PASA Pacific AIDS Alert Bulletin No. 40 | October 2013 ISSN 1018-2152

Trend setters and leaders faith-based organisations respond to HIV

Involving everyone improving national strategic Cross Pacific planning in the Pacific Sharing spear-heading innovative behaviour change campaigns Part of the process locally relevant, Targeting comprehensive STI Chlamydia management guidelines success in STI control in and Nauru HIV in the Pacific 2012 epidemiology No. 40 | October 2013 PASA ISSN 1018-2152 Pacific AIDS Alert Bulletin

Prevention 04 Cross Pacific sharing: spear-heading innovative behaviour change campaigns Reducing stigma and encouraging HIV testing in the Marshall Islands Outreach, edutainment and incentives: youth get tested Stepping forward together: reaching at risk groups with peer education

Counselling and testing 11 Highlights from HIV and STI counselling and Treatment diagnosis in the Pacific in 2012 18 Part of the process: locally relevant, comprehensive STI management guidelines STI control explained Treatment is my life now: Experiences of Targeting Chlamydia: success in STI control treatments among people living with HIV in in Cook Islands and Nauru Pacific Island countries and territories Faster diagnosis of STIs Enabling environment 21 Trend setters and leaders: faith-based organisations respond to HIV Tackling stigma and discrimination in the workplace

Research 24 HIV in the Pacific: 2012 epidemiology Know your epidemic

Governance 30 Involving everyone: improving national strategic planning in the Pacific Building capacity and improving sustainability for M&E in the Pacific Renewing the sexual health response in the Pacific: the Pacific Sexual Health and Well-being Shared Agenda

Young women in use painting to learn and communicate about sexual health and gender equality in a Response Fund supported project ‘HIV/AIDS Awareness Through Arts and Craft.’ Rather than talking about what they’ve learnt, the programme requires them to communicate their understanding through painting. This special edition of the Pacific AIDS Alert Bulletin is dedicated to sharing research and evidence, successes and lessons learned in the response to HIV and other STIs in the Pacific region.

The Pacific region’s experience of HIV is unique. While Papua New Guinea has an HIV epidemic that is concentrated in certain populations, the rest of the region has an extremely low HIV prevalence. However, risk factors exist, indicating the potential for the virus to spread. Challenges include sky high rates of other STIs as well as gender inequality and stigma and discrimination.

However, with the support of the Pacific Islands HIV and STI Response Fund, a programme managed by the Secretariat of the (SPC) and funded by the Australian and New Zealand governments, Pacific Island countries and territories (PICTs) are successfully developing targeted prevention/ Strategic Health Communication campaigns, expanding voluntary HIV counselling and testing, improving Chlamydia testing and treatment, strengthening national and regional laboratory services, and collecting data on epidemiological trends and socio- behavioural changes, to assist in evidence- based decision making. PICTs are also improving their capacity to develop national strategic plans (NSP), with 362 health care workers newly trained on NSP development processes and the Pacific Basic Monitoring and Evaluation Curriculum in 2012.

Building on these gains made to date, the Pacific is looking to the future and moving towards a more integrated approach for reproductive and sexual health, as part of an effort to achieve sustainable social and human development in the region.

We hope you enjoy this edition of the Pacific AIDS Alert Bulletin.

Cover: A Kiribati Family Health Association (KFHA) peer educator poses for a portrait on the runway of Bonriki International Airport in South Tarawa, Kiribati between flights. KFHA, Kiribati Red Cross and the Kiribati Ministry of Health are mixing education with entertainment to encourage young people to get an STI test. See page 7 for more. Condom distribution in nightclubs in Noumea, by Homosphere, an NGO working to provide services for LGBTI communities in New Caledonia. PREVENTION

Islands who co-facilitated an SHC Cross Pacific Sharing: spear- training workshop in Vanuatu, says that the experience enabled heading innovative behaviour him to ‘build networks and share ideas with our Melanesian brothers and sisters on how change campaigns best we can strengthen strategic health communication in the region’.

A workshop participant from Vanuatu agrees. ‘When colleagues in Solomon Islands shared what they had done and what they had achieved, we started to believe that we could do the same in Vanuatu. We face the same challenges, but we can overcome them.’

‘Peers learn best The Cross Pacific Sharing and Skills Transfer Programme is from peers. When founded on an ancient Chinese countries with similar SHC master trainer Elwin Taloimatakwa proverb: ‘Tell me and I forget, challenges share their supporting SHC training teach me and I may remember, in Vanuatu. Photo experiences and work source: Nicol Cave. involve me and I learn.’ To together, they are able reinforce facilitation skills and to develop innovative, SHC content knowledge, master home-grown, locally- strong leadership and trainers need opportunities to relevant solutions,’ facilitation skills to co-facilitate use and practise their skills. As SHC training with SPC staff the saying goes, ‘You learn how in neighbouring countries as to cut down trees by cutting master trainers. In this way, the them down!’ PC’s Public Health Division ‘sending’ country strengthens its Shas successfully spear- in-country SHC training capacity, Marson Rosario from Pohnpei in headed an innovative initiative and the host country learns Federated States of to build capacity and strengthen from, and is motivated by, the echoes this sentiment: ‘I leadership in strategic health experiences and achievements of welcomed the opportunity communication (SHC) across their neighbouring countries. to train with PHD staff in the Pacific region. The field of Chuuk because it gave me the SHC aims to change individual ‘Peers learn best from peers. opportunity to practise what and community behaviours, When countries with similar I have learned and to learn by attitudes and norms as a means challenges share their practice.’ of improving public health. experiences and work together, For example, SHC campaigns they are able to develop Mr Taloimatakwa goes further, advocate for condom use, STI innovative, home-grown, saying that the debriefing session testing or healthy eating. locally-relevant solutions,’ says after each day’s training was a Nicol Cave, Strategic Health learning opportunity to reflect on The Cross Pacific Sharing and Communication Team Leader at what had been achieved during Skills Transfer Programme SPC’s Public Health Division. the day and to redirect the focus provides opportunities for Pacific of the workshop to improve the Islanders who have been trained Elwin Taloimatakwa, an SHC next day’s training sessions. in SHC and have demonstrated master trainer from Solomon

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because I am not going to speak the UN Secretary General called was able to share in English all the time. English is on donors and international information about ‘I not my language; I just borrow organisations to intensify their my organisation and what it from time to time to be able to efforts to mainstream the use we do in Marshall Islands. speak to other people who do not of South-South cooperation I described how we develop speak my language,’ says Shima in the design, formulation radio spots and also how Seese, a master trainer from and implementation of their we distribute condoms to Marshall Islands. programmes, and to consider places where young people increasing allocations of human, can get them. This sharing Janet Jack from Vanuatu says, technical and financial resources encouraged the participants ‘With the Cross Pacific Sharing to support South-South in Kiritimati to develop a plan experiences I gained in Solomon cooperation initiatives. for peer condom distribution. Islands, I am a stronger facilitator. Some of the young people in I will now be able to strengthen At the end of October 2013, the the workshop volunteered to our programme activities in the Pacific has a pool of 13 Pacific- be the ones to always have Ministry of Health and achieve based regional SHC master condoms and other young the targets set.’ trainers to draw from to provide people can come to them inter-PICT or ‘South-South’ when they need condoms. In recognition of the importance training and technical support, This makes it easier for young of South-South cooperation for thus reducing reliance on outside people because the clinic is development, the United Nations training and technical assistance. far away.’ General Assembly declared 12 Shima Seese, September each year the United Marshall Islands Nations Day for South-South Cooperation. On this day in 2012,

‘The sharing of ideas during Pacific regional SHC master trainers are: these reflection meetings and SHC MASTER FROM COUNTRY CO- CURRENT the delegation of tasks and TRAINER COUNTRY FACILITATED STATUS responsibilities to master TRAINING trainers was a gesture of trust Ms Ana File Cook Working in Cook Islands Ministry Islands of Health and confidence in us as co- Ms Janet Jack Vanuatu Solomon Islands Working in Vanuatu Ministry of facilitators. It really made us feel Health empowered and confident to Ms Lorraine Satorara Solomon Fiji Working in public health Islands programme, Solomon Islands replicate SHC training of a high National University quality in our own country,’ says Mr Henry Oti Solomon Fiji Working in Solomon Islands Mr Taloimatakwa. Islands Ministry of Health Mr Elwin Taloimatakwa Solomon Vanuatu Working as media coordinator for Islands Police Youth Project in Honiara Together with building Mr Wayne Sade Solomon Vanuatu Working as HIV Programme skills, South-South learning Islands Manager in Oxfam, Honiara Ms Nancy Pego Solomon Vanuatu programmes such as this one Islands also create opportunities for an Mr George Pitakoe Solomon Vanuatu Working as Media and STI Project expression of solidarity among Islands Coordinator in Solomon Islands Planned Parenthood Association peoples and countries of the (SIPPA) South Pacific, which contributes Mr Shima Seese Marshall Kiritimati Island Working as Media Coordinator Islands in Youth to Youth in Health in to national and collective Majuro, Marshal Islands confidence and self-reliance. Mr Lono Leneuoti Kiritimati Island Working as HIV Coordinator in and Tokelau Tuvalu Family Health Association in Tuvalu ‘Travelling to Kiritimati Island to Ms Taborenga Takabea Kiribati Kiritimati Island Working as HIV Officer in Red co-facilitate with Nicol Cave was Cross, Tarawa, Kiribati a big opportunity for me. I speak Ms Emaima Iotebwa Kiribati Kiritimati Island Working in Kiribati Ministry of Health I-Kiribati and I think it will be Mr Marson Rasario Pohnpei Chuuk State, FSM Working in Pohnpei national peer more interesting for participants education programme

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after attending a national planning workshop last year. The Youth to Youth in Health perform a drama workshopp was supported by the raising awareness of the importance of using a Burnet Institute, an Australian condom every time you research institute, and the Pacific have sex. Islands HIV and STI Response Fund. Ms Shoniber says, ‘Before, I had a lot of prejudices and I fell into that category of people who thought that anything I heard about HIV was true. I didn’t take the time to find real information.

