Table of Contents
Foreword…………………………………...... iii Acknowledgements……………………… ...... vi Abbreviations……………………………… ...... vii Executive Summary……………………… ...... vii Introduction………………………………… ...... 1 Section I: Background…………………… ...... 2 1.1 Contexts of the epidemic ...... 2 1.2 Summary of the national response ...... 3 1.3 Contexts of the official estimates and projections ...... 5 1.4 Previous consensus workshops ...... 5 Section II: Overview of Surveillance System and Data ...... 6 2.1 Routine Surveillance ...... 6 2.1.1 Routine HIV case reporting of HIV/AIDS ...... 6 2.1.2 Distribution of HIV infection by age ...... 8 2.1.3 Province of Detection ...... 8 2.1.4 Mode of Transmission ...... 9 2.1.5 Routine STI case reporting...... 10 2.1.6 HIV infection Among Blood Donors ...... 11 2.1.7 HIV infection among VCT clients ...... 11 2.2 Sentinel surveillance of HIV infection ...... 12 2.2.1 Antenatal Clinics (ANC) ...... 12 2.2.2 STI clinics ...... 14 2.2.3. HIV in TB Patients...... 15 2.3 Behavioural Surveillance Surveys and Other Behavioural Research ... 16 2.3.1 Behavioural Surveillance Surveys (BSS) 2006 ...... 16 2.3.2 Behavioural surveys using RDS ...... 17 Sex Workers ...... 17 Men who have sex with men ...... 18 2.3.3 Consensus Workshop Behavioural Surveillance Working Group .. 18 2.4 Hospital experience with HIV and Antiretroviral Therapy (ART) ...... 19 Section III: Updated Estimation of HIV prevalence...... 20 3.1 Previous methods of estimating the HIV prevalence ...... 20 3.1.1 Workbook ...... 21 3.2 Process for estimating HIV infection in PNG ...... 21 3.3 Methodology and assumptions for 2007 estimations ...... 21 3.3.1 Methodology ...... 21 3.1.1.1 Estimation and Projection Package (EPP) ...... 22 3.1.1.2 Spectrum ...... 22 3.3.2 Data Used ...... 23 3.3.3 Methods and assumptions ...... 23 3.3.4 Quality of Data ...... 24 3.3.5 New estimates: the new face of the epidemic ...... 25 3.5 Comparison between new and old estimates ...... 26 3.6 Update and Projection of key HIV Indicators ...... 28 Conclusions and Recommendations…………...... 30 References………………………………...... 33 Appendix 1: Participant Lists……………...... 36
ii
Lists of Tables
Table 1: New and Cumulative HIV infections detected in Papua New Guinea, 1987 - 2006 ...... 7 Table 2: HIV infections reported in Papua New Guinea, 1987–2006, by mode of transmission ...... 9 Table 3: ANC Antenatal HIV Prevalence, Urban Sites 2002-2006 ...... 13 Table 4: ANC Antenatal HIV Prevalence, Rural Sites 2002-2006 ...... 14 Table 5: HIV Prevalence in STI Clinics, 2002-2006…. ………………………..15 Table 6: Organizations involvement and contribution in ART Program……...19 Table 7: Assumptions and errors in adult HIV prevalence estimates in generalized epidemics using EPP………………………………………………..23 Table 8: Estimated HIV Prevalence……………………………………………...25 Table 9: Previous and new estimates of HIV prevalence in PNG………….…27 Table 10: Update and projection of key indicators on the HIV epidemic….…29
List of Figures
Figure 1: New and cumulative annually reported HIV infections in Papua New Guinea, 1987–2006…………………………………………………………………7 Figure 2: HIV infections detected in PNG by age, 1987 – 2006………………..8 Figure 3: HIV infections reported in Papua New Guinea, by province of detection 1987 – 2006………………………………………………………………9 Figure 4: HIV Testing Amongst Blood Donors, 2002-2006……………….…...11 Figure 5: HIV tests conducted amongst VCT clients 2002 – 2006…… …….12 Figure 6: TB testing by year 2002 – 2006………………………………………16 Figure 7: Quality of global sero-surveillance system quality…………………………………………………………………………...... 24 Figure 8: Urban, Rural and National trends in the HIV Epidemic in PNG……26 Figure 9: HIV prevalence in ANC from Port Moresby General Hospital 1992 – 2006…………………………………………………………………..……………..28
List of Charts
Chart 1: Data and tools used for estimation and projection in generalized epidemics………………………………………….………………………………..22
iii Foreword
It is my pleasure to introduce this milestone HIV and AIDS Estimation Report for 2007, developed by the National AIDS Council Secretariat and the National Department of Health. The compilation of this report is an important step in the provision of strategic information for the national response to the HIV epidemic.
This document provides updated information on the HIV situation in the country and these data are the cornerstone for planning, resource allocation, advocacy, and HIV policy formulation, in addition to the design of prevention, behaviour change, treatment, care and support programs in Papua New Guinea.
The compilation of this report satisfies one of the key objectives of the government through the National AIDS Council and the National Department of Health to provide up to date information on the HIV epidemic so that all stakeholders can access and use this information to plan and implement their response to HIV.
The data used in this report were collected from STI, HIV, ANC and TB clinics, VCT sites and behavioural surveillance sites. About 4,017 people tested HIV positive in 2006; 30% more than in 2005. Sero-surveillance sites showed an increase in prevalence levels with the total number of reported HIV infections reaching 18,484 by the end of 2006.
Despite the lack of comprehensive information about the age and sex of people diagnosed with HIV, as age was not recorded in one-third of the data; where age was recorded, the majority of HIV infections were in people aged between 20 and 35, with higher numbers of HIV infections found in female youth and younger women. According to the data available, the most common age at diagnosis for men is in the 25-29 and 30-34 year age groups, with 60% of all infections in males under the age of 35 and three quarters below the age of 40. More female youth and young women are diagnosed with an HIV infection at an earlier age particularly in the 20-24 and 25-29 year old groups, with 61% of infections by the age of 29, over three quarters of infections diagnosed by the age of 34, and 94% by the age of 44.
The national HIV prevalence is estimated to be 1.28% among adults aged 15- 49 at the end of 2006, which means there are about 46,275 people estimated to be living with HIV. The trend of the epidemic is showing a high increase, especially in rural areas where 85% of the PNG population lives. It is projected that starting in 2007 the prevalence among the rural population will become higher than in urban areas. The new 2006 prevalence estimate, when compared to previous estimates, show that while the prevalence is lower than what has been previously estimated; the trends in the epidemic are increasing more sharply than what has been previously documented.
iv Other projections in this report estimate that in 2007, 3,700 people will die of AIDS. Increased numbers of people dying of AIDS continue to impact on the vulnerability of children and youth, and it is projected that in 2007, 3730 children (0-17) will be orphaned due to AIDS.
These alarming statistics are a cause of grave concern for the government and we are mobilizing all of our resources to minimize the impact of the HIV epidemic on people‟s lives in rural and urban areas. The current HIV reporting system has suffered from serious weaknesses and a large amount of resources have now been mobilized to support the strengthening of the national surveillance system through the implementation of the 1st National Surveillance Plan 2007-2010. This will improve the quality of HIV surveillance data so that changes in the HIV epidemic can be monitored more closely, and resources and strategies allocated more effectively for HIV prevention, treatment, care and support.
I am confident that this 2007 HIV Estimation Report and the information provided by the National Surveillance Plan will assist in ensuring a continuous improvement in the quality and amount of data, and an increase in the understanding and dissemination of information about the HIV situation in PNG. This information will assist in ensuring that the scale up strategies for the response to HIV are accessible and equitable for all, are gender sensitive, and include measures to ensure that there is no stigma, discrimination or barriers for people living with HIV or for those from other more vulnerable populations.
This Estimation Report provides surveillance data until December 2006, with estimations and projections based on these, to enable us to provide the most up to date data for all stakeholders to plan their response. Understanding trends in HIV infections and HIV risk related behaviours allows us to create a more evidence based response to HIV. I recommend that the official data and information provided here, be disseminated to all sectors and stakeholders.
Finally I would like to thank the Surveillance Technical Working Group, ADB, AusAID, CBSC, Clinton Foundation, FHI, GFATM, NACS, NDOH, NRI, WHO, UNAIDS, UNDP, UNFPA, UNICEF and all other partners and stakeholders who supported the NDOH to develop and compile this report.
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Hon. Sir Peter Barter, Kt, OBE, MP Minister for Health, Bougainville Affairs and Minister assisting the Prime Minister on HIV
v Acknowledgements
The National AIDS Council and the National Department of Health would like to express their sincere gratitude to all who have actively contributed towards the development of this important HIV estimation report.
We thank those who collected the surveillance data and those who provided technical assistance and guidance in the collection and analysis of data, and in the development and preparation of this document. We acknowledge ADB, AusAID, CBSC, Clinton Foundation, FHI, GFATM, IMR, NACS, NDOH, NRI, UNAIDS, UNDP, UNFPA, UNICEF, WHO, Provincial Hospitals and Provincial Health Administrations. Particular gratitude is extended to the National Department of Health and technical specialists from partners for their invaluable contributions and insights.
Special appreciation is noted to the core working group and writing team and the Surveillance Technical Working Group who coordinated and developed the drafts, provided editorial comments and efforts, and to the team who created communication strategies for the dissemination of this estimation report.
This report was compiled with data collected and gathered from all the surveillance sites in the country. The final numerical data were then generated using the most up-to-date modeling software and methods used globally by the WHO and UNAIDS to produce the estimations and projections of HIV prevalence and of its impact at country levels.
The information provided in this estimation report is to guide planners and all stakeholders to plan HIV interventions that will decrease the further growth in HIV prevalence and to mitigate the impact of the epidemic in PNG.
Finally, I look forward to the implementation of the recommendations of this estimation report and the 1st National Surveillance Plan 2007-2010, and to the implementation of interventions that will be implemented for the benefit of our people, the majority of whom live in rural areas.
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Dr Clement Malau Secretary for Health
vi Abbreviations
ADB Asian Development Bank AIDS Acquired Immunodeficiency Syndrome ANC Antenatal clinic ART Anti-Retroviral Therapy AusAID Australian Agency for International Development BAHA Businesses Against HIV and AIDS BSS Behavioural Surveillance Surveys CBSC Capacity Building Service Centre DMS Director of Medical Services EPP Estimation and Projection Package FBO Faith Based Organization FHI Family Health International GFATM Global Fund to fight AIDS, TB and Malaria HAMP HIV/AIDS Management and Prevention Act HEO Health Extension Officer HIV Human Immunodeficiency Virus HRC HIV Response Coordinator IMAI Integrated Management of Adults and Adolescent Illness IMR Institute of Medical Research MLT Medical Laboratory Technician MSW Male Sex Workers NAC National AIDS Council NACS National AIDS Council Secretariat NCD National Capital District NDOH National Department of Health NGO Non Government Organization NHASP National HIV/AIDS Support Project NHIS National Health Information System NRI National Research Institute NSO National Statistical Office PAC Provincial AIDS Committee PDCO Provincial Disease Control Officer PLO Provincial Liaison Officer PLWHA People Living with HIV/AIDS PMGH Port Moresby General Hospital PMTCT Prevention of Mother to Child Transmission PNG Papua New Guinea PNGDF Papua New Guinea Defense Force RDS Respondent Driven Sampling SPC South Pacific Commission STI Sexually Transmitted Infection STWG Surveillance Technical Working TB Tuberculosis UNAIDS Joint United Nations Program on HIV/AIDS UNDP United Nations Development Program UNICEF United Nations Children Fund UPNG University of Papua New Guinea VCT Voluntary Counseling and Testing WHO World Health Organization
vii Executive Summary
Since 2000, national consensus workshops have been organized by the National AIDS Council Secretariat and the National Department of Health to estimate the level of HIV prevalence in Papua New Guinea. Consensus workshops were organized in 2000, 2004 and 2007 and these have provided a good opportunity to analyze available data and to formulate recommendations to improve the national surveillance system.
