HIV in PNG: Epidemic, Epidemics, Endemic?

HIV contributes to Papua New Guinea’s difficult mix of challenges for health and development. In mid-2010, PNG was home to roughly 6.7 million people, speaking some 800 languages and living mostly in small, dispersed communities, heavily dependent on a mix of cash-cropping and subsistence activities. About 85 percent of the population is classed as ‘rural’. On the United Nations’ human development index, PNG ranks 145 out of 177 listed countries and is the least developed of the Pacific Island states and territories. Despite PNG’s great wealth of natural resources, the gulf between ‘haves’ and ‘have nots’ is wide and widening; and much of PNG’s population is poor, and growing poorer. Roads and government services have deteriorated. About 40 percent of men and 50 percent of women are illiterate. Life expectancy at birth is the lowest in the Pacific: 54 years.

PNG’s first notified case of AIDS was in 1987: a policeman who had been serving in Bougainville; his wife and child were subsequently found to have HIV too. But the virus was probably in PNG before that date and in the 1990s spread rapidly. HIV nevertheless remains difficult to track or quantify because surveillance, while improving, is still weak. At the end of 2008, cumulative notifications numbered 28,294 and estimates of prevalence, as this volume goes to press, seem to range between 1.5 percent and the projected figure of roughly 3 percent for 2010, though some informed observers ‘feel’ this range, particularly the bottom end, is too low. Whereas injecting drug use (IDU) and sex between men are important means of HIV transmission in many south east Asian nations and in Australia and New Zealand, IDU is negligible in PNG, while sex between men seems to play a small, but perhaps underestimated role. The main mode of transmission is heterosexual, with secondary transmission from mother to child. For ages 2-29 years, cumulative notifications are higher for females than males and Papua New Guinea is experiencing the ‘feminisation’ of HIV and AIDS—with respect both to transmission and impacts.

HIV is also believed to be ruralising. AIDS has always been most noticed in the National Capital District, other urban centres, along transport routes such as the Highlands Highway and, more recently, in the vicinity of development enclaves. But in 2007, for the first time, rural HIV prevalence was estimated to have surpassed urban and very high prevalence has been found in some localities—for instance, 40 percent of 15–45 year olds sampled from Tari in the Southern Highlands. This ruralisation and feminisation pose a double challenge for the response to HIV—of reaching the most disadvantaged members of what are many of the most disadvantaged communities in PNG.

Among the conditions favouring the spread of HIV is PNG’s predominantly youthful and rapidly growing population, poor and in many parts of the country deteriorating health services, and the co-presence of other sexually transmitted infections that can assist transmission. High levels of rape and sexual abuse, domestic violence, and multiple sexual partners have contributed to HIV’s spread. The relationships between development and HIV are complex. Sizeable urban populations and uneven development, conducing to migration, social stress, widening disparities along axes of location, class and sex, and the commodification of female sexuality have shaped environments and patterns of human interaction in which the risk of infection is heightened.

PNG has been routinely described as experiencing a ‘generalised’ epidemic, meaning that prevalence has reached or exceeded 1 percent and HIV has spread beyond so-called high-risk groups and settings. In the wider Asia-Pacific, PNG is one of only two nations currently so classified. (The other is Thailand, but its estimated prevalence is marginally lower than PNG’s). Among the member states and territories of the South Pacific Community, PNG accounts for 95 percent of the total reported cases of HIV and AIDS. Among PNG’s neighbours, the Indonesian province of Papua, comprising the western half of island of New Guinea, comes closest to PNG in the scale and prevalence of HIV. In 2006, among a population of roughly two million, prevalence was calculated to be 2.4 percent, perhaps 15 times higher than Indonesia’s national average.

But is ‘generalised epidemic’ the best description? As indicated above, while PNG’s national epidemic may be described as ‘generalised’, subnationally it has ‘concentrated’ and ‘micro’ epidemics within certain networks and locales. Some connotations of the word ‘epidemic’ can be misleading too. Consider speed and infectiousness, two qualities often implied. Epidemic HIV however, unlike for instance epidemic influenza, is not so easily passed from one person to another and is even less infectious than most common STIs. Consider transience. Unlike, say, the 1918-19 ‘flu, which swept across the globe in several rolling waves and then completely petered out, HIV is now deeply rooted in the world and in PNG, embedded in the very means by which humans reproduce. Finally, ‘epidemic’ triggers fight or flight. This reaction can be useful in the immediate response to HIV, but we also need to tackle HIV’s ‘non-epidemic’ qualities, to prevent and mitigate, in the very long term, a disease that is difficult to dislodge.

Some researchers have tried to epitomise the non-epidemic characteristics of HIV in new metaphors. Barnett and Whiteside have described HIV as a ‘long wave’ and ‘multi-wave’ event. De Waal has pictured it as a structural and structuring component of our social and biological evolution. But a catchy formulation that counters some of the misleading connotations of ‘epidemic’ seems elusive. In this article, though the conventional parlance of ‘epidemic’ is used, as editors we prefer, following Barnett, to describe PNG as experiencing an ‘HIV endemic’. This reminds us that HIV is here to stay, at least for the foreseeable future.

Several studies have modelled the medium- and longer-term social and economic impacts of AIDS on PNG (e.g., CIE 2002; Hauquitz 2004; HEMIS 2006). These studies depend on underlying projections of AIDS-related morbidity and mortality, in turn dependent on calculations of HIV prevalence. According to recent projections, HIV will stabilise around the year 2012 at a prevalence of 5.07 percent. While certain impacts on the formal sector—on hospital beds, gross domestic product, salaried labour force and so forth—can be relatively easily calculated, the harshest damage affects individuals, households, and the informal sector, with repercussions for possibly generations. This damage is difficult to track and quantify. Indeed, some of the human costs of AIDS—such as grief, or a parent’s love that orphans may never know—are unquantifiable.

The national response to HIV has many achievements. These include the formation of the National AIDS Council and a network of Provincial AIDS Committees, a series of public education campaigns, national strategic planning and policy development, workplace reforms, and the passage of the HIV/AIDS Management and Prevention Act in 2003. In recent years, the contribution of churches, non-government organisations (NGOs) and the private sector—through such bodies as the PNG Business Coalition Against HIV and AIDS (BAHA)—has strengthened, as has leadership at national and subnational levels of government. Since 2004, care and treatment services have also rapidly extended, and at the end of 2007, close to 35 percent of people who need antiretroviral therapy were estimated to be receiving it. Great weaknesses in the response remain, some indicated by recent scandals engulfing the National AIDS Council Secretariat and in reasons for the Global Fund’s rejection, in 2009, of PNG’s application for continued financial assistance. Nonetheless many recent initiatives appear to have answered to the call ‘for renewed energies and directions to contain a fast spreading epidemic’, guided by ‘the rights of all PNG citizens, as enshrined in the national constitution’.

Finally, this short survey of HIV in PNG would be incomplete without some reflection on the term itself. As many readers will know, since 2006 UNAIDS has discouraged the usage ‘HIV/AIDS’. Either ‘HIV’ or ‘HIV and AIDS’ are preferred. With some regret, this article uses HIV very elastically, depending on context, to refer to: stages 1–3 of HIV disease; stages 1–4 (that is, including AIDS); the HIV endemic; the broader historical, social, cultural, and political phenomenon centred on HIV and AIDS; and finally, to imply specific issues associated with the progress of the disease through individuals and collectivities. But the retention of ‘HIV/AIDS’ is warranted in some contexts.

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