Papua New Guinea: Sti and HIV Surveillance Techniques - Essay Example

? PAPUA NEW GUNIEA: STI AND HIV SURVEILLANCE TECHNIQUES AND FACTORS THAT AFFECT STI AND HIV PREVENTION AND CONTROL PROJECTS Number: Name September 23, 2011 TABLE OF CONTENTS Introduction………………………………………………………………………….…………..3 Method of Surveillance and Monitoring of STI and HIV………………………………….……3 a. Coverage…………………………………………………………………………….…...5 b. Effectiveness…………………………………………………………………………..…6 c. Cost…………………………………………………………………………………..…..7 Issues Having a Significant Bearing on STI and HIV Prevention and Control in PNG…………8 a. Gender Disparity…..……………………………………………………………………..8 b. Religious Practises………………………………………………………………………..9 c. Economic Challenges……………………………………………………………………10 Evaluation……………………………………………………………………………………….11 Conclusion………………………………………………………………………………………12 Introduction In 2004, Papua New Guinea (PNG) became the fourth country in the Asia-Pacific region to have a generalized HIV epidemic, which means that the prevalence of HIV in the general population is more than 1% (Secretariat of the Pacific Community 2004). Between the years 1995 and 1997, the diagnosed cases of HIV increased by 50% per year (AusAID 2005). However, since 1997, the annual increase has been around 30% each year (Cullen and Callaghan 2010). It is estimated that nearly 34,100 people are currently living with HIV in the country; with 3,200 people having been newly infected with HIV in the year 2009 (UNAIDS 2010). According to the World Health Organization, each year, more than one million new cases of treatable STIs are diagnosed in PNG, which includes at least 363,000 cases of gonorrhea, 750,500 cases of Chlamydia and 10,000 cases of syphilis (UNGASS 2006). The prevalence of STIs and HIV was found to be the highest in the highlands and southern regions. The chief mode of HIV transmission in Papua New Guinea has been through heterosexual activity and transmission from mother to child (USAID 2007). Other factors contributing to the transmission of STIs and HIV include, “multiple sexual partners, poverty, urbanization and sexual activity in exchange for cash, goods and services” (USAID 2007). This paper aims to provide an overview of the current methods of STI and HIV surveillance and monitoring in Papua New Guinea. The paper also helps to identify some of the economic, gender and religious issues with respect to STI and HIV prevention and control in the country. In light of these facts, an evaluation of the current challenges with possible recommendations to prevent and control these diseases has also been made. Method of Surveillance and Monitoring of STI and HIV According to a report released by AusAID (2006), the prevalence of HIV in the rural parts of Papua New Guinea (PNG) has been increasing over the years. Surveillance and monitoring of STI and HIV in these areas have been extremely challenging when we consider the remote nature of many parts of the country, geographic and cultural diversity, weak infrastructure and poor quality of services (AusAID 2006). The country has a national surveillance system which is also extended to monitor rural areas. However, numerous inconsistencies have been reported with the current methods of data collection and analysis and the quality of data collected has also been found to be poor (AusAID 2006). Studies have revealed that HIV transmission in PNG is largely driven through sexual contact but nearly two-thirds of people in the country, who have been diagnosed with HIV, are unaware of its mode of transmission (AusAID 2010). Again, the current surveillance system does not provide comprehensive information on age, sex and province of origin. In fact, the Independent Review Group on HIV/AIDS reports that, “There are vast areas of the country where there is insufficient information to characterize either current levels of infection or the potential for further epidemic growth” (AusAID 2010). The growing rates of STI and HIV infections in different parts of the country underscore the need to collect reliable information and assess the effect of the response programs in the country. The current surveillance techniques in the country include routine data collection from institutions like blood banks, antenatal clinics, STI clinics and sentinel surveillance sites (Secretariat of the Pacific Community 2004). Periodically, selected populations in the country are also surveyed for STI and HIV prevalence. The procedures include both sero-surveillance and behavioural-surveillance techniques so as to track the trends and long term implications of the epidemic in Papua New Guinea and ensure that appropriate interventions can be designed (Secretariat of the Pacific Community 2004). Again, all blood donations through Red Cross Blood Transfusion Service are screened for HIV and Hepatitis B (NHASP 2003). However, very