From the 19th to the 23rd of March 2007, groups of partners and field officers participated in consecutive meetings held in Lae, including a data collectors‟ workshop, an HIV and STI surveillance planning workshop, and the 3rd national consensus workshop. Participants looked at the available data and recommended a formation of a core working team from the Surveillance Technical Working Group (STWG), who in collaboration with international experts would estimate the HIV prevalence of PNG, using the most up to date tools and methodologies.
Data collected from the different surveillance sites, including VCT (voluntary counseling and testing), ANC (antenatal clinic) and TB (tuberculosis), are showing a high increase in the level of the epidemic in Papua New Guinea. The total number of reported HIV infections reached 18,484 by the end of 2006. For 2006 alone, there were 4,017 people who tested positive, 30% more than 2005.
The reporting system for HIV suffers from serious weaknesses; for instance, in the majority of the reported HIV infections, information regarding mode of transmission was not recorded, while data on age, sex and province of origin are not always systematically recorded. Only two-thirds of the data on individuals had age recorded. For the majority of these, most people were aged between 20 and 35; with many more females infected at an earlier age than males. Many more females were diagnosed with infections at an earlier age than males, with 61% by the age of 29; while 60% of infections in males are diagnosed by the age of 35. HIV infections have been detected in all provinces of PNG, with most of the reported infections diagnosed in Port Moresby.
Behavioral surveys conducted in recent years have documented that certain sexual behaviours create high risk for HIV transmission, through unprotected anal and vaginal sex between men and women and unprotected anal sex between men. They also found condom use is inconsistent. The exchange and sale of sex by female and male adults and youth; sexual violence, including gang rape; and multiple sexual partners, including polygamous relationships, are prevalent. Economic, political and socio-cultural contexts are characterized by unemployment and poverty, high population mobility, gender inequity and misconceptions about HIV transmission, and stigma and discrimination towards people living with HIV; these heighten risk and vulnerability to HIV infection.
viii
UNAIDS and WHO have developed computer software for making estimates and projections of the magnitude and impact of HIV and AIDS at a country level. These software use a standardized model to estimate HIV prevalence depending on the level of the epidemic. Among these are the Estimation and Projection Package (EPP) and Spectrum.
For PNG, the core working group to make HIV prevalence estimations comprised of technical staff from NDOH, NACS, WHO and UNAIDS. They used EPP and Spectrum to estimate the level and trend of HIV prevalence based on existing data from a large number of ANC sites from both urban and rural areas. For the first time, the data available came from 29 ANC sites representing rural and urban Government facilities and Catholic Health services. This was a good opportunity to generate separate estimates for urban and rural epidemics.
At the end of 2006, the national HIV prevalence was estimated to be 1.28% among youth and adults aged 15-49, with an estimated 46,275 people living with HIV in PNG. The new 2006 estimates, when compared to previous estimates, show lower prevalence; however these new estimates have a steeper increasing trend than what has been documented before. All other HIV related indicators also project increases in 2007 in the numbers of new infections, in the numbers of AIDS related deaths and in the numbers of orphans (0-17 years). The trend of the epidemic is projected to greatly increase, especially in the rural areas where 85% of the PNG population lives. It is projected that from 2007, the prevalence among rural populations will become higher than the urban prevalence with the numbers of people requiring treatment projected to also increase.
With regards to the estimated increasing trend in the epidemic among the population living in rural areas, it is crucial to develop effective strategies and targeted interventions to reduce the spread of HIV. It is also important to further strengthen national efforts for the scaling up of VCT, prevention, care, support and treatment throughout the country among both the general population and groups most at risk.
From the results and the lessons learned from this estimation and projection process, it is recommended that improvements be made in the surveillance system through the implementation of the 1st National Surveillance Plan 2007 - 2010, which incorporates recommendations from the 3rd Consensus Workshop and this estimation report. Some other recommendations are to: conduct bio-behavioral surveys to provide a clearer picture of the characteristics and level of the epidemic in the general population and with groups at higher risk; improve technical and financial support to the PMTCT program; prioritize sites and targets for behavioural and sentinel sero- surveillance research through analysis of existing data and criteria; strengthen central and provincial coordination mechanisms and partnerships; increase technical and resource support to provincial laboratories and data collectors; and form provincial surveillance and monitoring and evaluation teams.
ix Introduction
The first diagnosis of HIV infection in Papua New Guinea (PNG) was reported in 1987. Since that time, the numbers of people diagnosed and living with HIV and AIDS has risen continuously. In 2003, when HIV prevalence among antenatal women in the Port Moresby General Hospital passed 1.05%, PNG became the fourth country in the Asia Pacific region to have a generalized HIV epidemic (NAC and NHASP, 2004).
As of the end of December 2006, a cumulative total of 18,484 people have been diagnosed with HIV infection; 8530 (46%) infections were in males, 8824 (48%) in females, and 1130 or 6% of infections were in individuals whose sex was not reported. HIV has been diagnosed from every province, with 61% percent of all HIV infections reported from NCD, 17% from the Western Highland Province, 6% from Morobe, 4% from the Eastern Highlands Province, and the remaining 12% distributed across all other provinces.
Of those people who tested HIV positive by the end of 2006, data was not reported for the majority [9,709 (52.53%)] as to whether they were classified with HIV infection or with an AIDS defining illness at the time of their diagnosis. From the data that are available, just over a third (6,666; 36.06%) presented with an AIDS defining illness at the time of diagnosis, and 2,109 (11.41%) people were classified with HIV infection. Much remains unknown about people living with HIV or AIDS at the time of their diagnosis and their treatment needs. Currently, there is no formal notification system for AIDS or HIV-related deaths (NACS and NDOH, 2006).
The 1st National Consensus Workshop was held in 2000 and it was estimated that the total number of people living with HIV in PNG was in the range of 10,000 to 15,000. The report of the workshop subsequently became an important resource document for those involved in PNG‟s response to HIV and AIDS (MOH et al. 2000). The 2nd Consensus Workshop Report provides a review of data available on the occurrence of HIV, AIDS and sexually transmitted infections (STI), and on social and behavioural factors that influence the dynamics of epidemics in PNG. The report summarises workshop outcomes, including estimates of the number of people living with HIV infection in PNG, while providing recommendations for improving the national HIV and STI surveillance systems. In 2004, it was estimated that there were between 25,000 to 69,000 people infected with HIV in the country, with a median estimate of 47,000. This translates to a median adult prevalence of 1.7% (NAC and NHASP, 2004).
From March 19th to the 23rd 2007, using the most recent and more surveillance data than has ever been available before, groups of partners participated in consecutive meetings held in Lae, including a Data Collectors workshop, a STI/HIV Surveillance Planning Workshop, and the 3rd Consensus Workshop (see Appendix 1: Participant List). Surveillance data and statistics collected until the end of December 2006 were presented, questioned, verified and discussed during the 2007 Data Collectors and Consensus workshops,
1 and recommendations to improve and strengthen the national surveillance system were made and incorporated into the 1st National Surveillance Plan 2007-2010. After the Consensus Workshop, a team from the Department of Health, the WHO and UNAIDS worked with the ANC surveillance data during their participation in an international workshop on HIV estimates and projections held in Bangkok in April 2007.
This 2007 Estimation Report provides an update of the HIV epidemic in Papua New Guinea. Section I, provides a background on the PNG national response, the contexts of official estimations and projections, and outlines data from previous consensus workshops. Section II outlines the most recent epidemiological data on routine case reporting of HIV and AIDS, sentinel surveillance data from ANC, STI and TB clinics, and behavioural surveillance data. Section III provides the most recent official HIV estimations and projections based on the ANC data set.
Official estimations and projections should be used as a common reference for all stakeholders to report on the epidemic, and to develop informed strategies and plans to reduce the spread of the epidemic nation wide. The estimated values, determined this year through valid methodologies and improved data, will also be used for 2008 UNGASS report regarding the level of the epidemic in PNG.
Section I: Background
1.1 Contexts of the epidemic The spread of HIV in PNG is fuelled by individual practices and behaviours and complex social, cultural, health, economic and political contexts. PNG has experienced great socio-cultural and economic changes and continues to experience changes with urbanization, mobility, increased travel and increased access to communication and global flows of images and information (Clark, 1997; Hughes, 2002; O‟Collins, 1986; Jenkins, in press). Unemployment is high, particularly for young people, contributing to the sale and exchange of sex for cash and other services or goods in urban and rural areas (Jenkins, in press; Levantis, 2000); while corruption can result in the inequitable distribution of resources and poverty (Government of Australia, 2006). Drug and alcohol use is widespread, and marijuana and alcohol use have been linked to not using condoms and to sexual violence (Jenkins and Alpers, 1996; NACS and NHASP, 2007; NHASP, 2003).
Gender inequity is normative, physical and sexual violence are prevalent, including line up or gang rape, and child sexual exploitation and child abuse occur. This creates heightened risk of HIV transmission through diminished power to negotiate condom use and through biological vulnerability and physical trauma from forced sexual violence (Bradley and Kesno, 2000; Help Resources, 2005; Humanity Foundation, 2003; Lewis et al., 2006; NSRRT and Jenkins, 1994; UNICEF PNG, 2006).
2 There is heightened risk of HIV transmission through certain sexual practices, including: early sexual debut; multiple premarital and extramarital sex partners; unprotected anal and vaginal sex between men and women and unprotected anal sex between men; inconsistent condom use during the exchange or sale of sex by female and male youth, men and women; sexual violence including gang rape; and in some areas the use of penile inserts or products which dry the vagina (Jenkins, 1997a; Jenkins,1997b; Jenkins, in press; Maibani-Mitchie, 2005; Mgone et al., 2002; NAC, 2005a; NACS and NHASP, 2007; NHASP, 2006; NSRRT and Jenkins, 1994; Yeka et al 2006).
Poverty, high population mobility and areas of intensive rural economic development contribute to higher risk situations and increases in the exchange and sale of sex (NAC, 2005b; NACS and NHASP, 2007; NHASP, 2006). The transmission of HIV is heightened through unprotected anal and vaginal sex between men and women and unprotected anal sex between men, within networks that include a range of male and female partners, including those who exchange or sell sex, regular and marital partners, including polygamous relationships, and casual non-commercial sexual partners (IMR, 2007; NACS and NHASP, 2007; Maibani, 2005).
