routinely.

Saliva plays an important role in maintaining microbial homeostasis in the oral cavity, while salivary gland hypofunction predisposes the oral mucosa to pathologic alteration and increases the risk for oral candidiasis. This study sought to determine the salivary flow rate (SFR) and secretory immunoglobulin A (SIgA) levels in HIV-positive and HIV-negative individuals and evaluate their relationship with the determinants of oral candidiasis. Sixty HIV-positive (30 with and 30 without oral candidiasis) and 30 healthy HIV-negative individuals were enrolled. Cotton pellet was weighed pre- and post-saliva collection for the assessment of SFR, while SIgA levels were estimated by commercial ELISA (Diametra, Italy) kit. The mean ± SD, SFR and SIgA levels in HIV-positive individuals with candidiasis, without candidiasis and HIV-negative controls were 0.396 ± 0.290, 0.546 ± 0.355 and 0.534 ± 0.214 ml/min and 115.891 ± 37.621, 136.024 ± 51.075 and 149.418 ± 31.765 µg/ml, respectively. A positive correlation between low CD4 counts (indicator of immunodeficiency) and SIgA was observed in HIV-positive individuals with candidiasis ( r = 0.373, p = 0.045). We also report here for the first time the significant decrease in SFR and SIgA levels in individuals presenting with pseudomembranous type of oral candidiasis and Candida albicans infection.