‘Now, I’m more sensitive when I try to advocate for this Reducing stigma and programme and when I try to get people to care about checking encouraging HIV testing their HIV status. I was one of the NAC members who got tested,’ in the Marshall Islands says Ms Shoniber. She praises the counselling outh to Youth in Health, a identified by the National provided at the Youth to Youth Ynon-government organisation Advisory Committee (NAC) on in Health clinic: ‘It was really promoting health, culture and STDs, HIV & TB as one of the key informative,’ she says. spiritual well-being in Republic barriers to effectively addressing of the Marshall Islands, is using HIV and other sexually Youth to Youth in Health baseball to encourage young transmitted infections (STIs) in provides a youth-friendly people to get an HIV test. Marshall Islands. sexual and reproductive health clinic where In 2012, young Marshallese Although HIV prevalence is low, it pregnancy testing, men and women formed eight is important that HIV prevention STI and HIV testing, efforts are maintained, as baseball teams, with a condition contraception and check- low levels of sexual health of entry being that all players ups are available. The went for an HIV test. knowledge, coupled with alcohol use and unprotected sexual organisation addresses issues of adolescent The final took place on World activity, put young people in sexual and reproductive AIDS Day 2012, with the Marshall particular at risk of HIV and health, substance abuse, Islands Minister for Health other STIs. presenting the awards. and suicide with peer A new NAC, drawn from education, outreach and government, community NGOs, Shima Seese of Youth to Youth counselling. the private sector and learning in Health said, ‘Baseball is a institutions, is working to very popular sport, and this is Within the more than 1200 develop a coordinated national baseball season. We knew that, islands and islets of Marshall response that promotes sexual due to its popularity, a lot of Islands are three Youth to Youth and reproductive health, youth would want to register and community centres – in Majuro, acknowledges the strength of try to win a prize.’ Laura and Ebeye – where young culture, and encourages respect people can engage in sports, among all individuals, families Such incentives and high level music, arts, games, computer and the community. support for World AIDS Day help skills and dance. combat the stigma associated Deborah Shoniber, a member with HIV. Stigmatisation was of the NAC, shares her feelings

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backpacks,’ says Ms Iotebwa. A Kiribati Family Health Association ‘When we designed them, we (KFHA) peer educator poses for thought they shouldn’t be given a portrait on the out at testing sites because it runway of Bonriki International would stigmatise those coming Airport in South Tarawa, Kiribati for STI tests. However, during the between flights. campaign, we found that people didn’t care; they really wanted a bag. We found that there was no stigmatisation associated with having these incentives for STI testing.’

Samples were collected for HIV and STI testing on the first day of the competition, with laboratory technicians testing the samples the next day. Counsellors then communicated results back to concert goers on the evening of second day.

Outreach, edutainment After completing a knowledge attitudes and practice (KAP) and incentives: Kiribati survey to understand people’s knowledge and beliefs in relation youth get tested to STIs, the Ministry of Health developed information education and communication (IEC) materials, such as brochures, ncreasing numbers of young ‘Edutainment,’ or the mix of wristbands and string bags people in Kiribati are getting STI education with entertainment, I with youth-friendly messages tests, thanks to an innovative has delivered results in and designs encouraging strategic health communication international contexts for many people to get tested. They are (SHC) campaign conducted by decades1 and has proved very in the process of evaluating the the Ministry of Health and local popular with Kiribati’s more than effectiveness of these products. NGOs, supported by technical 65,000 young people. ‘Everyone assistance from SPC’s Public is asking when the dance Health Division. competition will happen again,’ says Emaima Iotebwa, Field In April 2013, the Ministry Officer with the Kiribati HIV and of Health held a two-day STI Unit. street dance competition. Six groups competed. During the More than 1000 people watched competition, the Kiribati Family the dance performances, and Health Association and the over 100 samples were collected Kiribati Red Cross performed for HIV and chlamydia testing. dramas relating to condom use, The testing was made available STI testing and communication on site, with branded string bags skills. providing an additional incentive for young people to get tested.

1 http://www.comminit.com/edutain-africa/ ‘There was a lot of demand for Ms Iotebwa with the string bags. category/sites/africa/edutainment-africa testing because of the string

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civil society – they are more likely to be persuaded to adopt KFHA peer educators showcase the drama the behaviour being promoted. performances Too often, youth are bombarded they use to convey their sexual health with different messages from messages. different sources, leaving them confused as to what to do. One message repeated over time and by multiple sources is the key to behaviour change,’ says Ms Cave.

In keeping with a key principle of effective strategic health communication – that target audiences should be actively involved in campaign design – the committee also actively involved young people in campaign planning.

The old adage, ‘Nothing for us, make sure we support access to Too often, youth are without us’ is an important those services,’ says Ms Iotebwa. bombarded with different mantra in strategic health messages from different communication. When target The Kiribati STI campaign sources, leaving them audiences are involved in the committee responsible for the confused as to what to do. design and development of strategic health communication One message, repeated messages and materials from the campaign is made up of over time and by multiple start, the likelihood of impact on representatives from the Kiribati behaviour increases considerably. sources is key to behaviour Family Health Association, the In Kiribati, the brochures, change... Kiribati Red Cross, the Kiribati wristbands and string bags were Artistic Youth Association and designed during workshops with ‘A tracking survey will help us the Ministry of Health. young people. know if the IEC materials we developed have helped change A key aspect of the STI testing Kiribati’s SHC activities have been people’s behaviour or not,’ says and condom use campaign in funded by the Pacific Islands HIV Ms Iotebwa. Kiribati is the collaboration and STI Response Fund. between the Ministry of ‘This is very new to us. We now Health and local NGOs, says understand that we have to work Nicol Cave, Strategic Health with behaviour change of our Communication Team Leader at people. They have a high level of SPC. ‘All stakeholders have been knowledge of HIV; the problem involved in the planning, design, is behaviour change. We know implementation and monitoring we have to help them move from of the campaign since the start risky to safe behaviours, and to in 2011. This has allowed the do this they need more support, pooling of resources and skills such as condom negotiation and ensured that messages are skills. Knowledge is not enough. consistent. People need easy access to services and testing and they ‘When audiences receive the need skills. People know they same message from a range of Above: Uenikai Kouraiti, a lab technician at have to be tested and we need to sources – both government and Tungaru Central Hospital in Kiribati conducts HIV testing on blood samples.

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Stepping forward together: reaching at risk groups with peer education

Young women in Chuuk State, Federated States of Micronesia, complete a survey to help the Chuuk State Department of Health understand people’s knowledge, attitudes and ‘Mobile testing is behaviour in relation to sexual health, in an effort to aid prevention. important because most islands do not normally have access to HIV or STI testing. Making hrough the peer step, but others really the effort to go to them ‘Teducation programme, change (significantly).’ I learnt about youth, young means we can provide and STIs. I learnt how on the spot counselling, Young Chuukese women to help myself, how to change testing and treatment and exchanging sex for money my behaviour, how to step confidentiality is or goods are particularly forward.’ assured’ vulnerable, due to their social and economic status, low Violet Maka2 is a peer educator knowledge of prevention and with the Sex Workers Peer sex, while strengthening their high risk sexual behaviours. Educator’s Project, delivered peer-to-peer network to provide These include low levels of STI by Chuuk Women’s Council in mutual support. testing and condom use, early partnership with Chuuk State onset of sexual activity and the Health Services in Federated ‘When I talk to girls, they’re strong likelihood of them having States of Micronesia (FSM) – really interested (to learn about multiple sexual partners. 607 islands dotted across the HIV and other STIs). They don’t Northern Pacific. Funded by know how they can get it and According to a 2011 survey of the Pacific Islands HIV and STI they don’t know how to protect Chuukese women engaging in Response Fund, the project aims themselves,’ explains Violet. transactional sex, only 16 out of to reduce HIV and other STIs in the 68 women surveyed (29%) female sex workers and young ‘When I talk to them, I bring reported use of a condom with girls engaging in transactional condoms and brochures. Some their most recent client. Eight make a small change, step by women had ever had an STI test 2 Names have been changed