There is a high prevalence of untreated sexually transmitted infections in the general population and in higher risk groups, including syphilis, trichomoniasis, chlamydia, syphilis and gonorrhea, increasing the probability of HIV transmission during unprotected sex (MOH et al., 2000; IMR, 2007; Mgone et al., 1999; Mgone et al., 2002; NAC, 2005a).
The impact of HIV and AIDS is being felt at a number of different levels, including at personal, familial, social, cultural, economic, legal and political levels. Misconceptions about HIV transmission and AIDS continue to create stigma and discrimination towards people living with HIV (Lewis et al., 2006). An integrated national response is required to address the impact of HIV at many different levels.
1.2 Summary of the national response Over the last twenty years, the HIV epidemic in PNG has significantly and consistently increased, demanding more efforts and strategic directions to contain a fast growing epidemic and provide treatment, care and support to those living with HIV and those affected. Even though response to the epidemic by government and various organizations has been varied, the National Department of Health (NDOH) and the National AIDS Council Secretariat (NACS) have been instrumental in taking leading roles in addressing the epidemic.
The national government‟s response is demonstrated by the creation of the National AIDS Council Act 1997, followed by the 1998-2002 National Medium Term Plan, and more recently, the PNG National Strategic Plan on HIV/AIDS 2006-2010 (NAC, 2006). Other important milestones in the national response include the establishment of:
3 the National AIDS Council (NAC) and its secretariat (NACS); the Provincial AIDS Councils (PAC) and their secretariats (PACS) and memoranda of understanding with provincial governments; the Special Parliamentary Committee on HIV/AIDS; the NEC Directive – Decision No. 124/2004 – which moved the National AIDS Council to the Prime Minister‟s Department; and the endorsement of the HIV/AIDS Management and Prevention (HAMP) Act 2003 (NACS, 2004).
The establishment of Provincial and District AIDS Councils (PAC and DAC respectively) are key committees that coordinate the response to HIV and AIDS at provincial and district levels. These committees are focal points for coordination and mobilization of provinces on HIV and AIDS and related issues.
The national response encompasses a multi-partner and multi-sectoral approach to the HIV epidemic. Partners in the national response, include, people living with HIV, faith based organizations, civil society organizations, national and international NGOs, the government and the private sector and economic enclaves. Development and donor partners are also key players in the national response.
The government has intensified its efforts in its response to HIV and AIDS through the 2006-2010 National Strategic Plan (NSP). In search for a more holistic and effective national response, the NSP identifies and provides strategic plans for seven focal areas for five years. These priority areas include: 1) treatment, counseling, care and support; 2) education and prevention; 3) epidemiology and surveillance; 4) social and behavioural change research; 5) leadership, partnership and coordination; 6) family and community; and 7) monitoring and evaluation. This report will highlight the epidemiology and surveillance component.
Component Three, epidemiology and surveillance, takes a Second Generation Surveillance approach. Surveillance is a Department of Health driven focus area to track the trends and characteristics of the epidemic, by collecting, analyzing and reporting STI, HIV and behavioural data. Current activities in the surveillance response have been: the consensus workshop and international projection and estimation workshop; the writing of this 2007 Consensus Report; the writing of the 1st National Surveillance Plan 2007 – 2010; the transition of surveillance activities from NACS to the NDOH; and the establishment of the surveillance units at the NDOH and NRI. The selection of 2007 surveillance sites and targets will frame the ongoing activities which include: the routine case reporting of HIV, AIDS and STI and sentinel sero- surveillance and behavioural surveillance research in the general population and with key populations at higher risk, in collaboration with the NDOH, the National Research Institute (NRI) and other research institutions.
4 1.3 Contexts of the official estimates and projections Strong leadership from government is important in the collection, dissemination and use of HIV, AIDS, STI and behavioural surveillance data. The National Department of Health now takes the leadership role, in collaboration with the WHO, UNAIDS, NACS, research institutes and other partners. This role is demonstrated through developing and implementing surveillance, in writing this 2007 Estimation Report and the 1st National Surveillance Plan, and in disseminating present and future research findings. A surveillance unit at the NDOH and a behavioural surveillance research unit at the NRI are being established, and a surveillance technical working group consisting of a large range of expertise, guide and support the NDOH and their partners.
The estimates and projections presented here by the NDOH, with assistance from NACS and development partners, should be viewed and used as the official national figures. There are many partners involved in using data at the field level for implementing programs and the use of “official” statistics by all stakeholders will ensure consistency of information.
The current estimates and projections that are presented in section III of this report are the best official estimations and projections produced to date for a number of reasons. They are derived from more antenatal clinic (ANC) data than has ever been available before, and from far more sites (both urban and rural) than previous estimates. As further discussed in section III, the estimation model used for the calculation of official national rates is internationally accepted and standardized, is much more robust than other previous models, is continuously being improved annually, and is well suited for estimating HIV infections in generalized epidemics, such as in PNG.
1.4 Previous consensus workshops In May 2000, the first National Consensus workshop was held in Port Moresby by the National AIDS Council and the National Department of Health, and was facilitated and supported by WHO and AusAID. The goal of the workshop was to bring together and consider epidemiological information on the occurrence of STI, HIV, and AIDS, with social and behavioural data. The first National Consensus Workshop estimated the national HIV prevalence to be 0.7% and the total number of people living with HIV infections in PNG was estimated to be in the range of 10,000 to 15,000. The estimates ranged from 5,500 to 22,000 depending on the lowest and highest prevalence used (MOH et al. 2000).
In 2004, four years after the first consensus meeting, the second National Consensus Workshop was held. This time more new data was available. The meeting estimated that there were between 25,000 to 69,000 people infected with HIV in the country, with a median estimate of 47,000. This translated to an adult prevalence of 0.9 % to 2.5%, with a median of 1.7% (NAC, 2005).
The workshop participants discussed a number of challenges and issues for Papua New Guinea‟s surveillance system to monitor HIV, AIDS, STI and
5 behavioural data. The participants unanimously made strong recommendations to the national government in several key areas, in the hope that adequate resources and commitment could be allocated for surveillance, such a key component of the national HIV response.
In 2006, the Workbook Program was used to do a mid-term estimate with 2005 data. Because of the lack of trend data for ANC in rural and urban areas, the working group agreed to apply the Workbook Method for HIV estimation by region. A meeting among key stakeholders was organized and moderated by the NDOH to discuss and agree on the estimate results preliminarily prepared by the Working Group; to ensure the submission of new estimates to the Global UNAIDS/WHO estimates Group; and to refine recommendations for an improved surveillance system in the future. The group estimated HIV prevalence ranging from 0.8% to 3.2%, with an estimated 57,000 of the population infected and a median prevalence of 2%. They drafted recommendations for improved data collection based on the gaps in data that were identified.
The reports of the consensus workshops have become very useful and important resources in Papua New Guinea‟s response to HIV for advocacy, policy and planning, and in surveillance development. Recommendations from consensus workshops have been instrumental to creating change within the surveillance system and in enhancing data quality, and are integrated into the 1st National Surveillance Plan 2007 – 2010 that is presently being developed.
Section II: Overview of Surveillance System and Data
2.1 Routine Surveillance 2.1.1 Routine HIV case reporting of HIV/AIDS The reporting of HIV positive tests is managed through the HIV/STI Surveillance Unit under the Department of Health, and in collaboration with the National AIDS Council Secretariat. Currently, NACS and the Department of Health manage databases on all confirmed HIV infections in the country and publish quarterly reports on the number and characteristics of HIV and AIDS diagnoses reported in Papua New Guinea. The movement of the surveillance databases to the Department of Health will occur when the Surveillance Unit acquires adequate office space.
The following statistics are taken from the December 2006 Quarterly Report (NACS and NDOH, 2006). Table 1, shows the reported number of HIV infections to the end of December 2006, with the total number of people diagnosed with HIV reaching 18,484. Figure 1, indicates the new and cumulative annually reported HIV infections.
6 Table 1: New and Cumulative HIV infections detected in Papua New Guinea, 1987 - 2006 Total HIV Year of Infections Cumulative Diagnosis Male Female Unknown by year HIV Infections 1987 2 4 0 6 6 1988 8 5 0 13 19 1989 11 7 0 18 37 1990 24 12 0 36 73 1991 17 16 2 35 108 1992 12 18 0 30 138 1993 19 21 0 40 178 1994 42 31 1 74 252 1995 68 57 1 126 378 1996 94 96 2 192 570 1997 173 174 1 348 918 1998 331 307 23 661 1579 1999 418 335 37 790 2369 2000 598 448 27 1073 3442 2001 642 615 56 1313 4755 2002 840 796 78 1714 6469 2003 1058 1137 121 2316 8785 2004 1152 1193 284 2629 11414 2005 1310 1587 156 3053 14467 2006 1711 1965 341 4017 18484 Total 8530 8824 1130 18484
Source: December 2006 Quarterly Report (NACS and NDOH, 2006).
Figure 1: New and cumulative annually reported HIV infections in Papua New Guinea, 1987–2006
20000
18000 New cases Cumulative cases 16000
14000
12000
10000
8000 Number of cases 6000
4000
2000
0
1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year of detection
7 2.1.2 Distribution of HIV infection by age Of all the reported HIV infections, age was not recorded for 6175 or 33% of people diagnosed. Of the remaining 67%, the most common age at diagnosis for males is in the 25-29 year and 30-34 year age groups. From what data is known, close to 60% of all infections in men and male youth are diagnosed under the age of 35; with 74% of all male infections occurring under the age of 40; 85% by the age of 44, and 92% by the age of 50. For females, the most common age at diagnosis is in the 20-24 year and 25-29 year age groups. From what data is known, 39% of all infections occur in female youth by the age of 24; 61% by the age of 29; 78% by the age of 34; 88% include women to the age of 39 and 94% by the age of 44. From the data available, there are higher numbers of infections detected in younger woman.
Figure 2: HIV infections detected in Papua New Guinea by age, 1987 – 2006
2.1.3 Province of Detection HIV infection has been reported in all provinces; however, over 50% (9312) of all HIV infections have been reported in the National Capital District. The Western Highlands province recorded the second highest number of infections with 3554 (19.48%), while Morobe Province had a total of 1673 (9.05%). The remaining 3,744 (20%) infections are distributed among Eastern Highlands Province, Enga and the other provinces.
Reported HIV by province does not represent the level of the actual epidemic per province. Many people go to Port Moresby and other urban centers to get tested. This may be a deliberate decision to go to a place where they are not known in order to avoid stigma and discrimination. Another reason could be that the medical facility at the Port Moresby General Hospital is the only historically known site which has been providing VCT since the early nineties. This could explain why high numbers are observed in the major urban centers in the country.
8
Figure 3: HIV infections reported in Papua New Guinea, by province of detection 1987 – 2006.
The inconsistent collection of information regarding province of origin makes it very difficult to have a clear representation of the spread of the epidemic across the country. From these data, we can only consider that HIV infections have been detected in every province of the country.
2.1.4 Mode of Transmission The majority (11947; 64.6%) of all HIV infections reported have no information recorded for mode of transmission.