few hospitals in the country are conducting regular HIV screening for all their antenatal and STI clinic attendees (NHASP 2003). Papua New Guinea was introduced to the second generation surveillance (SGS) techniques in 2004, which is the current best practise in the surveillance of HIV (Secretariat of the Pacific Community 2004). This SGS technique was developed by the WHO and UNAIDS and is used to monitor HIV, STI and behavioural risk factors pertaining to their transmission. The SGS merges routine data collected from screening programs with repeat surveys in high risk groups to track HIV rates. The data gathered are then used to develop programs and measure their effectiveness. Coverage Although both, sero-surveillance and behavioural-surveillance techniques are used to monitor STI and HIV trends in PNG, sero-surveillance of HIV is not complete due to two main factors (AusAID 2002): 1. Lack of funding to conduct baseline surveys and 2. Complexity in specifying the right sentinel groups and their small numbers Data on STI and HIV in the country is collected through community and clinic based surveys. The populations surveyed include groups like blood donors, pregnant women, STI patients, seafarers, visa applicants and prospective government employees. HIV/STI data for men, non-pregnant women and female sex workers (FSWs) are also collected in PNG. STI rates in the general population are monitored by tracking the rates in pregnant women who make their first antenatal clinic visit. Since the prevalence of STIs like gonorrhea, syphilis, Chlamydia and hepatitis B is a good indicator of HIV risk behaviours and HIV transmission can increase in the presence of ulcerative STIs, these women provide a good representation of the general population (Secretariat of the Pacific Community 2004). At risk populations like MSM, female sex workers, seafarers, patients diagnosed with STIs, police and military personnel are also monitored for STI and HIV. Data pertaining to age during the first sexual experience, number and kind of sexual partners, condom use and interaction with commercial sex are also recorded to gain clarity on the nature of the epidemic and identify prospective targeted interventions (Secretariat of the Pacific Community 2004). However, data on number of STIs like HSV-2 which is thought to be a vital co-factor in generalized HIV epidemics is limited (Freeman et. al. 2006). Again, clinic-based prevalence rates among female sex workers are also currently unavailable. Effectiveness Currently, routine testing and counseling services are provided in STI and TB clinics throughout the country (UNGASS 2010). This surveillance technique helps to effectively identify the prevalence of HIV in these two groups. One of the major concerns in this fight against HIV is that, there is no biological surveillance in place to monitor HIV epidemic among the high risk population groups of female sex workers or men who have sex with men (MSM) (UNGASS 2010). However, some biological studies have been conducted among high risk populations in the National Capital District (NCD) which estimate the HIV prevalence rates among female sex workers to be around 5% and among MSM to be around 4% (UNGASS 2010). But these findings cannot be generalized since they have been derived from one source during a specific time period. The current surveillance and monitoring techniques have not been very effective due to insufficient biological surveillance and lack of adequate coverage (as mentioned in the previous section). Cost Papua New Guinea, along with its counterparts in the pacific region has been able to mobilize significant amount of external funding in the past five years in order to address the HIV epidemic in the country. However, domestic spending on HIV activities has been currently very low in the country. One of the closest bilateral partners of PNG that is helping to manage the HIV epidemic in Papua New Guinea is the Australian Government, which funds various HIV/AIDS programs through AusAID (Commission on AIDS in the Pacific 2009). Global Fund and ADB are the two other sources that directly provide funding to PNG towards addressing the HIV epidemic in the country. Australia’s aid provides nearly 67% of the total funds committed to address the HIV/AIDS epidemic in PNG (AusAID 2010). AusAID contributed AU$ 24.3 million in 2008 to address Papua New Guinea’s HIV and AIDS program, held in collaboration with Australia (AusAID 2010). An additional AU$ 20 million was spent by AusAID in conducting programs in health and other sectors (AusAID 2010). In the year 2009, Papua New Guinea received 9,10,000 PKG from ADB and UN for epidemiology and surveillance and 80,62,444 PKG towards monitoring and evaluation (UNGASS 2010). Of all the funding received by PNG towards addressing the HIV epidemic in the