PASA No. 40 | October 2013 | 9 PREVENTION prior to the survey. And of these women, only three said they Strategic Increased knew the result of their test. Health knowledge of Communication HIV prevention Peer educators encourage young highlights in 2012 nowledge of HIV girls and women engaging in • New targeted multi- Ktransmission and transactional sex to use condoms media strategic health prevention has increased consistently and go for regular communication (SHC) significantly across the STI tests, running up to 20 peer- campaigns to increase region in the last decade. For example, HIV prevention to-peer education sessions each STI testing and consistent knowledge has significantly month. condom use launched in four PICTs (, Kiribati, increased among young Marshall Islands, Vanuatu) people in Solomon Islands Peer education programmes and Vanuatu. commonly target groups • 79,000 local language-, age- and culture-appropriate IEC considered to be at high risk In Solomon Islands, 88% of materials developed and young people in 2008 knew of HIV and other STIs, such distributed in 13 PICTs that abstinence, being faithful as young people engaging in • 121 radio spots produced and using a condom (or ABC) transactional or high risk sex. and aired in nine PICTs prevents HIV, as compared Over 24,000 young people in 13 with only 58% in 2005. In PICTs were reached with HIV/ • 37 TV spots produced and Vanuatu, more than eight out aired in three PICTs STI prevention messages through of ten young people in 2008 also knew that ABC prevents programmes such as this in 2012. • 12 dramas developed and field-tested prior to roll-out HIV, compared with less than to communities. Indigenous half of young people in 2005. Eleanor Setik Sos, Chuuk State’s forms of communicating HIV/ AIDS Coordinator says such as community theatre Increased prevention that the Peer Educator’s Project and drama are a powerful knowledge means that young has given young girls more tool to demonstrate to people are better equipped to protect themselves from HIV confidence to talk about their audiences the skills needed and other STIs. In Vanuatu, sex lives and come and collect to change and maintain new behaviours. for example, the latest data condoms. ‘Before they were show there has been an ashamed and thought they were • 222 youth under 25 almost 100% increase in only for boys,’ she explains. years of age participated youth reporting consistent directly in STI/HIV condom use between 2005 prevention campaign and 2008 – a behaviour that The project is unique due to strategy and IEC materials is key to reducing the spread the link between government development. Involving and transmission of HIV and and a strong local NGO. ‘By target populations in the other STIs in our region. working with Chuuk Women’s programming cycle of Council, we get access to our interventions aimed at them is critical to success. audience. At the Department of Health, we have the technical • 287 health workers and people and the funding. They volunteers trained in new approaches to behaviour have good identification and change communication, communication with the including social communities we serve. They give marketing, inter-personal us our audience.’ communication and community theatre ‘We see the importance, • Expansion of the regional usefulness and benefits of corps of SHC master working together. We learn trainers to seven trainers from them, they learn from us. through implementation of the Cross Pacific Together, we can achieve good Sharing and Skills Transfer SHC workshop participants in outcomes,’ says Ms Setik. Solomon Islands investigate condom Programme. use in the country.

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Highlights from HIV and STI counselling and diagnosis in the Pacific in 2012

Increased HIV testing due other settings, to reach high risk Improved chlamydia testing to improved voluntary, and vulnerable groups including and treatment confidential counselling and youth, sex workers, men who PICTs have also considerably testing have sex with men and seafarers. improved both reporting and The accreditation of an For example, in Cook Islands, performance in Chlamydia additional 23 sites offering 31% of youth have now been testing and treatment. The voluntary HIV counselling tested for HIV, up from 16% in number of chlamydia tests and testing, and the training 2006. SPC continues to encourage conducted and reported has of 80 health care workers to all PICTs to expand HIV testing increased by 46% from 12,806 in provide counselling and testing to reach high risk and vulnerable 2011 to 27,802 in 2012. contributed to a 39% increase in groups. HIV tests conducted across the One fifth of clients tested for Pacific region between 2011 and In-country HIV testing now chlamydia were found to be 2012. available positive. Treatment of those In-country HIV confirmatory found positive ranged from In 2011, 14,552 HIV tests testing is now available in 67% to 100%. Increasingly high were conducted in 13 PICTs, 100% of targeted PICTs (14), a treatment rates are contributing compared to 37,662 in 2012. All significant achievement since to curbing the long-term effects clients were counselled and 2010 when all of the targeted of chlamydia including pelvic tested in accordance with the PICTS were forced to send HIV inflammatory disease and Pacific essential standards for tests overseas for confirmation. infertility, as well as preventing HIV testing and counselling. -to-child transmission These standards ensure that Reliable in-country confirmatory and neonatal eye and lung health facilities fulfil minimum testing has resulted in a infections. acceptable standards including substantial reduction in Improved chlamydia testing and for physical factors, staff turn-around times for treatment has also been realised qualifications and confirmatory testing – as a result of an uninterrupted support, testing from three or four supply of materials required for and counselling Access A Guide to weeks to 24–48 STI testing in 2012. procedures Essential Standards hours. for HIV Testing and and protocols, Counselling in Pacific Island It is provision Countries and Territories of HIV on the SPC website. Go to anticipated results, data www.spc.int/hiv, click on that this will highlights management, ‘Downloads’ and then ‘HIV considerably • HIV testing increased client & STI Treatment, Care & decrease the 39% between 2011 and Counselling’. referral and numbers lost 2012. information, to follow-up after • HIV testing has been education and initial testing, and expanded to reach high- communication (IEC) increase HIV testing in the risk and vulnerable groups, including youth, sex materials. general population. Anecdotal workers, men who have sex evidence in a number of PICTs with men and seafarers. Previously, the majority of suggested that people were • In-country HIV HIV tests were conducted in hesitant to be tested because it confirmatory testing is took so long to receive results. antenatal care settings. A key now available in all achievement in 2012 has been targeted PICTs the expansion of HIV testing to

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STI control explained

STI burden STIs impose an enormous burden of morbidity and mortality in developing countries, both directly through their impact on reproductive and child health, and indirectly through their role in facilitating the sexual transmission of HIV infection. Chlamydia infections in particular may cause pelvic inflammatory disease, preterm labour and infertility.

There are four main treatable STIs under surveillance in the Pacific region: gonorrhoea, chlamydial infection, syphilis and trichomoniasis. Chlamydia is most common in the Pacific, with Rochelle Naulunimagiti poses for up to 30% of antenatal women a photo at Empower Pacific with an award for her achievement as found to have the STI in several a peer educator. Peer education is PICTs3 – among the highest rates an effective prevention strategy to help stop the spread of STIs, in the world. particularly for vulnerable groups such as sex workers. STI control Various methods have been used in an effort to screen and control management, and targeted the Oceania Society for Sexual STIs. These methods are well interventions such as periodic Health and HIV Medicine documented and range from presumptive treatment and mass (OSSHHM). behavioural methods, barrier treatment. methods, the use of vaccines, The technical working screening, STI case management, The Pacific Regional STI group developed eight partner notification and Working Group was established recommendations for STI control in 2006 to provide evidence- in the Pacific region4 as part of 3 Cliffe, S.J., Tabrizi, S. and Sullivan, E.A. 2008. based recommendations to a regional, comprehensive STI Chlamydia in the Pacific region, the silent epidemic. Sexually Transmitted Diseases 35(9): PICTs to help reduce the high control strategy. Two of these are 801–806. prevalence of STIs. The working discussed below. WHO, Antenatal clinic STI survey, Port Vila, Vanuatu. WHO Regional Office for the Western group is comprised of technical Pacific, 2000. Sullivan, E.A., Abel, M., Tabrizi, S., Garland S.M., specialists from SPC, the World STI screening Grice A., Poumerol G., Taleo H., Chen S., Kaun Health Organization (WHO), Universal screening of all Katimal, O’Leary M. et al. 2003. Prevalence of sexually transmitted infections among the Center for Disease Control antenatal clinic attendees for antenatal , 1999–2000. Sexually Transmitted Diseases 30(4): 362–366. and Prevention (CDC), the Sullivan, E.A., Koro S., Tabrizi S., Kaldor J., United Nations Children’s Fund Poumerol G., Chen S., O’Leary M., Garland 4 Ali, S. 2010. Breaking the silence: Responding S.M. 2004. Prevalence of sexually transmitted (UNICEF), the United Nations to the STI epidemic in the Pacific. Summary of diseases and human immunodeficiency virus Population Fund (UNFPA) and recommendations., Secretariat of the Pacific among women attending prenatal services in Community, UNICEF, WHO, UNFPA: New Apia, . Int J STD AIDS, 15(2): 116-119. Caledonia.

12 | PASA No. 40 | October 2013 COUNSELLING & TESTING syphilis is recommended by WHO. It is a highly cost-effective health intervention, even in settings where the burden of syphilis is low, and is also one of the four pillars of the global strategy to eliminate congenital syphilis.5

Periodic presumptive treatment approaches Periodic presumptive treatment A urine specimen is an intervention that has been jar is labeled by a successfully used to target key VCCT counselor in Bikenibeu, South populations at high risk of STI Tarawa. infection, who have multiple sex partners, and thus may be more likely to acquire and transmit mining community and in a blindness. This approach STIs. Treatment is provided group of female sex workers is currently being used in to individuals based on their living around the mine8. Six several PICTs.11 increased risk of exposure.6 It observational studies also is useful in situations where • The use of mass treatment confirmed earlier randomised infections are asymptomatic for yaws12, an infectious controlled trial findings that and/or sensitive screening tests disease caused by the periodic presumptive treatment are not affordable or feasible. reduces gonorrhoea and Periodic presumptive treatment chlamydia prevalence among sex has been used as one component Access the Summary workers.9 of a package of STI control of Recommendations interventions to rapidly reduce for STI Control 2010 on Mass treatment approaches STI prevalence, and has been Mass treatment approaches the SPC website. Go to shown to be useful through have been used for the rapid www.spc.int/hiv mathematical modelling,7 control of several infections at and click on especially in instances where STI the population level and are prevalence is high. ‘Downloads’, and then recommended by WHO. ‘Recommendations

For example, periodic for STI Control in the Here are some examples: presumptive treatment Pacific’. • The use of mass drug (azithromycin), coupled with administration with safe strategic health communication, oral anthelminthic drugs 8 Steen, R., Vuylsteke, B., DeCoito, T., Ralepeli, significantly reduced the S., Fehler, G., Conley, J., Bruckers, L., Dallabetta, (praziquantel, ivermectin prevalence of N gonorrhoeae, C G., Ballard, R. 2000. Evidence of declining and albendazole) for control STD prevalence in a South African mining trachomatis and genital ulcer community following a core-group intervention. of onchocerciasis, lymphatic Sexually Transmitted Diseases 27(1): 1–8. disease in a South African 9 Steen, R., Chersich, M. and de Vlas, S.J. filariasis and schistosomiasis. 2012. Periodic presumptive treatment of This approach is currently curable sexually transmitted infections 5 WHO, The Global elimination of congenital among sex workers: recent experience syphilis : rationale and strategy for action. being used in several PICTs.10 with implementation. Current Opinion in W.L.C.-i.-P. Data, Editor. 2007: Geneva. Infectious Diseases 25(1): 100–106. 10.1097/ 6 Steen, R. and Dallabetta, G. 1999. The use of • The use of mass treatment QCO.0b013e32834e9ad1. epidemiologic mass treatment and syndrome 10 Huppatz, C., Capuano, C., Palmer, K., Kelly, P.M. management for sexually transmitted disease for the control of trachoma and Durrheim, D.N. 2009. Lessons from the Pacific control. Sexually Transmitted Diseases 26(4): programme to eliminate lymphatic filariasis: a S12-S20. caused by the bacterium case study of 5 countries. BMC Infect Dis. 9: 92. 7 Vickerman, P., Ndowa, F., O’Farrell, N., Steen, R., Chlamydia trachomatis, 11 Mathew, A.A., Keeffe, J.E., Le Mesurier, R.T. Alary, M. and Delany-Moretlwe S. 2010. Using and Taylor, H.R. 2013. Trachoma in the Pacific mathematical modelling to estimate the impact which can cause a severe Islands: evidence from Trachoma Rapid of periodic presumptive treatment on the Assessment. Br J Ophthalmol, 2009. 93(7): transmission of sexually transmitted infections inflammation of the 866–870. and HIV among female sex workers. Sexually ocular surface, resulting in 12 Mitja, O., Asiedu, K. and Mabey, D. 2013. Yaws. Transmitted Infections 86(3): 163–168. The Lancet 381(9868): 763–773.