Table 2: HIV infections reported in Papua New Guinea, 1987–2006, by mode of transmission Sex not Mode of Transmission Male Female stated Total %
Heterosexual 2712 3386 194 6292 34.04
Homosexual 18 8 0 26 0.14
Perinatal 118 97 4 219 1.18
Blood transfusion 0 0 0 0 0.00
Contaminated needle 0 0 0 0 0.00
Mode not recorded 5682 5333 932 11947 64.63
Total 8530 8824 1130 18484 100.00
9
The predominant mode of transmission recorded for the remaining 35.4% is unprotected heterosexual intercourse and peri-natal transmission. Based on the lack of routine data collection about transmission, it is presently not possible to ascertain the primary mode of HIV transmission in PNG.
2.1.5 Routine STI case reporting. PNG has the highest prevalence of gonorrhea (12%) and genital chlamydia (27%), and the second highest prevalence of syphilis (3.7%) in the Asia- Pacific Region, the 4th highest prevalence of HIV in Asia Pacific and the highest HIV prevalence of all Pacific Island nations (WHO, 1999)
Community based studies conducted by the PNG Institute of Medical Research of asymptomatic people in 10 provinces show that of the total 3288 people tested, 40% (1315) were infected with at least one STI. Of those infected the prevalence of chlamydia was 13.2% (434), syphilis was 15.0% (493), gonorrhea 11.5% (378) and trichomoniasis 19.7% (648). The prevalence of HIV from these studies was 3.4% in urban areas and 1.3% in rural areas, with an overall prevalence of 2.4%. Females showed higher levels of HIV infection in both rural and urban areas (IMR, 2007).
The presence of an STI greatly increases a person‟s risk of contracting and transmitting HIV. Statistics from the provinces provide evidence of the increasing prevalence of syphilis and information and experience from the STI clinics in POM, Lae and the Highlands provinces indicate an increasing prevalence of genital herpes and genital warts. As herpes and syphilis are both ulcerative STI, there is increased chance of HIV transmission during unprotected sex if these infections are present. As the IMR national mapping study has shown there was 2.5 times more chance of also being infected by HIV if syphilis was a co-infection (IMR, 2007).
The current passive surveillance system is not capturing all STI data, and many people have asymptomatic infections or do not present until complications appear. Many provinces do not have facilities that offer a genuine sexual health service and some health workers can have judgmental attitudes towards people who have an STI. Many people with an STI or who are worried that they have, one don‟t present at health clinics and self medicate, which affects treatment of STI, and data quantity and quality.
To date there has been two different systems of passive data collection for STI Surveillance in PNG, these include: STI data generated from syndromic diagnosis and STI etiological diagnosis based on syndromic analysis where an etiological cause is then assigned. STI data from health centres and hospital outpatients is reported monthly to the Provincial Information Officer and then to National Health Information System (NHIS) under categories from syndromic diagnosis. STI data from Provincial STI clinics is reported on a monthly basis directly to the STI/HIV Section of NDOH with assumed and potentially inaccurate etiological diagnosis attached. This means that sexually transmitted infections are reported under two different systems, using different
10 diagnostic criteria; neither of which gives accurate information or can confirm what the actual STI infections are. Statistics from aid posts are not recorded at all. The information from the 2 reporting systems does not give a complete or accurate picture of the prevalence of sexually transmitted infections in PNG. Currently, the NHIS is updating and revising its reporting system and will be developing a unified system based on syndromic diagnosis for all levels of reporting.
2.1.6 HIV infection Among Blood Donors A screening of all donated blood occurs throughout the country. Blood donor testing decreased in 2003 by 35% and decreased again by 20% in 2004; but HIV testing of donated blood gradually improved in 2005 (21% increase) and 2006 (12% increase). There was also a steady increase in blood donors testing HIV positive between 2002 and 2004, with a significant increase in 2005 and decline in 2006. There have been significant variations in HIV prevalence detected among blood donors. The highest prevalence of HIV infection detected among blood donors was reported in 2005 (1.49%), with the lowest in 2002 at 0.2%.
Figure 4: HIV Testing Amongst Blood Donors, 2002-2006
30000 29134 Tested Positive 25000 21916 18867 19195 20000 15109 15000
10000
Number of Tests of Number 5000 57 43 80 286 58 0 2002 2003 2004 2005 2006 Year of Test
2.1.7 HIV infection among VCT clients Voluntary Counselling and Testing (VCT) roll out to all provinces has been one of the major achievements of the NACS. The Surveillance Unit has now registered about 75 sites across the country doing Voluntary Counselling and Testing. In 2006 only 47 out of the 75 sites sent in their reports. Information on the referral of clients is currently unavailable and the Surveillance Unit plans to capture this in future.
HIV testing at VCT sites increased by 79.5% from 2002 to 2003, followed by a 10.2% increase between 2003 and 2004, then a drop in testing by 1.2% from 2004 to 2005, and then rose significantly by 27.0% from 2005 to 2006. From 2002 onwards, NACS with the support of NHASP embarked on the roll out of VCT services to more sites. This exercise highly probably contributed to the increase in VCT testing between 2002 and 2003.
11 HIV prevalence from VCT sites increased from 1.95% in 2002 to 3.72% in 2003; and significantly increased from 3.72% to 8.19% between 2003 and 2004. HIV prevalence dropped from 8.19% in 2004 to 6.66% in 2005 and further decreased to 5.70% in 2006.
Figure 5: HIV tests conducted amongst VCT clients 2002 – 2006
3500 Number Tested 3052 3000 Positives
2431 2500 2403 2206
2000
1500 1229
1000 Number Number Tested/Positves
500 199 160 174 24 82 0 2002 2003 2004 2005 2006 Year
2.2 Sentinel surveillance of HIV infection HIV sentinel surveillance was established in 2002 with the assistance of the National HIV/AIDS Support Project (NHASP). Since then surveillance has been conducted amongst antenatal women in Port Moresby, Lae, Goroka and Daru, and STI clinic attendees in Port Moresby, Goroka and Mt Hagen. Tuberculosis patients were surveyed in Port Moresby, Lae and Goroka hospitals. Surveillance activities have progressed over the last 4 years with continued strong collaboration between the NACS and the NDOH. Sentinel sero-surveillance sites have successfully been established in 14 provinces expanding to provincial and district level sites. A total of 39 sentinel sites including 31 ANC, 5 STI and 3 TB clinics have already been established and this number is anticipated to increase. Successful collaboration has been developed with the Papua New Guinea Defense Force for surveillance amongst the military. HIV sentinel surveys found the following National HIV prevalence estimates in particular groups to be: 1.6% for ANC; STI clinic attendees at 12.7%; tuberculosis patients at 16% and VCT attendees at 11.3%.
2.2.1 Antenatal Clinics (ANC) A pattern of increasing HIV prevalence was observed among women attending antenatal clinics at Port Moresby General Hospital and the Goroka
12 Base Hospital. These two sites have had sentinel surveillance conducted annually for more than 5 years. In 2006, the HIV prevalence from the two sites showed lower rates than the previous year. At PMGH, the decrease in prevalence may have been due to the closure of the ANC clinic for renovation and the commencement of ANC screening at the 9-Mile Clinic. Testing in ANC was inconsistent at the other sites and showed varying HIV prevalence. It is important to note that antenatal HIV screening is not a routine practice in many provinces. Table 3: ANC Antenatal HIV Prevalence, Urban Sites 2002-2006
Year 2002 2003 2004 2005 2006 1. Daru (%) 0 0 - - - (N) 492 204 - - - 2. Kerema (%) 0 0 3.03 - 0 (N) 232 44 99 - 34 3. PMGH (%) 0.73 1.06 1.16 1.26 1 (N) 5171 4539 4052 4057 3514 4. St Mary's Boroko (%) - - 12.12 8.77 5.19 (N) - - 66 171 443 5. Alotau (%) - - - 0.5 1.3 (N) - - - 600 1245 6. Popondetta (%) 0 0 - - - (N) 101 90 - - - 7. 9 mile (%) - - - - 2 (N) - - - - 300 8. Wabag (%) 0 0.42 0.2 0 2 (N) 443 473 489 68 594 9. Mt Hagen (%) 0 - - 3.7 - (N) 2691 - - 267 - 10. Kundiawa (%) - 0 - 2.2 - (N) - 51 - 184 - 11. Goroka (%) 0.37 1.77 - 2.1 1.3 (N) 1614 678 - 2233 3496 12. Angau (%) - 2.5 - - - (N) - 480 - - - 13. Madang (%) 0 - - - - (N) 59 - - - - 14. Wewak (%) - - - 1 0 (N) - - - 850 1553 15. Vanimo (%) 0 - - - 0.22 (N) 326 - - - 465 16. Lorengau (%) - - - 0.17 0.42 (N) - - - 605 713 17. Vunapope (%) - - - 0 1.46 (N) - - - 774 751 18. St Theresa (%) - - 7.14 0 3.14 (N) - - 14 32 382 19. Buka (%) - 0.19 - 0.4 0.86 (N) - 516 - 537 699
13 PMGH antenatal clinic and the hospitals in Vunapope, Mingende, and Goroka are the only sites offering HIV testing to all attendees. But HIV testing is subject to supplies of test kits and reagents being available. This area is being addressed by the Department of Health through the employment of a full time officer who will be responsible for the procurement and distribution of test kits.
Table 4: ANC Antenatal HIV Prevalence, Rural Sites 2002-2006
Year 2002 2003 2004 2005 2006 20. Tabubil hospital (%) 0 0.3 0.2 0.7 0.2 (N) 631 646 538 431 591 21. Yampu (%) 0 0.6 0.3 0 16.3 (N) 235 310 331 33 43 22. Mingende (%) - - 0.65 0.71 1.22 (N) - - 612 704 658 23. Vei'fa (%) - - - 1.5 1.57 (N) - - - 200 255 24. Kainantu (%) 0 - - 2 - (N) 207 - - 100 - 25. Kudjip (%) 0 0 0.43 1.37 0.86 (N) 100 356 699 1019 2097 26. Banz clinic (%) - - - 1.5 0.48 (N) - - - 133 209 27. Kumin (%) - - - 15 2.97 (N) - - - 40 438 28. Braun HC (%) 0 - - - 0 (N) 52 - - - 57 29. Maprik (%) - - - 0.5 - (N) - - - 202 -
NB: Two of the 31 antenatal sites were not included in EPP as the numbers tested were too small.
2.2.2 STI clinics As with sero-surveillance at antenatal clinics, HIV prevalence among patients attending STI clinics across PNG has been rapidly rising. In 2005, one in five patients who consented to be tested at Port Moresby‟s Heduru Clinic and Kainantu‟s STI Clinic had an HIV infection; with one person out of eight at Mt Hagen‟s STI clinic, one in ten at Friends clinic in Lae, and one in 20 at Michael Alper‟s clinic in Goroka. All STI clinics offer a VCT service and the HIV prevalence data presented below includes both patients with symptoms of a STI and clients attending for voluntary counselling and testing.