country, currently only 2% is spent on epidemiology and surveillance and 6% towards monitoring and evaluation (Commission on AIDS in the Pacific 2009). Nearly 51% of these funds are used towards treatment, counseling, education and prevention while another 28% of these funds are spent towards leadership, partnership and coordination (Commission on AIDS in the Pacific 2009). Issues Having a Significant Bearing on STI and HIV Prevention and Control in PNG There are numerous factors that affect the STI and HIV prevention and control efforts in Papua New Guinea. Some of them have been discussed below: Gender Disparity Women in Papua New Guinea, lack empowerment and are especially vulnerable to these diseases because sexual violence is very common in this society. Young women in particular are at higher risk of infection because premarital sex, polygamy, sex outside of marriage and commercial sex are especially common in this country (Jenkins 1995). According to one study conducted on female sex workers (FSWs) in PNG, 36% were diagnosed with gonorrhea, 31% with Chlamydia and 32% with syphilis (USAID 2007). An assessment conducted by the Institute of Medical Research in PNG has revealed that FSWs in the country are mostly unaware about the mode of HIV transmission, do not consistently use condoms and rarely avail the benefits of confidential Voluntary Counseling and testing services (Gare et. al. 2005). One of the major challenges associated with this group is that it has been extremely difficult to implement interventions that target the clients of FSWs. Projects like IMPACT, which aim to address these issues in the country, are limited because of factors like the enormous cultural diversity, geographical range, poverty and gender disparity. Again, the rate of STI and HIV among MSMs in the country are not available because MSMs do not use STI services at the clinics where surveillance is conducted (USAID 2007). They avoid these centers due to issues like stigma and discrimination associated with these diseases. Lack of access to care and the discrimination associated with these diseases present a major obstacle to reach out to this group with prevention and control services. Religious Practises Papua New Guinea is culturally very diverse and has more than 850 indigenous languages. Although Christianity dominates as the major religion in Papua New Guinea, nearly 33% of the people, especially those living in the remote mountainous areas still practise some traditional indigenous religions. Some of these religious practises are a major obstacle in the prevention and control of STIs and HIV in the country since they promote sexual promiscuity. These religious and ethnic beliefs, as recorder in the International Encyclopedia of Sexuality (2001), are listed below: Marriages are typically endogamous, i.e., it is held between individuals who are from near by villages but from a different clan, since most of the clans are patrilineal. In the highland areas of Simbai, women have been observed to choose a man from a group of men who come together to dance in a ritual that ends with having sex with the chosen man. After spending the night with the man, word is sent to the woman’s parents to come and discuss the bride-price (Francoeur 2001). In the Trobriand Islands of PNG, a public event is organized wherein men from one village come to have sex with women from another village. These public sexual events are considered to be “rituals of reversal, fertility or renewal, allowing people to have sex with those with whom they ordinarily had no sexual right, e.g., the spouses of other men and persons within proscribed kinship relationships” (Francoeur 2001). Group sex is also practised in some remote areas, where a woman can have sex with several men in tandem. Among some groups, like the Ok of Highlands and the Sepik of North Coast, this is used as a method of punishment. However, in some groups residing in the Papuan Coast, it is considered an honor (Francoeur 2001). In some remote regions in the country, there are religious practises that involve older men inseminating younger men, either anally or orally (Francoeur 2001). The Banaro is an ethnic group in Papua New Guinea. According to their culture, each man has a “ritual brother” and the two can have sex with each other’s wives. According to their religious practise, a Banaro man’s wife is required to have her first intercourse with her father-in-law’s ritual brother (Davenport 1977). The Fasu group residing in the Southern Highlands has religious ceremonies which involved older men having sex with younger men (Davenport 1977). Among the Enga group residing in the Highlands, single men very rarely had sex with women and married men would be reluctant to have sex with their wives because they believed that any contact with menstrual