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bacterium Treponema pallidum pertenue, which closely resembles the causative agent of syphilis. It causes disfiguring, and sometimes painful lesions of the skin and bones. This approach is currently being used in several PICTs.13 • Although not as widespread, the mass treatment approach has also been used to control STIs. It has been shown to be an effective approach in

several studies. One study Sulia Nonu, the Chief shows significant reductions Infection Control officer at Nuku`alofa’s Vaiola in the prevalence of syphilis Hospital in Tonga practices her counselling skills and trichomonal infections during a training session in the general population;14 run by Empower Pacific. another shows significant reductions in the prevalence Although not as Pacific Island settings with of chlamydia, widespread, the mass small populations and gonorrhoeal treatment approach has discrete island geography. infections and genital also been used to control However, this approach ulcers in targeted, should be considered ‘at risk’ women in a STIs. It has been shown to be an effective approach in only if there are both the mining community. resources and the capacity several studies. A targeted mass to implement the campaign treatment programme in and sustain STI control Vancouver also provided measures – including primary oral azithromycin to control prevention and improved 15 an outbreak of syphilis. case management – as well as maintain access to STI

13 Capuano, C. and Ozaki, M. 2011. Yaws in • Cook Islands and Nauru health services. the Western Pacific region: a review of the recently conducted a mass literature. J Trop Med.: 642832. 14 Wawer, M.J., Gray, R.H. and Quinn, T. 1995. treatment campaign to AIDS intervention in Uganda. Science 270(5236): 564–565. reduce the prevalence of 15 Rekart, M.L., Patrick, D.M., Chakraborty, chlamydia. A significant drop B., Maginley, J.J., Jones, H.D., Bajdik, C.D., Pourbohloul, B. and Brunham, R.C. 2003. in chlamydia prevalence was Targeted mass treatment for syphilis with oral azithromycin. The Lancet 361(9354): 313–314. observed in Nauru – from 49% in 2009 to just 4% in 2012 – among antenatal clinic (ANC) women (with a coverage rate of 95%). In Cook Islands, a significant drop was also observed, from 20%16 to Azithromycin tablets at a VCCT clinic in 11.5%17 (with approximately Rarotonga, Cook Islands, for chlamydia. 55% coverage during the mass treatment campaign).

Lalit Prasad, Cook Islands • This approach is an effective 16 Cook Islands 2006 Second Generation Survey Red Cross counsellor. and 2009 routine testing data strategy for use in some 17 Cook Islands 2012 routine testing data

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Targeting Chlamydia: success in STI control in Cook Islands and Nauru

Ana File, Cook Islands Ministry of Health’s National HIV STI Coordinator, inside her Rarotonga office.

n some Pacific countries, as Nauru and Cook Islands, for ‘Advocacy and media Imany as one in two young example, where chlamydia has collaboration were the people have chlamydia, an been aggressively targeted, have underpinning pillars to the infection that, if left untreated, made considerable progress. In campaign, with special care can lead to serious reproductive 2009, 49% of pregnant women given to cultural and religious and other health problems. High in Nauru had chlamydia. In sensitivity. rates of sexually transmitted Cook Islands, it was one in infections also leave Pacific five. By 2012, the proportion of ‘Workshops were conducted Islanders particularly vulnerable pregnant women with chlamydia for all district leaders, youth, to HIV. in Nauru and the Cook Islands had dropped to 4% and 11.5% Patience Vainerere, an outer islands peer ‘If you have an STI, you are respectively. educator with Cook Islands Red Cross. at greater risk of HIV due to behavioural, biological and ‘In Nauru, STI control measures, gender-related factors,’ said Dr mass treatment for chlamydia, Dennie Iniakwala, HIV and STI coupled with community Team Leader at SPC. awareness and education were actively used to address high STI Despite the high rates of STIs rates, with a particular emphasis across the Pacific region, there on condom promotion’, said Dr have been significant successes. Seta Vatucawaqa, Director of Public Health at the Nauru Public Health Centre.

PASA No. 40 | October 2013 | 15 COUNSELLING & TESTING

women’s groups, church leaders, health workers, and people in work places. Brochures and posters were disseminated and key health officers gave TV interviews,’ said Dr Seta.

In Cook Islands, targeted strategic health communication campaigns are the first of eight components of the regional STI control strategy successfully implemented by the Polynesian nation. A second key component of this strategy is targeted population-based presumptive chlamydia treatment. Such presumptive treatment – whereby infection is presumed in people at high risk of infection

Disc jockeys George Williams, left, and Mii whether or not they show Taokia, work the airwaves from their radio symptoms – rapidly reduces the station 88 FM in Rarotonga, Cook Islands. The station has hosted many segments chlamydia rate in target groups. discussing HIV and other STIs. Such strategic health communication campaigns are the first of eight components of a comprehensive ‘Azithromycin was provided to STI control strategy successfully implemented by the Polynesian nation. the individuals with water, and they took the tablets on the spot. Booth style clinics were set up around the island so that people could drop in and Figure 1: Improvements in reducing Chlamydia in Cook Islands. take their medication,’ explains Source: IBBS survey and routine testing data. Population: antenatal clients. Cook Islands National HIV STI First locally Coordinator Ana File. diagnosed HIV case, VCCT SHC campaign, guidelines VCCT training, Prevention and STI control SHC developed, VCCT Accreditation activities across the Pacific, campaign sites established of VCCT sites, Targeted, including in Cook Islands and presumptive Nauru, have been supported by chlamydia treatment the Pacific Islands HIV and STI Response Fund. SHC campaign, Mobile testing outreach

“Aunty Kath”, Ritua Kath Koteka, long time nurse at Cook Islands Family Welfare Association.

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Faster diagnosis of STIs

An IATA-certified shipper packages samples for transport overseas from State, Federated States of Micronesia.

ine PICTs renewed their in this workshop; the first time ‘This is a dangerous prospect Ninternational licenses to that quarantine officers had been for any PICT, given the limited ship samples by air to reference included. number of airlines operating in laboratories this year, enabling the region, potentially prohibiting them to identify sexually The licensing enables certified PICTs from monitoring and transmitted infections (STIs) and PICTs to access laboratory testing responding to disease outbreaks other diseases, such as dengue overseas, when those services within their borders,’ says Mr fever, typhoid fever and measles, are not available at home. Toatu. more promptly. ‘It is very important that PICTs PICTs send 1000 to 2000 Initial and re-certification of 21 comply with IATA shipping samples every year to regional shippers was organised by SPC regulations and renew their reference laboratories in Fiji, and the Pacific Island Health licenses every two years so that Guam, New Caledonia, French Officers’ Association (PIHOA) they are able to send samples to Polynesia, Australia, New Zealand during a three-day workshop regional reference labs with more and for testing and on International Air Transport extensive testing capabilities,’ confirmation. Association (IATA) regulations says Mr Tebuka Toatu, HIV and for infectious substances, which STI Laboratory Specialist at SPC. The workshop was funded by took place on 13–15 June 2013 at the Pacific Islands HIV and STI SPC in Suva, Fiji. ‘If PICTs don’t comply with Response Fund and facilitated international regulations for the by the Pacific Public Health Participants included human and packaging and transportation of Laboratory Network (LabNet), animal health technicians from samples, airlines can refuse to a function of the Pacific Public Nauru, Kiribati, Tonga, Samoa, transport their samples and even Health Surveillance Network. SPC Tokelau, Vanuatu, Solomon blacklist them from shipping and PIHOA have been organising Islands, Tuvalu and Fiji. Two biological samples in future.’ IATA training courses for PICTs quarantine officers also took part since 2010.