14 Table 5: HIV Prevalence in STI Clinics, 2002-2006
Province Site 2002 2003 2004 2005 2006
13.1% EHP Goroka 12.4% 5.9% 6.0% 7.2% (49/2004) (46/775) (32/529) (40/555) (115/876) EHP Kainantu 2.0% 7.4% 19.0% (6/303) (19/255) (55/290) Lae 7.3% Morobe 5.1% 7.1% 8.3%. 6.9% (34/671) (64/903) (44/529) (43/628) (17/232) Morobe Finschafen 0.0% 100% 8.3% 0.0% 5.6% (0/3) (1/1) (2/24) (0/12) (1/18)
WHP Mt Hagen 6.5% 7.4% 7.2% 10.5% 16.9% (160/2480) (212/2851) (135/1867) (200/1896) (228/1350) WHP Kudjip 30.8% 0.0% 6.0% 41.3% 11.4% (32/104) (0/29) (4/67) (26/63) (33/2290) PMGH 14.8% NCD 7.3% 7.8% 15.8% 12.7% (3/41) (5/64) (115/730) (66/519) (64/431) Western Daru 20.0% 0.0% 25.0% 20.0% 5.0% (2/10) (0/4) (3/12) (2/10) (2/20) OTML - 0.0% Western 0.0% 0.0% 7.7% 2.9% Tabubil (0/129) (0/71) (5/65) (1/34) (0/48) 0.0% 30.8% Gulf Kerema 0.0% 10.0% 0.0% (0/19) (1/10) (0/4) (0/0) (4/13) SHP Mendi 10.2% 9.6% (40/391) (48/502) SHP Yalibu 9.1% 0.0% 0.0% 25.0% 8.6% (1/11) (0/0) (0/0) (3/12) (14/162) SHP Tari 4.0% 20.8% 10.5% 26.4% 10.3% (4/101) (25/120) (6/57) (19/72) (15/145) Enga Yampu 4.3% 0.0% 2.7% 6.6% 3.3% (1/23) (0/81) (3/113) (5/76) (2/61) Simbu Kundiawa 7.6% 9.0% 9.5% 7.8% 16.2% (17/223) (20/223) (19/199) (30/385) (33/204)
2.2.3. HIV in TB Patients Active sero surveillance was conducted amongst TB patients in NCD (PMGH), EHP (Goroka) and Morobe (Angau) hospitals in 2003 and 2004. The results showed HIV prevalence of 20% (60/300) in PMGH, 15% (18/117) in Lae and 12% (12/97) in Goroka.
Active surveillance of TB patients has not been done in the last two years, however, adhoc HIV testing has continued in many hospitals through out the country. The graph below shows the number of tests carried out and the numbers of HIV positive infections that have been detected among TB patients.
15
Figure 6: TB testing by year, 2002-2006
1000 923 849 800 588 569 600 Total Test 400 Positives
200 90 34
No Positive/No Tested Positive/No No 32 5 16 19 0 2002 2003 2004 2005 2006 Year of Test
Based on these adhoc HIV testing among TB patients, there was a continuous rise in the prevalence of HIV amongst TB patients between 2003 and 2006. The prevalence increased from 2.81% in 2003 to 3.23% in 2004, with further increases to 3.47% in 2005, before reaching a prevalence of 4.00% in 2006. Note that the highest prevalence of 5.56% was reported in 2002. This high prevalence In TB patients is due to the small number of patients tested. From available data the prevalence of HIV infection in TB patients has continuously been increasing since 2003.
2.3 Behavioural Surveillance Surveys and Other Behavioural Research A key component of second-generation surveillance is the collection of data on the behaviours and other characteristics within the general population and groups at higher risk, which can influence the course of the HIV epidemic in Papua New Guinea. Results from behavioural surveillance surveys and other behavioural research indicate elevated risk for transmitting and contracting HIV across the groups which were targeted because of unprotected anal and vaginal sex with multiple female and male partners, within broad networks of different types of sexual partners, from groups at higher risk and within the general population. A large percentage of male youth and men reported paying for sex, and male and female youth, men and women reported being involved in transactional sex for goods and services and for cash, with low consistent condom use. But condom use by sex workers was higher than in other groups at higher risk. The degree of reported involvement in or experience of sexual coercion, forcing and sexual violence, including gang rape was high. Important differences in practice are also seen between groups targeted and these differences are integral to understand when developing behavioural change programs and policy.
2.3.1 Behavioural Surveillance Surveys (BSS) 2006 In 2006, behavioural surveillance surveys (BSS) were conducted in high risk settings in NCD, Morobe and Western Highlands provinces (NACS and NHASP, 2007). The objectives of the BSS were to establish baseline data and a monitoring system to track trends in sexual behaviours in high risk settings,
16 provide information to guide program planning, to be used to monitor and evaluate the HRS strategy and to inform future behavioural surveillance.
The groups targeted in the BSS were recruited from high risk settings using a range of sampling techniques including random sampling, respondent driven sampling, and a random walk sampling frame, with the aim to create representative samples. The population groups and the specific sites sampled were: 1) adult male workers in private industries from Lae Port and Ramu Sugar and truck drivers based in Mt Hagen, and the military from Taurama, Murray and Igam Barracks; 2) out of school youth from Joyce Bay and Hanuabada settlements in Port Moresby; and women who sell sex either non- highway based from Lae, Ramu and Mt. Hagen or highway based from Minj Market, Umi Market, and Yang Creek Market.
Presently, the site and group specific results from these behavioural surveillance surveys are being prepared for dissemination with the population groups interviewed. The report from this research will be endorsed by the NAC, results disseminated with the groups and organizations targeted, and the results will be discussed in the 1st National Surveillance Plan 2007 – 2010. Follow-up BSS with these groups that were previously targeted will be prioritized in 2008 after further program intervention.
2.3.2 Behavioural surveys using RDS The IMR (Institute of Medical research) conducted research for the Poro Support Project in Port Moresby with men who have male to male sex and in both Port Moresby and Goroka with female sex workers (Maibani-Michie and Yeka, 2005; Yeka et al., 2006). Data is drawn from a sample of 235 sex workers in Port Moresby with a median age of 28, and from 227 sex workers in Goroka with a median age of 25. Respondent driven sampling was used.
Sex Workers It was found that most female sex workers had primary school education or less, or no schooling at all, and were responsible for financially supporting large numbers of relatives and children. Two-thirds of sex workers had been married; most sex workers who were married became separated or divorced, and started selling sex after their marriage ended between the ages of seventeen and twenty. The majority of women interviewed reported being victims of sexual and physical violence over the past year, and that they had experienced stigma and discrimination.
Reported condom use during commercial sex over the last month was high - Port Moresby (86.0%) and Goroka (79.0%); while consistent condom use was less (31.4% in Goroka; 62.6% in Port Moresby). Reported condom use at last sex and consistently with non-regular partners was less than during commercial sex in Port Moresby (48.3% last sex; 33.5% consistently over 4 weeks) and Goroka (43.7% last sex; 16% consistently over 4 weeks). Access to condoms and objection from partners was the main barrier to condom use.
17 Men who have sex with men (MSM) In Port Moresby, a sample of 223 young men who have sex with men, were interviewed using respondent driven sampling. The median age was 22, with a fifth under the age of twenty, 58% under 24 years, and 13.2% over thirty. Some (14.7%) were currently married, with a few (3.5%) reporting being separated or divorced. Most reported having low levels of education with 44.6% having primary schooling and 22.2% having no education. Just over half (52%) were unemployed, but the majority were responsible for financially supporting many children, parents and relatives. Alcohol and marijuana use was high, some reported using ecstasy and other tablets (16%), and 6.2% reported injecting; however the type of drug being injected was not reported.
Few men who reported having sex with men identified as „gay or homosexual‟ (23%); two thirds said they were bisexual and ten percent said they were heterosexual. They had diverse and large sexual networks that include both men and women. The men interviewed reported having both anal and vaginal sex with a range of partners: male (92%) and female (68%) non-paying partners; regular (66.9%) and one-time (55.3%) male clients; 25.2% had female clients; and some had had sex with other male sex workers (33.3) and female sex workers (25.4%).
Condom use during last sex varied between types of partners and was highest with MSW (61.5%), and lower with non-paying partners (32.3%), regular male paying clients (50%) and one time clients (54.2). Consistent condom use was highest (34.8%) with MSW. They reported low access to condoms and VCT services.
A large majority reported having experienced stigma and discrimination in their workplace (43.1%) and others (22.7%) were being beaten because of their sexual orientation. The majority had been raped and forced to have sex against their will with violence, with 60% being raped because of their sexual orientation. Forthcoming research from IMR in a follow-up study with MSM and sex workers in Port Moresby and Goroka allows for analysis of trend data.
2.3.3 Consensus Workshop Behavioural Surveillance Working Group It was identified during the behavioural surveillance working group discussions at the Consensus Workshop, that there is a need to update the behavioural research overview in the draft Surveillance Plan, and review available research material to generate a clearer „picture‟ of available BSS and other socio-behavioural data, and the gaps in present information.
It was recommended that prioritized sites and target groups for behavioural surveillance research for 2007-2008, would be selected based on criteria that considers and analyzes HIV prevalence and STI data, and available BSS and other behavioural and social research. This process will help to identify high risk groups in particular provinces and priorities for BSS, and other needed complementary behavioural, biological and social research. Some high risk groups were identified including: truck drivers, sex workers and others who exchange sex, men who have sex with men, the military, prisoners, both in and out of school youth, and workers in development enclave areas.
18
Other priorities for BSS in 2007 were identified as the recruitment of the BSS team, reviewing the lessons learnt from previous BSS, establishing sample sizes for each targeted group, and developing protocols and ethics submissions, research design, probability sampling methods and behavioural surveys. It was felt that research would commence at the end of 2007 or early 2008.
The need for a range of partnerships and institutional relationships to be established and strengthened was recognized, including: the NDOH, NAC and NACS; ADB via the rural enclave project; the NSO; with NGOs; with research and academic institutions such as, the NRI, IMR, FHI, University of Papua New Guinea, the University of Goroka, Divine Word University, and the Melanesian Institute; and with existing networks of people who have been trained and have experience in social and behavioural research.
The importance of integrating data and linking HIV prevalence, STI rates and behavioural studies was stressed, as was the importance of timely data dissemination at national, provincial levels, and with the groups targeted.
2.4 Hospital experience with HIV and Antiretroviral Therapy (ART) The ART program started as a pilot project in February 2004, at the PMGH Heduru Clinic under the 3x5 initiative. The program has since expanded to other sites with more health workers being trained to provide services. By the end of June 2007, there were twenty-six ART sites nationally with almost 1,400 patients on treatment. Overall, there were 2,367 registered clients from ART sites, of which 1646 (70%) were on treatment. Sixty (4%) patients on ART have died; 39 (2%) dropped out of the program.
Public hospitals account for 33 per cent (10) of all ART sites, Faith Based Organizations (FBO) 50 % (14), economic enclave sites 8% (2) and private hospitals 8% (2). Despite having only a third of all ART sites nationally, public hospitals are responsible for providing ART to 91 % of all patients. FBO, despite having the highest number of sites, cater for only 8% of all patients on ARV. Enclave sites (1.2%) and private clinics (0.6%) provide treatment on a much smaller scale.
