Angela Kelly

Now we are in a different time; various bad diseases have come. Understanding men's acceptability of male circumcision for HIV prevention in a moderate prevalence setting.

BackgroundAdult male surgical circumcision (MC) has been shown to reduce HIV acquisition in men and is recommended by the WHO for inclusion in comprehensive national HIV prevention programs in high prevalence settings. Only limited research to date has been conducted in countries experiencing moderate burden epidemics, where the acceptability, operational feasibility and potential epidemiological impact of MC remain unclear.MethodsA multi-method qualitative research study was conducted at four sites in Papua New Guinea (PNG), with 24 focus group discussions and 65 in-depth interviews carried out among 276 men.ResultsThe majority of men were in favour of MC being introduced for HIV prevention in PNG and considered improved genital hygiene, enhanced sexual pleasure and culturally appropriateness key factors in the acceptability of a future intervention. A minority of men were against the introduction of MC, primarily due to concerns regarding sexual risk compensation and that the intervention went against prevailing cultural and religious beliefs.ConclusionThis is one of the first community-based MC acceptability studies conducted in a moderate prevalence setting outside of Africa. Research findings from this study suggest that a future MC program for HIV prevention would be widely accepted by men in PNG.

Hope Is Forked: Hope, Loss, Treatments, and AIDS Dementia

In the HIV epidemic hope and loss are temporally structured according to pre, and post highly active antiretroviral therapies (HAART). AIDS dementia is a neurological condition on which HAART has had an important impact, yet this form of dementia has received little sociocultural attention. In this article, the author explores ethnographically personal hope from the perspective of “Matthew,” a significant other to a person with AIDS dementia, and how treatments influence this. Hope is present in Matthews narrative, but its nature is complex and fluctuates with the arrival and perceived failure of HAART. The author concludes by suggesting that hope in this context is forked, which is suggestive of the tenacious nature of hope in the context of AIDS dementia in the era of HAART.

A typology of penile cutting in Papua New Guinea: results of a modified Delphi study among sexual health specialists

Male circumcision (MC) significantly reduces the risk of HIV acquisition in men. The geographical, linguistic and cultural diversity of Papua New Guinea (PNG) makes issues of acceptability and implementation complex, and culturally appropriate HIV and Sexually Transmissible Infection (STI) prevention strategies are crucial in this setting. A modified Delphi approach was conducted with sexual health specialists to document and classify variants of penile cutting as part of a programme of research being carried out to investigate the acceptability and potential epidemiological impact of MC for HIV prevention in PNG, and options for future roll-out. Three broad categories were identified: circumcision, longitudinal incisions (including dorsal slit procedures) and incisions that did not alter the profile of penis or foreskin. The typology provides a universal language for health practitioners and policy makers that will inform future sexual health deliberations. The popularity of dorsal slit procedures in PNG has significant implications due to its procedural simplicity and limited resource requirements, making it an attractive provider option compared to medical circumcision. Further research is urgently required to examine the effectiveness of dorsal slit procedures for HIV prevention in PNG, the prevalence of various forms of penile cutting and the extent to which health staff are currently engaged in dorsal slit procedures.

More than just a cut: a qualitative study of penile practices and their relationship to masculinity, sexuality and contagion and their implications for HIV prevention in Papua New Guinea

BackgroundMale circumcision (MC) has been shown to reduce vaginal transmission of HIV to men. While community acceptability is important in a countries preparedness to introduce MC, it is equally important to map contemporary MC and other penile cutting practices, and the socio-cultural dimensions underpinning these practices.MethodsA total of 482 men and women (n = 276 and n = 210, respectively) participated in 82 semi-structured and 45 focus group discussions from four different provinces of Papua New Guinea (PNG), each representing one of the four socially and geographically diverse regions of the country.ResultsOf the men interviewed 131 self-reported that they had undergone a penile alteration with some reporting multiple types. Practices were diverse and could be grouped into five broad categories: traditional (customary) penile cutting; contemporary penile cutting; medical circumcision; penile inserts; and penile bloodletting practices in which sharp objects are used to incise the glans and or inserted and withdrawn from the male urethra or in order to induce bleeding. Socio-cultural traditions, enhanced sexual pleasure and improved genital hygiene were key motivators for all forms of penile practices.ConclusionsThe findings from this study highlight the complex and diverse nature of penile practices in PNG and their association with notions of masculinity, sexuality and contagion. Contemporary penile practices are critical to a community’s acceptance of MC and of a country’s ability to successfully implement MC in the context of a rich and dynamic culture of penile practices. If a MC program were to be successfully rolled out in PNG to prevent HIV it would need to work within and build upon these diverse cultural meanings and motivators for penile practices already commonly performed in PNG by men.

The Body of Christ has AIDS: The Catholic Church Responding Faithfully to HIV and AIDS in Papua New Guinea

Using the example of the Catholic Church in Papua New Guinea (PNG), I detail how, through praxis, it has brought to life a living theology of HIV and AIDS. In this way, the Catholic Church in PNG is responding faithfully to the epidemic. As a Christian country with a generalised HIV epidemic, where the body of an individual is reconstituted through the liturgical practices of baptism and Eucharist, theologically, in PNG the body of Christ has AIDS. In order to examine the ways in which the Catholic Church in PNG has responded faithfully to the Christian body with AIDS, I do so in relation to the three theological virtues of faith, hope and love.