PASA No. 40 | October 2013 | 17 TREATMENT

The guidelines were developed Part of the process: locally with the participation of the World Health Organization, the relevant, comprehensive STI United Nation Children’s Fund, the United Nations Population Fund, the Oceania Society for management guidelines Sexual Health and HIV Medicine, the Centers for Disease Control acific Island countries and The guidelines equip Pacific and Prevention and the College territories are better able ministries of health and clinics P of Medicine, Fiji National to address STI prevention, with information and skills University. diagnosis and treatment with the in syndromic diagnosis and completion of the Comprehensive treatment, education and The guidelines were launched in Sexually Transmitted Infections counselling, and recording and Nadi, Fiji on 11 September 2012 Management Guidelines published reporting, providing a holistic and were funded by the Pacific by SPC in 2012. and comprehensive approach to Islands HIV and STI Response STI management. Fund and the Global Fund for ‘The guidelines support health HIV, Malaria and Tuberculosis. care providers, ensuring that Syndromic diagnosis is diagnosis they manage STI cases in the based on the patient’s symptoms, best possible way,’ says Dr and can often be undertaken Access Sophaganine Ty Ali, SPC STI and during the patient’s first visit to Comprehensive Counselling Adviser. the clinic and later supported by laboratory testing, where Sexually Transmitted The guidelines are uniquely available. Infections Management adapted to the Pacific context, Guidelines on the SPC and were developed after It enables health care providers website. Go to extensive training and to treat patients on the spot, www.spc.int/hiv and consultation with ministries without waiting for the results click on ‘Downloads’, of health around the region. of time-consuming and costly ‘Recommendations Countries can now use them laboratory tests. This approach to support the development of helps to prevent the further for STI Control in their national STI treatment spread of STIs and reduces the Pacific’ and then guidelines. the risk of developing other ‘Comprehensive STI infections. Management’. ‘We were a part of the process; that’s why these guidelines are different. The islands are different, families are close together. It’s a small island, everyone knows everyone,’ says Nancy Lynn Edward, HIV/ STD Coordinator with the Department of Health in Pohnpei State, Federated States of Micronesia.

‘It’s good to have locally relevant, comprehensive, management guidelines to guide us in our work, because it helps us improve the health of our Former MSM peer educator people,’ says Mrs Edward. Peter Uhi at the Wan Smolbag clinic in Port Vila, Vanuatu.

18 | PASA No. 40 | October 2013 TREATMENT

Luke Nayasa, HIV advocate and Fiji’s 2012 National Volunteer of the Year, at home with his family in Fiji.

Treatment is my life now: Experiences of treatments among people living with HIV in Pacific Island countries and territories

he Pacific Islands AIDS Funded by the Pacific Islands TFoundation (PIAF) and the HIV and STI Response Fund, the Cook Islands National HIV, STI & The study summarises study was launched in Fiji on 27 TB Committee have completed a the results of qualitative June 2013. study describing the treatment research examining experiences of HIV positive In total, 49 PLHIV were people in Fiji, Guam, Kiribati, reasons for initiating, interviewed: 23 in Fiji, 11 in Samoa and Solomon Islands. continuing and ceasing Guam, 2 in Kiribati, 5 in Samoa treatment among People and 8 in Solomon Islands. The study summarises the results of qualitative research Living with HIV (PLHIV) Most respondents said that examining reasons for initiating, in the Pacific Islands. ART had an immensely positive continuing and ceasing The research focuses impact on their lives because treatment among People Living it increased their strength and specifically on diagnosis with HIV (PLHIV) in the Pacific helped them to regain their Islands. The research focuses and medications, health health, prolonging life and specifically on diagnosis and services, anti-retroviral giving them hope. However, they medications, health services, treatment (ART) also noted adverse side effects anti-retroviral treatment (ART) associated with ART, as well as adherence, alternative therapies, adherence, alternative challenges relating to adherence and attitudes to treatment. therapies, and attitudes and access to health services. PLHIV were involved as peer to treatment. researchers. Immediate family, partners and children, who reminded the

PASA No. 40 | October 2013 | 19 TREATMENT

Luke Nayasa, HIV advocate and Fiji Network Plus (FJN+) member, with his family outside their home in Fiji. FJN+ is a non- government organisation that provides support to people living with HIV.

Immediate family, partners and children, who reminded the respondents to take their medication and provided food, comfort and emotional support, enabled them that medication is family support in treatment to adhere to their available to treat HIV, adherence; but that it is a lifetime treatment. • funding and supporting commitment; PLHIV network organisations • educating PLHIV about so that they are able to HIV treatment so they continue to offer support respondents understand the benefits of to PLHIV, their families and to take their medication and ART, how to cope with side communities; provided food, comfort and effects, the purpose of CD4 emotional support, enabled them • ensure that ministries of and viral load testing and the to adhere to their treatment. health integrate the cost of support available to them: ART into health budgets; • continuing to train and More than half of the • conduct further research on build the capacities of respondents saw a link between HIV treatment adherence. their religious faith and their Pacific health workers to treatment. Some felt that their understand the importance faith had strengthened after of offering confidential, being diagnosed and receiving non-judgemental care and treatment and some viewed support to PLHIV; Access the faith and treatment as being • improving access to ART and complementary in supporting CD4 and viral load testing; complete report on them to live. the SPC website. Go to • ensuring that families of www.spc.int/hiv and PLHIV are educated about The report’s recommendations click on ‘Downloads’, include: how HIV is and is not and then ‘HIV & STI • providing more information transmitted, the role and that addresses fears of dying importance of ART for PLHIV Treatment, Care & so that people understand and the significance of Counselling’

20 | PASA No. 40 | October 2013 ENABLING ENVIRONMENT

concrete lessons, and spiritual as The guide was developed as Trend setters well as practical advice. part of the Transformational Leadership Development and leaders: ‘To be able to reach our goal of Programme (TLDP), delivered zero new infections we will need by the Joint United Nations full openness. We need to allow Programme on HIV/AIDS faith-based ourselves to talk about HIV and (UNAIDS) and the United Nations what causes transmission. And, Development Programme organisations equally important, what does not Pacific Centre, and funded by cause transmission,’ said Knut the Pacific Islands HIV and STI respond to Ostby, UN Resident Coordinator, Response Fund. TLDP empowers at the launch of the guide in Fiji individuals to take action on HIV on 13 December 2012. issues such as stigma and discrimination, human rights, Pacific Guide on Responding ‘To avoid a hidden transmission and gender, and includes to HIV for Christian Ministers, A of the disease we need to fully sessions on positive thinking, Pastors and Communities, launched accept our fellow human beings leadership and communication in December 2012, is being who are HIV infected as exactly skills. snapped up by communities what they are – as human beings. around the Pacific. An additional 1200 copies have had to be Fiji launched its Inter- ‘For this to happen, we need the Faith Strategy on HIV & printed by the UNAIDS Pacific full involvement by people across AIDS in 2012, highlighting Office responsible for its all walks of life. This is exactly the directions that faith- production, due to high demand. where faith-based organisations based organisations are willing to take in order to play a key role. Faith-based The guide provides a set of prevent HIV transmission organisations are trendsetters; simple lessons that are intended in key populations. These they are leaders, and they often include: to be tools in the hands of set standards for what can be priests, pastors and Christian • prevent mother-to- discussed and how. ministers in order to raise child transmission, transmission among awareness and provide advice ‘With your commitment, we can youth, and in the general and support to those affected reach people from all walks of population; by HIV from a strong religious life; we can get knowledge and • provide care and support platform. It contains seven messages out to those who need to people living WITH them,’ said Mr Ostby. HIV/AIDS; • provide capacity Faith-based building for faith-based organisations organisations in this work. are trendsetters; they are leaders, and they often set Access the Pacific Guide standards for what on Responding to HIV for can be discussed Christian Ministers, Pastors and Communities and Fiji’s and how. Inter-Faith Strategy on HIV & AIDS 2013-7 on the SPC website. Go to www.spc.int/ hiv and click on ‘Downloads’, and then ‘Enabling Environment’. Alternatively, contact the UNAIDS Pacific Office in Fiji for a hard copy TLDP graduate Reverend Taniela Balenaikorodawa inside a chapel at www.unaids.org.fj or at Davuilevu Theological College, Fiji, where he lectures. (679) 3310 480 / 3310 481.

PASA No. 40 | October 2013 | 21 ENABLING ENVIRONMENT

Port Vila’s picturesque deep harbour, Vanuatu.

Tackling stigma and discrimination in the workplace

n mainstreaming HIV prevention gender relations. The workplace treatment, care and support Ibeyond the health sector, the provides a context and avenue services for workers and their workplace has been recognized through which new knowledge families, and create an enabling as an important locale within and values can be introduced working environment for all. which to implement a response and shared, in turn reaching to the epidemic. In an effort families, peers and communities. to share achievements and Boys fish at North lessons learned, the article The ILO, the World Health Tarawa, Kiribati. below presents a brief Organization, and the Joint summary of the end of project United Nations Programme on evaluation of ‘Pacific Island HIV and AIDS (UNAIDS) provide workplaces combating HIV/ comprehensive frameworks to AIDS’ – a project implemented guide national action on HIV and by the International Labour the workplace. Organization (ILO) and funded by the Pacific Islands HIV and Some of these frameworks stand STI Response Fund from 2012 to alone, while others are integrated 2013. into existing workplace and occupational health and safety Prevailing societal values, norms policies for the protection of and prejudices are present in the workers. The relevance of any workplace, not only in relation of these is the extent to which to the perception of diseases they assist in facilitating access such as HIV, but also in terms of to appropriate HIV prevention,

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The objectives of the project were twofold:

To improve the lives of working women and men by reducing discrimination and stigma associated with HIV and AIDS, through the establishment of effective national and workplace policies and programmes on HIV.

To encourage working women and men to embrace known or presumed HIV positive workmates, change their behaviours and attitudes and, over time, also encourage their communities, churches and villages not to stigmatise or discriminate against people living with HIV.