Table 6: Organizations involvement and contribution in ART Program
Organization Percent of all Proportion of all patients sites (%) on Treatment (%) per organization Public 33% 91% FBOs 50% 7.7% Private hospitals/clinics 8% 1.4% Enclave sites 8% 0.6% Total 100% 100% Source: ART Experience in PNG Dr. Goa Tau‟s presentation, Lae
19 The training of health workers has intensified with the roll out of a national training on the comprehensive management of HIV and AIDS with the Integrated Management of Adults and Adolescent Illness (IMAI) model. Since the beginning of the IMAI training in 2006, a total of 229 health workers from seventeen different provinces have been trained on the management of HIV infection and AIDS.
Since mid-2001, AIDS has been the leading cause of admission and death in the medical wards at the Port Moresby General Hospital. AIDS patients (mainly young adults) now occupy 70% of medical ward beds at PMGH and 30% of patients with TB are HIV positive. Fortunately, there has been a 25% reduction in the case fatality rate between 2000 and 2006 for those on ART; in 2004, 45% of all patients on ART died, in 2005 17% died and by the end of 2006, only 3% died.
The country faces an enormous task in trying to provide ART to all people living with HIV throughout PNG. The present major challenge is to upscale ART training to include general medical officers, paramedical and nursing officers as prescribers. There is also the urgent need to put in place an effective referral system to cater for the referral of serious complicated cases to the appropriate personnel.
Section III: Updated Estimation of HIV prevalence This section provides a description of the estimation and projection process and the results for the HIV epidemic in PNG. It provides an analysis of the methodologies that were used in previous consensus workshops. This analysis attempts to compare the results and to provide an interpretation of the actual estimates. Additionally, this section includes an explanation of the assumptions, methodology, tools and data used to estimate the level of the HIV epidemic in PNG as of December 2006. Finally, this section presents updated trends and the level of the epidemic for urban and rural areas, and provides projections of key HIV indicators based on different scenarios. The following areas, 3.1 and 3.2, discuss the methods applied and assumptions made in 2000, 2004 and 2007.
3.1 Previous methods of estimating the HIV prevalence The methods used for generating estimates for each consensus meeting has been dictated by the type of data available. Over the last six years, there has been considerable improvement in the quantity and quality of data generated, and the methods used. For generalized epidemics, if data is available for at least five years, the Estimation and Projection Package (EPP) software using urban and rural prevalence data from ANC is recommended. Due to a lack of rural and urban ANC prevalence data for the estimation exercises between 2000 and 2005, PNG was not ready to use the EPP method. The only option was to apply the Workbook Method for HIV estimations with some modifications.
20 3.1.1 Workbook The Workbook Method is a simple computer program based on Excel sheets. It is generally recommended for HIV estimates in low prevalence and concentrated epidemics. It is comprised of estimation and projection spreadsheets. The estimation spreadsheet provides national estimates as a sum of sub-regional estimates. In each sub-region, HIV estimates result from data entered for both sub-populations at high risk and low risk of HIV infection.
3.2 Process for estimating HIV infection in PNG The availability of more data has greatly improved the estimation and projection process. Data used in the current estimates and projections were derived from 19 urban and 10 rural ANC sites across the country. The current estimates and projections were facilitated by the Lae Consensus Workshop, and the Bangkok Joint UN Workshop on HIV and AIDS Estimates and Projections in March and April 2007 respectively. During the Lae Consensus Workshop, provincial participants involved in HIV and AIDS data collection were invited to make presentations of provincial data. This exercise facilitated the reconciliation and collation of data needed for the UN regional estimates that followed in Bangkok.
The Consensus workshop in Lae was attended by people who were directly involved with data collection, those responsible for policy and program delivery, and national and international observers. Most of the discussions centered on the quality of data and how best to improve the country‟s surveillance system. It was then recommended that any missing data or doubts on data quality had to be completed and any doubts on data quality had to be verified before it could be used to make estimates and projections. A core team was tasked to update the all surveillance data in order to have the most recent and complete data set readily available for the UN Regional Estimation in Bangkok from the 18th -20th April, 2007.
International standardized methods on HIV Estimation and Projection developed by UNAIDS-WHO and relevant partners have been introduced during the past two regional workshops in 2003 and 2005. During the 2007 Bangkok Workshop, EPP was highly recommended to be used in estimating the HIV infection rate in PNG since the country‟s epidemic is classified as generalized. In addition, the country now had some trend ANC data disaggregated by urban and rural sites making it possible to use the EPP model.
3.3 Methodology and assumptions for 2007 estimations
3.3.1 Methodology UNAIDS and WHO have developed computer software for making estimates and projections of the magnitude and impact of HIV and AIDS. The estimation process use standardized tools to estimate HIV prevalence that can be applied in all countries depending on the level of the epidemic (low, concentrated or generalized). These tools consist of three computer software including the Estimates and Projections Package (EPP), Workbook and
21 Spectrum. EPP and Workbook produce and estimate HIV prevalence, which are then fed into Spectrum for projections and impact analysis. This is illustrated in Chart 1 below.
3.1.1.1 Estimation and Projection Package (EPP) This software is used more for generalized epidemics, as it has features for the use of data on sub-populations to produce specific estimates for these sub-populations and the general population. This software uses data from ANC clinics and makes an uncertainty analysis that takes into consideration a calibration rate to balance the over-estimation of the epidemic by ANC data.
Chart 1: Data and tools used for estimation and projection in generalized epidemics
Surveillance data from pregnant women at ANC and survey data Estimation and Projection from national population based Package (EPP) surveys
Adult HIV prevalence
UN Population Division‟s Spectrum population estimates
Epidemiology • PLHIV assumptions • New HIV infections • AIDS deaths • Orphans due to AIDS • Treatment needs
The EPP software assigns an epidemic curve on the antenatal (ANC) HIV surveillance data which has been collected overtime, to generate an estimated trend of the epidemic. These prevalence estimations, together with various additional assumptions, are then applied into the Spectrum software, to estimate and project the impact of HIV epidemics overtime.
3.1.1.2 Spectrum This software is very handy for generating many of the variables that can be used for planning purposes and policy development. Most of the outcomes generated by this software originate from the EPP software. The Spectrum software is able to generate projections for different HIV indicators including: the number of people living with HIV, new HIV infections, AIDS deaths, treatment needs and unmet needs, and projected children and orphans due to AIDS.
22 3.3.2 Data Used The antenatal data that was used in the current estimations was collected from a range of sites and to varying degrees (see Tables 3 and Table 4). . Antenatal Clinic data from service delivery sites (Prevention of mother to child transmission). . Irregular data from 29 sites representing Government facilities and Catholic Health Services (19 Urban and 10 Rural). . Historical Data from most sites over the Period 2002 – 2006. . The National Capital District had the longest historical data from Port Moresby General Hospital providing a trend of the epidemic between 1993 and 2006.
3.3.3 Methods and assumptions For the first time, the data available came from a large number of sites representing both urban and rural areas. This was a good opportunity to generate separate estimates for urban and rural epidemics, allowing useful information for planning and management of the national response. As a result of this exercise, it was expected that the trend and the level of the national epidemic would be mostly determined by the rural areas, as in Papua New Guinea almost 85% of the population is rural.
It is has been observed in several countries that the ANC data tends to over- estimate the HIV epidemic among the general population by 15 to 25%. International experts recommended using a calibration rate to compensate this risk of over-estimation. Thus the team used the calibration of 0.80 as no data from a national randomized survey was available.
The estimations and projections were applied on the most recent population projection estimates from UNFPA and the Papua New Guinea National Statistical Office.
Table 7: Assumptions and errors in adult HIV prevalence estimates in generalized epidemics using EPP
Parameters Base estimate Error ANC prevalence ± 2% ANC general population 1:1 SD 0.28 prevalence Adult survival Median 9 years SD 1 year with Weibull Population size UN population estimates Sex ratio 1.3 female : 1 male SD 0.25 Mother to Child 32% SD 5% transmission probability Child survival 39% at 5 years SD – 2 Weilbull SD: Standard Deviation
23 3.3.4 Quality of Data All stakeholders in PNG agree that the monitoring and evaluation of the HIV epidemic is still weak in Papua New Guinea. This applies primarily to the HIV surveillance system. An international assessment made by UNAIDS classifies the surveillance system in PNG as poor and non-functioning (Neff Walker et al, 2001). The criteria used for this evaluation were frequency and timeliness, consistency, appropriateness, and coverage. The results of this evaluation are shown in Figure 7.
An analysis of the quality of the data available in PNG shows a certain level of inconsistency in testing at a number of sites. Most of the sites had a number of tests not exceeding a hundred per year, which weakens the validity of the reported infection rate. Some sites were irregular in reporting, which led to some missing values. The best historical data available was from the Port Moresby General Hospital covering the years from 1993 to 2006 with a regular number of about 5,000 HIV tests per year.
Figure 7: Quality of global sero-surveillance system
Sero-surveillance system quality and number of countries per category
Fully implemented systems (47) Some aspects of a fully (51) implemented system Poor or non-functioning (69) system
However, when we consider the data that was used in the previous estimation exercises (Estimaton reports 2001, 2004 and 2006), it is clear that the data used has considerably improved both in quantity and quality. It meets the requirements of the EPP software, making a valid estimation and projection possible. As mentioned before, for the first time it is possible to use data from 29 ANC sites representing both urban and rural areas.
As it is the case for any estimation and projection software, the final result will only depend on the quality of the data that is used. Although HIV estimates are considered by the national government as the most valid up to date information available on the HIV epidemic. Estimates should be considered with caution given the quality and quantity of the data used.
24
A National Surveillance Plan for 2007-2010 has been developed and is being implemented by the National Department of Health with substantial support from bilateral and multilateral partners and research institutions. It is expected that with the implementation of the National Surveillance Plan, an even better data set will be available in the future, thus leading to an increased understanding of the epidemic and more refined and improved estimates and projections.
3.3.5 New estimates: the new face of the epidemic The availability of historical data from both urban and rural areas was key to the successful 2007 estimation exercise using the Estimation and Projection Package (EPP 2007). As explained in the methods and assumption section, a calibration rate of 80% was used to balance the known overestimation caused by the use of ANC data when estimating HIV prevalence among the general population. The following table details the estimations of HIV prevalence from 1993, with projections to 2012 at urban, rural and country levels.
Table 8: Estimated HIV prevalence
NATIONAL URBAN RURAL Num Num Num %HIV+ HIV+ %HIV+ HIV+ %HIV+ HIV+ 1993 0.05 1,310 0.1 438 0.04 871 1994 0.06 1,771 0.14 597 0.05 1,175 1995 0.08 2,387 0.18 807 0.07 1,580 1996 0.11 3,204 0.24 1,081 0.09 2,122 1997 0.15 4,282 0.31 1,433 0.11 2,848 1998 0.19 5,694 0.4 1,875 0.15 3,819 1999 0.24 7,530 0.5 2,412 0.2 5,118 2000 0.31 9,898 0.62 3,043 0.26 6,855 2001 0.4 12,931 0.75 3,754 0.34 9,176 2002 0.51 16,796 0.88 4,521 0.44 12,275 2003 0.64 21,714 1.01 5,308 0.57 16,405 2004 0.81 27,978 1.13 6,076 0.75 21,902 2005 1.02 35,988 1.24 6,787 0.98 29,200 2006 1.28 46,275 1.32 7,415 1.27 38,860 2007 1.61 59,537 1.38 7,943 1.65 51,594 2008 2.03 76,665 1.43 8,369 2.14 68,297 2009 2.56 98,757 1.45 8,698 2.76 90,059 2010 3.22 127,121 1.46 8,942 3.55 118,179 2011 4.05 163,245 1.46 9,119 4.53 154,126 2012 5.07 208,714 1.44 9,244 5.74 199,471
25
The national prevalence as of December 2006 is 1.28% and the number of people living with HIV is estimated at 46,275. The urban prevalence is 1.32% with an estimated 7,415 people living with HIV; while the rural prevalence is 1.27% with 38,860 people estimated to be living with HIV in 2006.