discharge would pollute a man and cause sickness including death. They participated in certain purification rituals that were important to keep them clean (Davenport 1977). These religious practises that promote sexual promiscuity and homosexuality present a major obstacle in the prevention and control of STIs and AIDS in this community since it is an integral part of their culture. Economic Challenges Currently, Papua New Guinea is facing several economic issues with respect to the implementation of STI and HIV prevention and control programs. In spite of its rich natural resources, nearly 40% of the population lives in poverty with less than US$1 a day (Australian Volunteers International 2011). According to the Human Development Index, the country has one of the lowest socio-economic positions among all the Pacific countries. Currently, only about 57% of the population is literate and school enrollments are below average when compared to other low income states in the region (WHO 2008). Gender disparity in the country is also extremely high, especially with respect to gaining higher education. Although employment rates increased after 2006, the urban unemployment rate is still very high. Currently, a significant portion of STI and HIV prevention and control programs are funded through external sources. Although there are government-run clinics in the country, they are not well equipped to meet the needs of the at-risk populations that have been identified earlier in this paper. The efforts made by prevention programs are crippled because of issues like lack of access to care and inadequacy in the availability of trained medical staff among the FSWs and MSMs (USAID 2007). There is also inadequate access to STI drugs and inadequate services in terms of laboratory testing to identify and treat asymptomatic STIs among this population (Government of Papua New Guinea 2010). There is a growing divide between the rich and poor which create an environment for rapid increase in the rates of STIs and HIV in the country. In light of this fragile economic infrastructure, STIs and HIV has definitely become an important growth issue in the country. Evaluation Although there has been active participation from external agencies to assist in addressing the needs of the country in terms of STIs and HIV, there is significant gap is access to services especially with respect to at-risk populations of female sex workers and MSMs. Again, relevant information regarding second generation surveillance mechanisms and prevention programs have been made available to the country, but the vast cultural diversity and geographical challenges present a significant problem in implementing these programs. The efficiency and effectiveness of the various surveillance and monitoring programs currently used in the country are questionable since there are inconsistencies in the process of data collection and analysis. Also, the quality of data collected has also been found to be poor. The impact of the surveillance and monitoring programs has also not been very significant when we consider the lack of data relevant data regarding at-risk populations like FWSs and MSMs. In fact, the efforts made towards the prevention and control of these diseases have also not made significant impact, since the rates of STIs and HIV in the country are on the rise and no major change has been observed in sexual practises, gender disparity and inadequate access to health care services. These factors present the dire situation that the country of Papua New Guinea is facing and highlight the need for revamping the current surveillance mechanisms, prevention and control programs, without which the future of this country looks very bleak. Conclusion In conclusion, the country of Papua New Guinea is facing a major challenge with respect to the increase in rates of STI and HIV. Numerous factors like the current sexual practises with the country, lack of adequate health care services, the position of women in the society and the gaping divide between the rich create an environment where these diseases can flourish. Although several international agencies are currently assisting the country with programs to prevent and control these disease, a lot more effort and resources need to be directed in this area. Preliminary steps could include the implementation of proper mechanisms to collect routine and periodic data regarding STIs and HIV throughout the country. Biological surveillance and monitoring of high risk groups like FSWs and MSM should also be conducted. These steps would help to develop and implement prevention and control programs that can be sustainable in the long run. References AusAID. 2002. “Potential Economic Impacts of an HIV/AIDS Epidemic in Papua New Guinea.” AusAID. 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