Key achievements Recommendations

• Thirty-five HIV workplace policies • The project should maintain funding drafted in seven PICTs (Fiji, Kiribati, support to the PNG Development Law Marshall Islands, Samoa, Solomon Association, in collaboration with Islands, Tuvalu, Vanuatu) with a joint the PNG Trade Union Congress, to communiqué developed between the continue with a landmark case that ILO and the Department of Labour examines the termination of an HIV and Industrial Relations in Papua New positive worker in PNG. The case will Guinea (PNG). have important implications on HIV and the world of work in Pacific Island • Both national and enterprise countries. level targets were reached in eight PICTs. • Provide immediate technical assistance • 563 individuals trained The workplace provides to support the in 17 workshops, to a context and avenue implementation of improve HIV and through which new finalised HIV workplace gender knowledge, knowledge and values can policies. and capacity in be introduced and shared, drafting HIV related in turn reaching families, • Provide further workplace policies. peers and communities. training to selected officers at the PNG and • Three HIV workplace Fiji Ministry/Department of policies were finalised Labour. and launched, including at the Fiji Corrections Services, • Provide co-ordinated technical the Fiji Trades Union Congress, and a assistance in PNG, to undertake an national memorandum of agreement audit of all existing HIV and workplace between the PNG Employers’ Federation policies and ensure coherence. and the PNG Trade Union Congress, together with a finalised employment • A second phase of the project, if award. An employment award is a set available, should further emphasise of employment terms and conditions gender inequality and the link to HIV agreed between an employer and a transmission. group of employees, which apply either to particular workplaces, industries or groups of employees.

PASA No. 40 | October 2013 | 23 RESEARCH

HIV in the Pacific: 2012 epidemiology Members of Vanuatu’s MSM community show off their new t-shirts, his summary of the 2012 provided to participants HIV epidemiological after a Wan Smolbag focus T group discussion on the update provides an overview organisation’s popular Love of estimated HIV prevalence, Patrol TV series. new HIV infections per year, cumulative HIV cases and transmission routes. It also offers Figure 1: Newly detected HIV cases in 21 Pacific Island countries and territories and four selected Pacific Island countries and territories: 2000–2012 recommendations. It was current as at 31 December 2012.

Data for this update was obtained from the reports provided by all 22 SPC Pacific Island countries and territories (PICTs) to the Secretariat of the Pacific Community, the Joint United Nations Programme on HIV/AIDS (UNAIDS) 2012 country progress reports for ten countries,1 and country- specific annual reports. Trends are shown for 21 PICTs (Figure 1) to enable readers to obtain a better regional perspective. Since data for Papua New Guinea (PNG) was not available after 2010, the Estimated HIV prevalence: Niue, Pitcairn and Tokelau) had report includes data from the Excluding PNG, there is a very no people living with HIV. The smaller 21 PICTs only. 2 low HIV prevalence3 across estimated prevalence among the region, even from targeted adults aged 15–49 years in the surveys among key populations. remaining 16 Pacific Island Fiji and Vanuatu recently countries and territories (PICTs) Summary of HIV cases by Pacific Island countries and territories, as of 31 December 2012 conducted surveys among men is low, less than 0.1%. having sex with men (MSM)

and sex workers. Fiji found a 1 UNAIDS progress report (Fiji, Federated States prevalence of 0.5% among MSM, of Micronesia, Kiribati, , Republic of the Marshall Islands, Samoa, Solomon Islands, a prevalence of 0.7% among all Tonga, Tuvalu, Vanuatu) 2 Data for PNG go up to Dec 2010, Australia up to sex workers and a prevalence Dec. 2011. For the other PICTs, data go up to 31 of 1.8% among transgender sex December 2012. 3 The term ‘low-level epidemic’ is used for workers. In Vanuatu no HIV cases epidemics where HIV prevalence has not consistently exceeded 1% in the general were detected among MSM and population nationally, nor 5% in any sub- female sex workers who were population. 4 One possible explanation for the higher surveyed. number of cases detected in 2011 could be the increase in targeted testing taking place. Countries that have reported the largest At 31 December 2012, five number of infections also have the most widespread voluntary confidential counselling countries (Cook Islands, Nauru, and testing (VCCT) facilities.

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New HIV infections each year: cases, whilst six countries Figure 2: People living with HIV by PICT as of 31 December 2012 The number of new HIV cases (, Cook in these 21 PICTs has slowly Islands, Nauru, Palau, increased over the past 12 years, Vanuatu, and Wallis and ranging from a low of 57 in 2003 Futuna) have had fewer to a high of 119 in 2012 (Figure than ten reported cases. 1).4 Diagnoses in the 21 PICTs, excluding PNG, rose over the Transmission routes: last two years from 68 in 2010, The primary mode of HIV to 98 in 2011 to 119 in 2012. This transmission in the 21 PICTs has been driven by more cases (excluding PNG) is heterosexual being reported in Fiji and New contact, with over half (52%) of Caledonia (Figure 2). There were all HIV infections attributed to this route (Figure 3). Over one- no new HIV cases detected in 13 Figure 3: Modes of HIV transmission across PICTs in 2012. quarter (27%) of HIV infections 21 PICTs are via men who have sex with • In Samoa, Solomon Islands, men. However, it is important Tonga and Vanuatu, there to note that the main reported were nine new HIV diagnoses mode of transmission of HIV in 2012. differs across countries. • In the Federated States of For example, when looking Micronesia (FSM), Kiribati, at combined data from three Marshall Islands, Palau, territories (, Samoa, Solomon Islands and Guam and New Caledonia) Vanuatu, there were nine new with relatively similar reported HIV diagnoses in 2011. modes of transmission, the main • In Australia, the number of reported mode of transmission and French Polynesia, there are new HIV diagnoses in 2011 was observed to be sexual more male HIV diagnosed cases was 1137. The annual number contact between males at reported. In Fiji, approximately of new HIV diagnoses has 43%, followed by heterosexual half of their diagnosed cases increased slightly over contact at 32%. This was in were female. the past ten years, but is sharp contrast to Fiji, which relatively modest when we cumulatively reported8 only 2.5% Future perspectives: More consider population increase. of cases due to sexual contact targeted surveillance and testing between males and the main • In New Zealand, there were of potential high-risk groups is mode of transmission reported 124 new HIV diagnoses in required, as well as expansion as heterosexual contact at 86%. 2012. of voluntary confidential counselling and testing sites. Cumulative HIV cases: Diagnosis by gender: HIV There is also a need to review diagnosis varies by country. • Since 1984, a total of 1,737 and update national policies Despite higher testing among HIV cases have been reported. to be in line with the new females in Guam, New Caledonia The cumulative HIV cases WHO recommendations, along in Fiji5, New Caledonia,6 with a review of patients not 5 5UNAIDS progress report, Fiji 7 currently on ART to determine French Polynesia and Guam 6 Agence Sanitaire et Sociale de Nouvelle Calédonie, and Direction des Affaires Sanitaires et Sociales whether they need to be placed represent 85% of all reported 7 Guam HIV surveillance report, February 2012 cases, with only 254 cases 8 According to the 2012 Fiji Global AIDS on it, based on these new progress report, community groups informing guidelines. More attention needs (15%) from the remaining 14 development of the 2012–2015 national strategic plan noted that the severe stigmatisation of to be paid to implementing PICTs. sex work and sex between men may mean that people under-report their involvement in these recommendations from the STI • Three countries (Niue, behaviours. control strategy9 and reducing 9 Breaking the silence: Responding to the STI Pitcairn and Tokelau) have epidemic in the Pacific, 2010 the very high prevalence of other 10 not had any reported HIV The Pacific responds to STIs: progress made 10 (2008–2011). InformAction 35, May 2012 STIs, in particular chlamydia.

PASA No. 40 | October 2013 | 25 RESEARCH

Know your epidemic

Access the complete 2011 and 2012 HIV epidemiological updates on the SPC website. Go to www. spc.int/hiv and click on ‘Downloads’, ‘HIV & STI Surveillance’ and then

A young visits the recently built ‘Routine Surveillance’. hospital in Gizo, Solomon Islands.

elow, we present a summary strengthening HIV integration Bof selected, recently- into global health and released reports examining the development efforts. epidemiology of HIV and other STIs in the Pacific region, as well The Pacific Islands HIV and as knowledge, attitudes and risk STI Response Fund supported behaviour. the preparation of these AIDS progress reports in partnership Behavioural surveys, conducted Global AIDS Response with a number of ministries at regular intervals, provide Progress Reporting (2012) of health including: Vanuatu, Official reports submitted by important information that Fiji, Kiribati, Tuvalu, Tonga and countries to UNAIDS monitor can be used to assess risk, Samoa. progress towards the targets set improve or evaluate the success in the 2011 Political Declaration of a programme, inform on HIV/AIDS. This includes, for policy making, or raise public example, targets on reducing awareness. It is important to Access these sexual transmission of HIV, note when analysing behavioural reports on the SPC eliminating new HIV infections surveys that they focus on what among children, accessing website. Go to www. people say they do. In other treatment, eliminating gender spc.int/hiv and click on words, data collection is based on inequalities, eliminating ‘Downloads’, and then self-reported behaviour. stigma and discrimination, and ‘HIV & STI Surveillance’.