It is worth noting that the trend of the epidemic in rural areas shows a late but strong increase. If we consider the prevalence only, it is clear that the HIV epidemic in PNG will become more rural as of 2007, affecting tremendously the national prevalence, given that 85% of the population is rural. The graph below shows the estimated and projected trends of the epidemic in PNG. The trend of the national epidemic is very close to the trend of the rural epidemic given the high percentage of the rural population.
Figure 8: Urban, Rural and National trends in the HIV Epidemic in PNG
4
3.5 National Urban Rural 3 2.5
2 1.5
HIV prevalence (%) prevalence HIV 1
0.5 0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year
The above graph shows the rural trend sharply increasing and that the rural epidemic is determining strongly the national trend. Based on these estimates, it can be concluded that the PNG HIV epidemic has now shifted to rural areas.
3.4 Comparison between new and old estimates It is important to note, that the new estimated prevalence rate of 1.28% in 2006, compared to the old estimates of 2% prevalence in 2005, does not represent in any way a decrease in the epidemic. The new prevalence estimates, when compared to previous estimates, show that while the HIV prevalence is lower, there is a sharper increasing trend in the epidemic than has been previously documented.
These increases are detailed in the table below. The reasons for the differences in prevalence estimates are essentially due to the methods of estimation that were applied, the assumptions that were made, the quality and the quantity data used, and an increase in the number of sites.
26
Table 9: Previous and new estimates of HIV prevalence in PNG
Type of Data Previous Year site source estimates New estimates
1999 Urban PMTCT 0.6% 0.24%
2004 Urban PMTCT 1.7% 0.81%
2005 Urban PMTCT 2% 1.02% Urban/ 2006 Rural PMTCT -- 1.28%
Until 2005, only data from a limited number of sites was used. This was mainly the case for 2000 and 2004 where the only data available was from the Port Moresby General Hospital. Consensus was made to consider the prevalence rate from that site as the national prevalence, with some assumptions. No calibration rate was applied.
For 2005 estimates, relatively more data representing exclusively government facilities was available, but from a very limited number of sites. Consensus was made to use the observed rates as representing the regional prevalence for five regions. The Workbook software, which is more appropriate to low and concentrated epidemic, was used on the available data to come up with the national estimate of 2% without using a calibration rate, and without weighing the observed rates by the number of people tested in each site. At that time, it was the best estimation possible using the available data.
For 2006 estimates, ANC data from the Catholic health facilities was used for the first time in addition to the public health facilities. The availability of this data covering the period from 2002 to 2006, and a bigger number of sites, made the application of the EPP software possible. The core team that worked on this estimation process strongly believes that they used much- improved data and a better methodology, leading to estimates that are more reliable.
Analysis of the observed prevalence trend among pregnant women who attend the ANC clinic at the Port Moresby General hospital demonstrates why the epidemic in PNG was considered generalized beginning in 2003. The line graph shows the HIV trend in antenatal mothers who attended the ANC clinic at the Port Moresby General Hospital and who tested positive for HIV between 1992 and 2006.
27
Figure 9: HIV prevalence in ANC from Port Moresby General Hospital 1992-2006
1.8 1.6 1.4 1.2 1 0.8
HIV prevalence HIV % 0.6 0.4 0.2 0
1992 1995 1998 1994 1996 1997 1999 2000 2001 2002 2003 2004 2005 2006 1993
This antenatal data from PMGH was used to declare the HIV epidemic as a generalized epidemic in December 2004. It is important to note that this was an urban, non-representative picture of the epidemic given the attraction that PMGH has had as a reference hospital in PNG. The decrease in prevalence in 2006, at PMGH has been attributed to the closure of the ANC clinic for renovation and the commencement of ANC screening at the 9-Mile Clinic.
3.5 Update and Projection of key HIV Indicators Other indicators for HIV are all increasing and provide a broader picture about the spread of the epidemic among the general population, and this data is invaluable to guide the national response.
The Spectrum software was used for the purpose of determining the values and trends for specific indicators of interest for the country. While the longer term projections provided by Spectrum will be determined and analyzed in the near future. Only updated indicators for 2007 will be provided in this report. Table 10 below provides a summary on the key indicators for HIV, with an update for 2003 and 2005, and projections for 2007. These indicators are related to the number of people living with HIV, the number of projected new infections, deaths due to AIDS, numbers of orphans and the number of people in need of treatment.
For instance, it is projected that in 2007 there will be 14, 638 new infections among adults and children; almost three times the number of new infections observed in 2003 (5227). This will confirm that the spread of the epidemic has taken an exponential trend, creating more challenges for the national response, and potentially having an important impact on the demography of PNG with at least 3,700 deaths due to AIDS in 2007 alone.
28 This increased number of deaths affects younger children, increasing their vulnerability to HIV through direct infection or through being orphaned. The estimations for the number of orphans have been increasing since 2003 and are projected to continue. By 2007, it is projected that 3730 children (aged 0- 17) will be orphaned.
Table 10: Update and projection of key indicators on the HIV epidemic
Indicator 2003 2005 2007 Trend Adult and 19738 32904 56175 Rising children People Adults 15+ 19117 31864 54448 Rising Living with Adults (15- HIV/AIDS 49) rates (%) 0.64 1.02 1.61 Rising Women 15+ 10806 18407 31883 Rising Children (0- 621 1040 1727 Rising 14) Adult and 5227 8531 14638 Rising children New HIV Adults 15+ 4874 7954 13684 Rising Infections Women 15+ 2819 4666 8174 Rising Children (0- 353 577 954 Rising 14)
AIDS Death in Deaths adults and 2185 3871 5995 Rising children
Orphans Orphans (0- 1549 2704 3730 Rising due to 17) currently AIDS living with HIV or AIDS
Number of Rising adults (15+) 2437 3204 5712 ART in need of Treatment treatment Number of Rising adults (15+) 80 1098 3000 on ART Number of Rising children (0- 233 384 636 14) in need of ART
29 Conclusions and Recommendations
This fourth estimation report compiles data about the HIV epidemic in PNG generated by the national surveillance system. National estimations have now been undertaken on data from the end of 2000, 2004, 2005 and 2006 by the NACS and the NDOH. The consensus and estimation reports provide a good opportunity to not only analyze the most recent available data on the HIV epidemic in PNG, but to also formulate recommendations on how to improve the HIV surveillance system to generate a higher quality and quantity of both behavioural and data from both rural and urban areas.
The HIV sero-surveillance statistics used in this estimation report show a high increase in the level of the epidemic in PNG, reaching a total of 18,484 people diagnosed with HIV at the end of 2006,and 4,017 people who tested positive in 2006. The number of people who tested positive in 2006 was 30% more than in 2005. From the data generated to the end of 2006, the national HIV prevalence is estimated to be 1.28% among people aged 15-49, translating to an estimate of around 46,275 people living with HIV in PNG.
While this estimated prevalence is less than previously documented, all HIV related indicators are increasing, with a sharp increasing trend in the projected number of HIV infections, particularly in rural areas, and projected increases in the number of AIDS related deaths, the number of people requiring treatment, and the number of children and youth (0-17) being orphaned.
HIV has been detected from all provinces, and the trend of the epidemic is projected to be strongly increasing, especially in the rural areas where 85% of the PNG population lives. It is projected that from 2007, the estimated prevalence among the rural population will be higher than the urban prevalence. This indicates an increased need for behavior change, VCT and referral systems, and increased access to ART, treatment, care and support programs in rural areas.
From available data there is close to an even distribution of infections between males and females; but female youth and young women are being diagnosed at a younger age than male youth and men. Little is known about the ways that HIV has been transmitted for those that have been diagnosed as there is no data for three quarters of those diagnosed.
Behavioural surveys implemented in recent years demonstrate that there are risk behaviours and situations that can impact on and heighten the transmission of HIV and the spread of the HIV epidemic heightened risk of risk of HIV transmission. Behaviours that can enhance the transmission of HIV exist, and include unprotected anal and vaginal sex between men and women and unprotected anal sex between men, inconsistent condom use, exchange and sale of sex, sexual violence, including gang rape, and a multiplicity of partners, including polygamous relationships, in broad sexual networks. Vulnerability is heightened by economic, social and cultural environments characterized by poverty and economic development, high population
30 mobility, gender inequity, misconceptions about HIV, and stigma and discrimination towards people living with HIV.
Increased behavioural surveillance and trend data will: support the development of programs that are evidence-based; increase understanding of behaviours over time for evaluation of programs and the national HIV response; fulfill data needs for UNGASS and MDG reporting; and identify gaps in knowledge and new areas for research.
The new data available and the lessons that have been learnt, indicate that it is extremely important to improve the national surveillance system to provide an improved quality and quantity of data to inform the response to HIV in PNG, particularly in rural areas, and to improve estimation and projection processes in the future.
Improved data generated through the surveillance system will enhance the development of evidence based policies and effective and targeted behaviour change strategies and interventions among the general and more at risk populations, and national efforts to scale up VCT, treatment, care and support interventions and HIV prevention throughout the country. These can be achieved through the implementation of the recommendations that follow.
Recommendations 1. Mobilize the budget to improve the surveillance system and the implementation of the 1st National Surveillance Plan 2007 – 2010, will enable the NDOH and its partners to improve the quality and quantity of behavioural and sero-surveillance data available.
2. Develop communication strategies to disseminate the current estimations and projections.
3. Strengthen and increase the surveillance coordination mechanism at central and provincial levels, through supervision, technical support, regular communication, and creating partnerships and working relationships with targeted groups, NGOs, FBOs, research institutions, and central and provincial health systems.
4. Gather available qualitative and quantitative information via an initial stock-take of all surveillance studies, STI data, social and high risk mapping, and anthropological and other social research written about PNG, to generate an understanding of the bigger picture, and identify additional research needs to fill gaps within the surveillance system.
5. Review previous consensus workshop recommendations to ensure that they are implemented. Form a small team of technical staff from the STWG to review and look at previous unimplemented recommendations with the aim to ensure that they are planned and implemented if they are still relevant to surveillance activities.
31 6. Prioritize behavioural and sentinel sero-surveillance based on analysis of existing information and established criteria that include HIV and STI prevalence, behavioural data and contextual factors. The importance of integrating data and linking HIV prevalence, STI rates and behavioural studies is stressed, as is the importance of timely data dissemination.
7. Review protocols, methods, and data collection tools used in behavioural and sero-surveillance, and revise to reflect international best practice.
