empty data despite improved surveillance.
special section on HIV
A decade, the forecast for the island of New Guinea was dire. A heterosexual epidemic was set to explode, leading a team of international epidemiologists predicted in a report AIDS in Asia: Face the Facts . They warned that "everything indicates that the island faces an epidemic that resembles those observed in regions of sub-Saharan Africa." Papua New Guinea (PNG), which shares the island with the Indonesia, structured its response to the epidemic based on these early predictions. But the bomb was never extinguished.
to date, PNG struggles to describe not only why the first predictions were so far from the truth but also the exact contours of the smaller, but still serious, the country's epidemic is today. this confusion has come at a high price, particularly as regards decisions on where to target prevention efforts. "it results in a very vague program," said Stuart Watson, national coordinator in PNG for the joint United Nations Programme on HIV / AIDS (UNAIDS). "We do not know exactly what we respond to, and therefore, we answer everything."
Epidemiologists have long had good reason to fear a serious heterosexual epidemic PNG. condom use is low. Medically supervised circumcision protects heterosexual men against HIV, is rare. Sexual violence, in contrast, is endemic; a study published in the October 2013 issue of The Lancet Global Health revealed that 40% of men surveyed said PNG raping a woman "no partner." A recent study in a highland community and Port Moresby, the capital, found that over 20% of the 154 people tested in sexual health clinics were infected with chlamydia or gonorrhea.
early predictions suggest that by 2014, 10% of PNG in adults is infected with HIV. According to the National Department of Health PNG, the estimated prevalence among adults today is 0.65%. Watson believed that underestimates the true prevalence. "Ask most people face cold if they believe these figures, no," he said. But he believes the real figure is well below 10%.
Angela Kelly-Hanku ( left ) with Jolyn Gane in an AIDS dining General hospital Goroka
PHOTO :. MALCOLM LINTON
"the epidemic in PNG is not much sense in some ways," said epidemiologist Andrew Vallely, who lives in Milne Bay Province and works with both the PNG Institute of medical research (IMR) and the University of New South Wales (UNSW) in Sydney. "Why has not taken off HIV?"
In trying to assess the prevalence of HIV in PNG, epidemiologists have been many more assumptions than hard data. Joanne Robinson, a strategic advisor information to UNAIDS in PNG, as noted from 1993 to 01, the only official data HIV prevalence came from a prenatal clinic at the General Hospital of Port Moresby. "They had very high prevalence, but it was not representative of the rest of the country," said Robinson. Today, data from 380 sites and that monitoring was expanded to rural areas, more more distant, the overall prevalence has decreased.
But the data still give an incomplete misleading image, if not outright. "Our estimates are based on very small samples of the population to date" Watson said. He noted that only 60% of pregnant women attending antenatal clinics only 40% receive HIV tests. the government has not made systematic studies, large-scale several "key populations" which often have a strong HIV prevalence. men who have sex with men (MSM), transgenders and sex workers a small study conducted in Port Moresby by IMR in 2010 showed the prevalence of extremely high HIV among people who sold sex, if they were women (19%), men (8.8%), or transgender women (23.7%).
Moreover, the outbreak is geographically uneven, with strong heterosexual prevalence in some areas. As the Ministry of Health noted that PNG year, only five of the 22 provinces of the country, all in the highlands, accounted for 60% of reported HIV cases even if they have only 40% of the population. "PNG is experiencing a concentrated epidemic, in particular geographic locations and population groups," says a progress report of the HIV / AIDS, he filed in March with UNAIDS.
This patchiness complicates monitoring. for one, it is hard to access many isolated communities on this island of volcanic steep mountains. to reach the Goroka mountainous city of Port Moresby, for example, requires either an expensive flight or a winding 7-day hike. and 800 different languages spoken on the island reflect cultural variation, including sexual practices that may affect the transmission, such as polygamy and age of initiation. "what you say one place is not what you say in another place, "says social anthropologist Angela Kelly-Hanku, who lives and works in Goroka on the team Vallely.
A surprising cultural factor that may have had a role in the fight against the epidemic is cutting traditional penis. Several large studies in Africa have shown that medical male circumcision, which removes all the foreskin reduces under-sterile conditions, the risk of sexual transmission of HIV from women to men by about 60%. While the medical circumcision is rare in Papua New Guinea, up to 70% of men in some communities report having had a traditional penis cut like a boy, a procedure that involves cutting the different types of slots in the foreskin, but not delete it.
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PNG circumcision practices, understanding of the scope of HIV in PNG, and HIV in a house PNG image, http://scim.ag /hiv2014.
Following a recommendation from UNAIDS and the World Health Organization in 07 that prevention programs in countries with high prevalence should include male circumcision, officials PNG health were interested in launching a national program. With funding from the Australian government, the group Vallely collaborated on a 4-year study to assess the acceptability of the procedure and the potential impact. What they found surprised them.
When the researchers assessed the penis cut across the country, places that practiced the most had the lowest prevalence of HIV. "It may help explain why the epidemic appears as it does in PNG," Vallely said. "To be honest, we never imagined when we heard these practices that would be the result."
In collaboration with colleagues in PNG, Vallely and colleagues are currently conducting epidemiological studies to see if the link holds up. At UNSW Kirby Institute for Infection and Immunity in society, another group is doing laboratory studies with PNG foreskins to explore fundamental mechanistic questions: How medical circumcision thwart HIV, and traditional cut no impact (see box)? Vallely said that if the cup of traditional penis proves capable of lowering the risk of HIV infection, it may eventually change the public health campaigns. "We do not want to stop something that stops HIV from taking off in PNG," he said.
Watson argues that the confusion over the contours of the epidemic and its pilots waste precious resources. In 2012, most government spending went towards the management of the response, not the provision of services such as prevention, treatment and care. "We have a heavy high national response engulfing nearly 80% of the funding" he said, noting that the National AIDS Council employs over 100 people.
the painful Catch-22 is that PNG is left with little money to improve monitoring and to find the best way to reduce the epidemic. "We do not have resources for this because we are always in response to an epidemic, we do not have," Watson said.
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