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the last six months. 80% of number of female HIV/AIDS forced sex was by someone diagnoses has been relatively close to the person. stable during this ten-year period (an average of one case per year); • High alcohol consumption male cases have averaged four with 73% of youth consuming per year for the last ten years. alcohol in the past year, down from 80% in 2006. 61% Those most affected by HIV/ of youth under 18 years had AIDS were between 30 – 39 consumed alcohol in the past and 40 – 49 years of age at year. Behavioural Surveillance diagnosis, followed closely by Survey Among Youth in the • Low transactional sex with individuals between the ages of Cook Islands (2012) 8% having paid for sex and 20 – 29. Pacific Islanders are the This survey aimed to assess 10% paid to have sex. predominant race affected by HIV/AIDS on Guam as they make the knowledge, attitudes and • Reported illicit drug use was up more than half of all cases risk behaviours among youth generally very low. However, in Cook Islands in order to (66%). 19 respondents reported use identify how to deliver targeted of injecting drugs (heroin and Male-to-male sexual contact interventions to reduce the risk cocaine), 13 of whom had (MSM) remains the most of HIV and STI infections. A total been off-island in the past frequently reported mode of 674 youth were recruited from year. of transmission associated various islands in the country. with HIV/AIDS, followed by The research was funded by heterosexual contact. Forty-six the Pacific Islands HIV and percent of all HIV/AIDS cases STI Response Fund. Some key diagnosed from 2003 to 2012 findings are given below. reported having male-to-male sexual relations. • There was an encouraging

increase in HIV testing and In the past two years, efforts receipt of results. 31% of have been expanded to include youth had been tested in targeted HIV rapid testing among 2012, up from 16% in 2006. Guam HIV Surveillance MSM and targeted outreach • Participants acquired Report (2013) through MSM peer networks. knowledge about sex from Between 2003 and 2012, 92 cases Surveillance data for injecting a variety of sources. The of HIV/AIDS were diagnosed/ drug users and sex workers is most useful sources reported reported on Guam. There is a limited. Strategies to address being lovers, followed by sex significant gender disparity in these key populations are being education in school. the diagnosis of HIV/AIDS. The pursued. • Behaviours that place

youth at risk include early Warming up before a game sexual debut with 40% of with MSM in Port Vila, Vanuatu. youth having had sexual intercourse before reaching 15 years of age. This is an increase from the 31% observed during the 2006 survey. Low condom use at first sex was reported, at 42%. • Almost a quarter of the participants reported ever having had forced sex, and 12% reported forced sex in

PASA No. 40 | October 2013 | 27 RESEARCH

Sex work and HIV/STI prevention in the Pacific region, including analysis of the needs of, and lessons learnt from, programmes in four selected countries (2013)

This University of New South Wales research report consists of a review of literature on sex work in the Pacific, as well as international literature on sex work and HIV prevention. It is based on key informant interviews with staff in regional agencies, and stakeholders and programme implementers in Fiji, Vanuatu, Kiribati and Chuuk State (Federated States of Micronesia). It is intended as a resource to inform the development of effective HIV and STI prevention programming for sex workers in the Pacific region. It was funded by the Pacific Islands HIV and STI Response Fund.

Key features of effective HIV/STI • motivations and concerns are often prevention programmes for sex different for transgender sex workers workers include: than for women sex workers, and often differ between ethnicities; • access to condoms and lubricant, • transgender sex workers tend to be where sex work occurs; more concerned with stigma and • access to accurate risk reduction discrimination; information and HIV/ STI testing and • female sex workers tend to be more treatment services; concerned with being able to safely • confidential, safe, free; earn an adequate income;

• peer education and outreach; • The leadership of individuals who champion the needs and rights of sex • sex worker organisations and networks workers is crucial. supported and well resourced; Current needs are: • HIV/STI testing services are less stigmatising when provided as part of • more extensive, regular and reliable a package with other health or welfare condoms, personal lubricant and services; outreach services; • a supportive enabling environment • access to safe, non-judgemental and fostered through public and service confidential sexual health services; provider attitudes, policing and the operation of the justice system, policy • ongoing training and support for peer and the law. educators;

The report found that in the Pacific: • inclusion of sex workers in processes of decision making at a range of levels; • sex work takes a range of forms, • addressing structural factors that and conditions under which it is create vulnerability in order to confront undertaken vary between and within stigma and discrimination, prevent PICTs; abuse and violence, and promote • not all those who sell sex identify as a an enabling environment for HIV sex worker; prevention activities.

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indicator was high and

Two boys climb a coconut tree was primarily pulled down in South Tarawa, Kiribati. by thinking HIV can be transmitted via mosquitoes. • There is a wide variance regarding methods that have been successful in reaching the MSM community. This should be taken into Access these account for future education reports on the SPC campaigns. website. Go to www. • A high proportion of spc.int/hiv and click on participants reported that ‘Downloads’, and then it was possible to get a ‘HIV & STI Surveillance’. confidential HIV test and 71% had been tested at some point in their life. However, only slightly less than half • Relatively high tobacco, (48%) received pre- and marijuana and betel nut use. post-test counselling, while Lower use of hard drugs. approximately two thirds (69%) received their HIV test • 175 participants used alcohol result. The remaining 30% in the last 12 months. The did not return for their HIV frequency of alcohol use results. among those that used alcohol was relatively high, Other upcoming reports include: and units consumed were Vanuatu Integrated Biological high with 40% consuming five Guam MSM behavioural and Behavioural Survey with or more drinks at one time. survey (2008) sex workers; Vanuatu Integrated A total of 212 men who have • 35% (74) participants Biological and Behavioural sex with men (MSM) were correctly identified all five Survey with MSM; a secondary surveyed between January ways of preventing the analysis of SGS surveys from 2007 and January 2008 in order sexual transmission of Vanuatu and Kiribati; Fiji to obtain baseline data on HIV, and rejected common Integrated Biological and demographic characteristics, misconceptions about HIV Behavioural Survey with sex sexual behaviours, substance use transmission. Individual workers; Health in Prisons in Fiji. and HIV knowledge and attitudes correct responses to in Guam. Some key findings are components of this UNGASS given below.

• The median age at first sex A family harvests watermelon in Tonga. was 16. • There was relatively low condom use (40%) at last sex with a male partner. • Approximately half (47%) of participants had travelled out of Guam in the last year and, of those, 58% had sex with a non-partner while off island.

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Involving everyone: improving national strategic planning in the Pacific

North Tarawa, Kiribati. The focus was on developing and he Federated States of are based on lessons supporting national TMicronesia (FSM), Solomon learned over four coordinating mechanisms, Islands, Kiribati, Tonga, Cook years of supporting National Strategic Plans (NSP) Islands and the Marshall Islands leadership in Pacific and national monitoring and have developed skills in national Island Countries, from evaluation frameworks that strategic planning for more 2009 to 2012, and aim to: are relevant to country effective responses to the HIV needs. and other STIs, with the support • Build national teams to of the Burnet Institute, SPC lead the responses to HIV and the Joint United Nations and STIs Programme on HIV/AIDS • Ensure that planning (UNAIDS), funded by the Pacific The resources promote takes account of evidence, Islands HIV and STI Response meaningful and sustained including the results of Fund. participation by all stakeholders research and people’s own and ensure that the most experiences The focus was on developing and vulnerable people can enjoy supporting national coordinating • Strengthen political confidence and respect from mechanisms, National Strategic commitment others during the planning Plans (NSP) and national • Enable shared planning process. monitoring and evaluation by groups of people from frameworks that are relevant to governments, community country needs. groups, vulnerable Access resources populations, and people who for improving national The Burnet Institute, an live on both capitol and outer Australian research body, islands. responses to HIV and developed resources describing other STIs on the SPC how to bring together The project developed some new website. Go to government leaders, community processes to develop national www.spc.int/hiv and leaders and health experts strategic frameworks. This set of click on ‘Downloads’, to develop more effective resources includes these options then ‘National Strategic prevention, treatment and and examples but not a set of Plans’. care strategies. The resources fixed methods.

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Curriculum workshops took Building capacity and place in Cook Islands and Tonga. This training covered basic M&E improving sustainability for definitions, setting goals and objectives, and the program logic model of planning and M&E, M&E in the Pacific and was directed at improving the capacity of national egionally delivered technical STI Response Fund. In 2011, a programs to collate, analyse, ‘Rassistance should focus on training-of-trainers curriculum synthesize, triangulate and in-country transfer of knowledge on the Fundamentals of M&E effectively communicate data and skills and enable the sharing was adapted for the Pacific. It and information from disparate of experiences between Pacific was first piloted in Tonga with sources, to facilitate program Islands countries wherever 3 sub-regional trainings of improvement and sound public possible. This will foster an trainers taking place in Fiji, New health decision making. environment that is conducive Zealand and Guam in 2011.These to sustainable programming trainers were then mentored The in-country delivery of and cooperation between and supported to deliver M & E this training was conducted countries, in any field of work, training in their own countries. with the support of SPC and especially in support of the They were provided with UNAIDS. In some cases, these delivery of regional public goods resources, such as a trainees’ trainers travelled to another and services,’ says Dr Dennie work book, a facilitator’s guide country to co- facilitate M &E Iniakwala, HIV & STI Team and a PowerPoint presentation training, as they became more Leader at the Secretariat of the for each of the nine modules of knowledgeable about certain Pacific Community (SPC). the curriculum. modules.

One example is the technical National rollouts of the Participants were drawn assistance in monitoring and Fundamentals of M&E training from various government evaluation (M&E) delivered took place in Guam, Kiribati, sectors, including civil society by SPC and the Joint United Niue, Fiji, Solomon Islands, organisations. Jill Julienne Nations Programme on HIV/ Vanuatu, Palau and the Republic Wai, M&E Officer with Youth AIDS (UNAIDS), with the support of the Marshall Islands, Challenge Vanuatu and one of of the Pacific Islands HIV and while advanced applied M&E the workshop participants, says she appreciated the ‘wonderful time of learning, sharing and An unnamed woman provides a sample for chlamydia skills gained from the M&E testing at Rove clinic in training, with words of wisdom, Honiara, Solomon Islands. encouragement and most of all the knowledge about M&E’.

Access the Fundamentals in Monitoring and Evaluation Curriculum for Pacific Island Countries on the SPC website. Go to www. spc.int/hiv and click on ‘Downloads’, and then ‘Monitoring and Evaluation’.