8. Advocate for and support the creation of joint provincial surveillance, monitoring and evaluation teams to coordinate surveillance activities in the provinces.
9. Increase the number of sites for HIV surveillance among ANC women, in combination with routine syphilis testing, and expand sentinel surveillance to include more urban and rural sites.
10. Strengthen technical and financial support to the PMTCT program to enable it to meet its goal of giving pregnant women access to HIV counseling and testing, follow up services and treatment as needed, as well as providing reliable, consistent and systematic data on the HIV prevalence and behavioural risks of pregnant women.
11. Review the current routine case reporting system and refine it to improve data flow and the technical presentation of the data generated.
12. Support and assist with the logistical requirements for laboratories, such as testing reagents, technical support and the equipment which are required by provincial and urban laboratories.
13. Focus on most at risk population sub-groups in behavioural, bio- behavioural and sentinel sero-surveillance to get more information on how the epidemic is evolving and to track trends in risk behaviours and the spread of STI and the HIV epidemic.
14. Design and implement a national population based bio-behavioral survey to provide a clear picture of the characteristics and level of the epidemic at a country level.
15. Strengthen the surveillance system so that it can provide and disseminate the most up to date strategic surveillance information in a timely manner to all partners and stakeholders at national, provincial levels, and with the groups targeted, so evidence based interventions can be planned in response to changes in the HIV epidemic and the needs of those involved.
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IMR, 2007. “It‟s in Every Corner Now”: A nationwide study of HIV, AIDS and STIs. Goroka: PNG Institute of Medical Research, Operational Research Unit.
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Jenkins, C. 1996. The homosexual context of heterosexual practice in Papua New Guinea. In Aggleton, P. (ed.), Bisexualities and AIDS. International Perspectives, Social Aspects of AIDS Series, pages. 191-206. London: London, Taylor & Francis.
33 Jenkins, C. and Alpers, M. 1996. Urbanization, Youth and Sexuality: Insights for an AIDS Campaign for Youth in Papua New Guinea. PNG Medical Journal 39: 248-51.
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Lewis, I., Maruia, B., Mills, D. & Walker, S. 2006. Interim Report on Links Between Violence Against Women and the Transmission of HIV in PNG. Supported by the University of Canberra, Australia & National HIV/AIDS Support Program, Papua New Guinea, and funded by the PNG National AIDS Council.
Maibani-Michie G. and W. Yeka 2005. A Baseline Research for Poro Sapot Project: A Program for Prevention of HIV/AIDS among MSM in Port Moresby and FSW in Goroka and Port Moresby Papua New Guinea. PNG IMR / FHI Research Report to USAID.
Mgone, C. S., Lupiwa, T., Passey, M. E., Alpers, M. P. 1999. High Detection Rate of Neisseria Gonorrhoeae Using Polymerase Chain Reaction Among Rural Women in the Eastern Highlands Province of Papua New Guinea. Presented at Disaster Medicine and Environmental Health. Medical Society of Papua New Guinea 35th Annual Medical Symposium, Rabaul, East Britain Province.
Mgone, C. S., Passey, M. E., Anang, J., Peter, W., Russell D. M. 2002. Human Immunodeficiency Virus and Other Sexually Transmitted Infections Among Female Sex Workers in Two Major Cities in Papua New Guinea. Sexually Transmitted Diseases 29: 265-70.
Ministry of Health (MOH), National AIDS Council Secretariat (NACS) and World Health Organization (WHO). 2000. National Consensus Workshop on the Epidemiology of Sexually Transmitted Infections and HIV/AIDs in Papua New Guinea. Port Moresby: MOH, NACS and WHO.
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National AIDS Council Secretariat and National Department Of Health (NACS and NDOH) 2006. National AIDS Council and Department of Health HIV/AIDS Quarterly Report, December 2006. Port Moresby: NAC.
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35 Appendix 1: Participant Lists
Name Designation Organization Contact Provincial Participants Albert Paligo PDCO Mendi 5491463 Bangan John Graduate Scientific Officer PNGIMR 7322800 Baru Dirye Kudjip Hospital Kudjip 5462208 Charles Pepe HRC MPAC Lae 4720644 Conrad Kambi PDCO Wewak 8581626 Daisy Bej Pathology M.C.T 4732223 Dr. Alex Wangnapi DMS Kavieng Hospital 9842040 Dr. Amos Lano DMS Daru Hospital 645 0166 Dr. Barnabas Matanu DMS Buka Hospital 973 9073 Dr. Elsie Apuahe MO HIV/AIDS/STI – MOMASE Region NDOH/CBSC 4732100 Dr. Francis Wandi DMS Kundiawa Hos 7351066 Dr. Kaima Petronia MO HIV/AIDS/STI –Highlands Region NDOH-CBSC 5426611 Dr. Louis Samiak DMS Wewak Hospital 8562166 Dr. Mawe Dala Medical Officer STI/ HIV Goroka Hospital 7312100 Dr. Michael Dokup DMS Goroka Hospital 7312102 Dr. Nano Gideon MO HIV/AIDS/STI –Southern Region NDOH/CBSC 301881 Dr. Naomi Pomat Paediatrician Goroka Hospital 7312133 Dr. Noel Yaubihi DMS Alotau Hospital 6411200 Dr. Nolpi Tawang DMS Mendi Hospital 5491167 Dr. Paison Dakulala Physician Alotau Hospital 6411200 Dr. Paul Harino MO HIV/AIDS/STI –NGI Region NDOH-CBSC 9827333 Dr. William Pyakale DMS Wabag Hospital 547 1360 Dr. Zure Kombati OIC Pathology Mt.Hagen Hos 5421166 Dr.Thomas Koimbu Medical Officer In Charge Kainantu Hospital 7371066 Eliza Mamu MLT Mendi Hospital 5491167 Elvis Pirika PDCO Kerema Hospital 6481268 George Tunao STI/HIV Kerema 6481223 Herbert Dimbalu Health Manager Tari 5491469 Jacinta Mangon Pathology Buka Hospital 9739709 Jackson Apo PDCO PHO 7321973 Jimmy Ravao DHC Rigo-Central H 321 7330 John Gelua MT Wabag Hospital 547 1360 Kalos Eliap MLT Lorengau Hos 4709055 Kastronics Esayamo MLT Kerema Hospital 6481207 Kenny Masalan PMH Maprik 8581378 Kreams Kune Pathology Kundiaw 7351066
36 Lucy Morris PDCO Daru Health 6459336 Marcel Buro DHC Central Health 3217330 Michael Uaiz PHA Central Health 3217330 Miherbon Dimbacy DHA Tari Hospital 5408066 Pana Rim PDCO Central Health 3212580 Patrick Vahin MLT Alotau Hospital 6411200 Peter Bulungol MLT OTML 5463071 Philip Pakaly DHO Mendi 5491469 Sisa Udu OIC Pathology Daru Hospital 6459166 Sony Ngahan Data Officer Anua Moriri, Lae 4732146 Steven Tiwara MLT Wewak Hospita 8572166 Steven Yangi OIC STI Clinic Kundiawa 7351066 Theresa Palau Scientific Officer Goroka Hospital 7312134 William Popon PDCO Lorengau Hospital 4709787 William Yeka Scientific Officer (Bio-statistics) PNGIMR 7322800 Yalaset Ktumusi PMH Angoram 8561253 National Participants
Agnes Gege Statistical Officer NACS 3236161 Andrew Egan Director/Evaluation AUSAID 3257333 Bomal Gonapa Legal Advisor NACS 3236161 Caroline Wayne Data Collector NACS 3236161 David Passirem Care & Counseling Adviser NACS 3236161 Doreen Mandari M&E Programme Officer NACS 3236161 Dr. Agatha Lloyd ART Specialist WHO 3257827 Dr. Anne Malcolm Senior Program Coordinator AUSAID 3259333 Dr. Anthony Gomes Lab Specialist WHO 3257827 Dr. Egil Sorensen Representative WHO 3257897 Dr. Daoni Esorom HIV/AIDS/STI Technical Advisor NDOH 3013737 Dr. Evelyn Lavu Director Blood Bank St John/BTS 3255750 Dr. Fabian Ndenzako Medical Officer WHO 3257827 Dr. Gideon Kendino Director Health Services PNGDF 3242312 Dr. Goa Tau Chief Physician PMGH 3248461 Dr. Greg Law STI/HIV/Technical Advisor NDOH-CBSC 3013977 Dr. Hilda Poluhe Principal Advisor – Family Health NDOH 3013701 Dr. Holly Aruwafu Behavioural Specialist NR/ADB 3260300 Dr. Isimel Urarang Kitur Epidemiologist HIV/AIDS/STI NDOH 3013733 Dr. John Milan Technical Advisor Surveillance CBSC 6845278 Dr. Kai Dagam Director – Curative NDOH 3013837 Dr. Kiromat Mobuno SSMO – Paediatrics PMGH 3248200
37 Dr. Maxine Whittaker Senior Adviser CBSC 3251172 Dr. Neil Brenden Project Coordinator HIV Enclave Project ADB/NDOH 6949443 Dr. Paul Aia a/Director-Disease Control Branch NDOH 3013757 Dr. Timothy Payakalia Deputy Secretary NDOH 3013776 Dr. Singh Bandari M&E Programme Manager NACS 3236161 Dr.Joachim Pantumari Senior Medical Adviser NACS 3236161 Dr.Ninkama Moiya HIV Advisor Sanap Wantaim 3259333 Dr.Yadav Medical Officer WHO 6943949 Duah Owusu-Safo Representative UNFPA 3210483 Gabriel Bona IT Administrator NACS 3236161 Gaye Moore 3rd Secretary for Health Department AUSAID 6911018 AUSAID Geoff Clark Technical Officer HRD WHO 3252827 Ismael Robert PLO NACS 3231616 Jennifer Paru Data Collector NACS 3236161 John Moni Statistical Officer HIV/AIDS NDOH 3013733 Junior Ovio Data Collector NACS 3236161 Louis Mara PLO NACS 3236161 Luke Keria Pri-Director Hope Worldwide 3256901 Maybel Mosina Administration Officer NDOH 3013733 Melchior Tazmiza Statistical Officer STI NDOH-CBSC 3013976 Michael Aglua Policy and Planning, M&E Manager NACS 3236161 Omana Sensip Data Manager CBSC - NDOH 3236161 Russel Kitau Lecturer UPNG 3243834 Ruth Beriso PLO NACS 3236161 Sharon Walker VCT Advisor CBSC 3013733 Taoufik Bakkali M&E Advisor UNAIDS 3212877 Willie Wari Data Entry Officer NACS 3236161 International Partner Participants
Dr. Ben Coghlan Epidemiologist Burnet Institute 61.39282119 Dr. Dimitri Prybylski Senior Technical Officer FHI 662.263.2300 Ext.129 John Izard Project Specialist (Health) ADB Professor. John Kaldor Deputy Director, UNSW Dr. Karen Stanecki UNAIDS Dr. Nguyen Thi Thanh Surveillance/M&E Adviser WHO WPR Manila +6328389717 Terry Opa KM and Communications Adviser AUSAID 3259333 Tim Rwabuhemba Country Coordinator UNAIDS 3212877
38
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