PASA No. 40 | October 2013 | 31 GOVERNANCE

Renewing the sexual health 2013 sees the end response in the Pacific: the of the implementation of the second Pacific Pacific Sexual Health and Regional Strategy on HIV and other STIs 2009–2013 Well-being Shared Agenda (PRSIP II). As it comes to an end, PICTs, regional partners and donors are discussing

A bus delivers a the way forward beyond group of staff to 2013. Tungaru Central Hospital, Kiribati.

any successes have been support. Programmes have also chlamydia in 6 Pacific countries Machieved in the STI and been established that engage and territories (PICTs) were HIV response over the past five parliamentarians as advocates found to be infected in 2004/5.20 years. Prevention and education for HIV and STI responses.18,19 Syphilis rates are worrying, programmes have been particularly congenital syphilis, conducted across the region. Despite this, high rates of STIs, which leads to 650,000 foetal Regional and national laboratory low condom use, a high level and neonatal deaths a year in and clinical services have of gender-based violence and developing countries around the been strengthened, improving sexual assault, and as well as world.21 The Pacific is committed capacities to diagnose, treat and other sexual health issues, are to the global pledge to eliminate monitor HIV and other STIs. driving a renewed response to congenital syphilis. Further, the There has been an increase sexual health in the Pacific. human papillomavirus (HPV) in the number of health care which causes cancer is an workers trained in HIV and STI STI rates are hyper-endemic. emerging issue in the region.22 prevention, diagnosis, testing and For example, as many as 26.1% Whilst the HIV epidemic in PICTs counselling, treatment, care and of antenatal women tested for remains low at less than 0.1%

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New SPC Public Health Division Strategy SPC’s Public Health Division (PHD) is in the process of developing and adopting a new strategy setting out the future priorities and direction of the division (2013–2022). Amongst other priorities, Representatives of civil society it includes prevention and organisations working directly with at risk groups such as women, youth, and control priorities for STIs lesbian, gay, bisexual, transgender and intersex people take part in a consultation (including HIV) becoming on the Pacific Sexual Health andW ell-being part of a broader sexual and Shared Agenda in Fiji in August 2013. reproductive health (SRH) and well-being approach in the (excluding Papua New Guinea), Women found rates of violence region. the region is off track to achieve against women as high as 80% Millennium Development Goal in some countries.24 Gender- An important component six, which is ‘to have halted by based violence and forced sex of PHD’s new strategy 2015 and begun to reverse the perpetuate the spread of STIs, is the introduction of a spread of HIV/AIDs’.23 In the including HIV, and affect sexual regional public goods (RPGs) Pacific, HIV rates continue to and reproductive well-being. framework that will inform increase every year. Fear of violence can make the design and delivery women less likely to negotiate of specific public health Other sexual health issues in safe sexual practices and may interventions. the Pacific enhance the risk of also deter women from seeking transmission of STIs, including a test or disclosing their HIV PHD uses the term regional HIV, and are of concern in status.25 public goods to denote public their own right. The region health services that are most has alarmingly high levels of Early sexual debut, early effectively and efficiently gender-based violence and forced marriage and teen pregnancy provided through cooperation sex. A study conducted by UN are common in the Pacific26 and collective action by two and can affect the physical or more countries, realising

18 O’Loughlin, B. 2013. Mid Term Review: Pacific and psychological health of all economies of scale and/ Regional Strategy on HIV and STIs (2009–2013). involved. or improved results. PHD 19 Wanyeki, I., Ty-Ali, S. and Toatu, T. 2012. The Pacific responds to STIs: Progress made provides, coordinates and (2008–2011). Inform Action 35. 20 Cliffe, S. J., et al. (2008). “Chlamydia in the With PRSIP II coming to a close, builds expertise, specialist Pacific region, the silent epidemic.” Sex Transm it is critical that momentum resources and technical Dis 35(9): 801-806. 21 WHO. Advancing MDGs 4,5 and 6: Impact on is maintained and built on to assistance which would be congenital syphilis elimination. WHO/RHR/ HRP/10.01. improve the sexual health and more expensive and less 22 Kuehn, R., Fong, J., Taylor, R., Gyaneshwar, R. well-being of people living in impactful if provided by and Carter, K. 2012. Cervical cancer incidence and mortality in Fiji 2003–2009. Australian the Pacific. In March this year, single countries. and New Zealand Journal of Obstetrics and Gynaecology 52: 380–386. the Secretariat of the Pacific 23 2011 Pacific Regional MDGs Tracking Report. Community, with support Access the new PHD strategy Pacific Islands Forum Secretariat. 24 Ending and girls: from UNAIDS, WHO, UNICEF as soon as it becomes Evidence, data and knowledge in Pacific Island countries. 2011. UN WOMEN. and UNFPA, held consultation available on the SPC website. 25 UNDP Pacific Centre, UN WOMEN Pacific workshops in Fiji and Guam with Visit www.spc.int/php/ Centre, SPC, 2009. 26 I feel I can never get infected. Understanding STI/HIV and reproductive health HIV and AIDs risk and vulnerability. 2010. UNICEF. programme coordinators and

PASA No. 40 | October 2013 | 33 GOVERNANCE

OUR VOYAGE In November 2013, Our Voyage: Stories of triumph in the response to HIV and other STIs in the Pacific, a photography book highlighting successes and challenges in the response to HIV and other STIs in the region will be launched in Suva, Fiji.

Through the photography book and accompanying mini exhibition, we follow personal stories illustrating the significant impact the Pacific Islands HIV and STI Response Representatives of civil society organisations during a consultation on the Fund has had on the lives of Pacific Sexual Health and Well-being Shared Agenda in Fiji in August 2013. Pacific peoples.

The exhibition and The purpose of the agenda is to provide shared photography book have regional targets for sexual health improvement and been produced by the Pacific Response Fund Committee a clear focus for sexual health programmes in the and the Secretariat of Pacific, so as to achieve the goal of improved sexual the Pacific Community. health and well-being of Pacific Island peoples by 2018. Email the Joint Secretariat at PRFCSecretariat@ jointsecretariat.net to doctors from 17 PICTs, to enable achieve the goal of improved request a copy. them to share their country sexual health and well-being of needs and priorities. Participants Pacific Island peoples by 2018. Evaluations are also currently agreed that there is a need for under way throughout the a further collective regional Three key strategic directions Pacific region in an effort response. emerged from the workshops, to further reflect on the which have shaped the shared achievements, lessons As a result, the Pacific Sexual agenda. learned and impact of the Health and Well-being Shared Pacific Islands HIV and STI Agenda is currently being 1. There is a need to take Response Fund. developed in consultation a more comprehensive with governments, key ‘at approach to sexual and risk’ populations, civil reproductive health in the society organisations, region. By strengthening, UN agencies, and linking and integrating HIV/ other stakeholders. STI services and programmes The purpose of the into those for tuberculosis, agenda is to provide primary health care, and shared regional targets sexual and reproductive for sexual health health, it is expected there improvement and a will be greater success in clear focus for sexual improving the sexual health health programmes of Pacific populations. This in the Pacific, so as to includes strengthening links

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with gender-based violence 3. There are certain populations and youth services. that are at greater risk of poor Joint sexual health, including HIV Secretariat 2. A number of socio-economic and other STIs. It was felt factors, such as gender news that more attention should inequality, culture and The Joint Secretariat was be paid to these populations tradition, legislation, stigma established in early 2011 and that interventions should and discrimination, were to support the work of two be tailored accordingly. identified as barriers to regional governing bodies - sexual health and well-being. the Pacific Islands Regional In order to improve sexual Multi-Country Coordinating health in the long term a Mechanism (PIRMCCM), greater focus needs to be which oversees Global placed on these areas. Fund grants for HIV, TB and malaria, and the Pacific Response Fund Committee (PRFC), governing the Pacific Islands HIV and STI Response Fund.

The Joint Secretariat publishes quarterly newsletters that are linked to the Joint Secretariat website. These newsletters provide updates on current PRFC and PIRMCCM events, feature your real life stories, and include pictures and blogs of our Men walk down a work. street in Kiribati.

Sign up and receive updates from the Joint Secretariat on a quarterly basis. Go to www.jointsecretariat.net, Have scroll to the bottom of the page and simply fill in your name and email address your say to subscribe to the Joint Secretariat Newsletter. What do you think are the main sexual health problems in the Once the email subscription Pacific region? How can we improve is complete, an email will be sent to the address you the sexual health and well-being of people entered. In this email is a living in Pacific countries and territories? confirmation link. Click on Email Michelle O’Connor, PRSIP Coordination this link to confirm your subscription. We look forward and Liaison Officer, Secretariat of the Pacific to your feedback! Community, at [email protected].

PASA No. 40 | October 2013 | 35 Keep Informed Share your story: Keep updated and contribute to contribute to PASA discussions on issues related to HIV and other STIs in the Pacific. Join the We love to hear from you! Share your AIDSTOK email discussion list! experiences, successes and lessons Go to www.spc.int/hiv and click on learned in the response to HIV and ‘AIDSTOK Network.’ other STIs in the Pacific, and have your story published in PASA. Email: [email protected].

PASA distribution list SPC’s Public Health Division is currently updating the PASA newsletter distribution list. If you would like to receive a hard copy of PASA or update your mailing address, please send your name, organisation and mailing address to [email protected]

A member of the Tonga Leitis Association (TLA) poses for a photo during a break at the TLA 2013 Annual Retreat.

© Secretariat of the Pacific Community, 2013– Original text: English PASA, The Pacific AIDS Alert Bulletin is a newsletter of the Secretariat of the Pacific Community (SPC) HIV & STI Section. Website: www.spc.int/hiv – For more information or to be kept updated of PASA news email: [email protected] Edited by Jacinta Isaacs. Photography by Sitthixay Ditthavong except where noted (photos on pages 3, 6, 7 (bottom), 9, 10, 17 by Jacinta Isaacs). Illustrations by Boris Colas. Layout and design by Ultimo Group, NZ. Printed by Star Printery, Suva. The opinions expressed in articles in this magazine are those of the authors of the articles and are not necessarily endorsed by SPC. The use of a photo in this publication does not imply anything about the person’s HIV status. Reproduction of this material whole or in part in any form is encouraged, provided that SPC and the source document are properly acknowledged. Original SPC artwork may not be altered or separately published without permission.