Vasectomy as a proxy: extrapolating health system lessons to male circumcision as an HIV prevention strategy in Papua New Guinea

BackgroundMale circumcision (MC) has been shown to reduce the risk of HIV acquisition among heterosexual men, with WHO recommending MC as an essential component of comprehensive HIV prevention programs in high prevalence settings since 2007. While Papua New Guinea (PNG) has a current prevalence of only 1%, the high rates of sexually transmissible diseases and the extensive, but unregulated, practice of penile cutting in PNG have led the National Department of Health (NDoH) to consider introducing a MC program. Given public interest in circumcision even without active promotion by the NDoH, examining the potential health systems implications for MC without raising unrealistic expectations presents a number of methodological issues. In this study we examined health systems lessons learned from a national no-scalpel vasectomy (NSV) program, and their implications for a future MC program in PNG.MethodsFourteen in-depth interviews were conducted with frontline health workers and key government officials involved in NSV programs in PNG over a 3-week period in February and March 2011. Documentary, organizational and policy analysis of HIV and vasectomy services was conducted and triangulated with the interviews. All interviews were digitally recorded and later transcribed. Application of the WHO six building blocks of a health system was applied and further thematic analysis was conducted on the data with assistance from the analysis software MAXQDA.ResultsObstacles in funding pathways, inconsistent support by government departments, difficulties with staff retention and erratic delivery of training programs have resulted in mixed success of the national NSV program.ConclusionsIn an already vulnerable health system significant investment in training, resources and negotiation of clinical space will be required for an effective MC program. Focused leadership and open communication between provincial and national government, NGOs and community is necessary to assist in service sustainability. Ensuring clear policy and guidance across the entire sexual and reproductive health sector will provide opportunities to strengthen key areas of the health system.

Living serodiscordantly in Papua New Guinea: sexual practices of HIV-positive people on ART by serostatus of regular heterosexual partner

Abstract This paper examines condom use in intimate relationships amongst Papua New Guineans on antiretroviral therapy (ART). These findings are from a mixed-method study in six provinces throughout Papua New Guinea (PNG). A total of 374 HIV-positive adult Papua New Guineans, over the age of 16 and on ART for more than two weeks were recruited using a non-probability, convenience sampling methodology. Participants were recruited through ART prescribing sites, People Living with HIV/AIDS (PLWHA) drop-in clinics and support groups. A small number (36) also participated in in-depth interviews. Of the sample 226 (60.4%) were women and 148 (39.6%) were men. The majority of the sample was aged below 40 years, with a median age of 30 years. Of the sample who were in a regular relationship 64.7% identified themselves as being in a relationship where both they and their partner were HIV-positive (seroconcordant). Smaller proportions (21.0%) reported being in a relationship with a HIV-negative partner (serodiscordant), or in a relationship where they were not aware of their partners HIV status (14.3%). The majority of participants who reported having a regular partner also reported having disclosed their HIV serostatus to their partner (91.8%). A significantly greater proportion of participants who reported being in relationships where they did not know the status of their partner, also reported living in the Southern Region of PNG (52.9%), while the majority of those in seroconcordant relationships lived in the Highlands Region (71.2%). There did not appear to be any differences in sexual practice of using condoms between the three groups. Knowledge of serostatus is important for “positive prevention”.

Why Women Object to Male Circumcision to Prevent HIV in a Moderate-Prevalence Setting:

Adult male circumcision has been shown to reduce the transmission of HIV. Women’s acceptability of male circumcision is important in Papua New Guinea’s preparedness to introduce male circumcision, and in ethical considerations of its use as a biomedical technology for HIV prevention. We conducted 21 focus group discussions and 18 in-depth interviews with women in all four regions of Papua New Guinea. The majority of women objected to the introduction of male circumcision for three main reasons: circumcision would result in sexual risk compensation; circumcision goes against Christian faith; and circumcision is a new practice that is culturally inappropriate. A minority of women accepted male circumcision for the prevention of HIV and other sexually transmitted infections, and for the benefit of penile hygiene and health. Women’s objections to circumcision as a biomedical method of preventing HIV reemphasize the importance of sociocultural and behavioral interventions in Papua New Guinea.

Exploring women's perspectives of access to care during pregnancy and childbirth: A qualitative study from rural Papua New Guinea

OBJECTIVES to explore womens perceptions and experiences of pregnancy and childbirth in a rural community in PNG. DESIGN a qualitative, descriptive study comprising focus group discussions (FGDs) and in depth interviews. SETTING this study took place in a rural community in Eastern Highlands Province, PNG. PARTICIPANTS 51 women participated in seven focus group discussions. In depth interviews were undertaken with 21 women, including women recruited at the antenatal clinic, women purposively selected in the community and three key informants in the community. FINDINGS the majority of women mentioned the benefits of receiving antenatal care at the health facility and the importance of a supervised, facility birth. Women faced numerous challenges with regards to accessing these services, including geographical, financial and language barriers. Cultural and customary beliefs surrounding childbirth and lack of decision making powers also impacted on whether women had a supervised birth. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE distance, terrain and transport as well as decision making processes and customary beliefs influenced whether a woman did or did not reach a health facility to give birth. While the wider issue of availability and location of health services and health system strengthening is addressed shorter term, community based interventions could be of benefit. These interventions should include safe motherhood and birth preparedness messages disseminated to women, men and key family and community members.

Lost the Feel for the Game: Meanings of Onset and Diagnosis of AIDS Dementia for Significant Others

The onset and diagnosis of AIDS dementia marks a new dimension to living with HIV, an aspect few imagine or are equipped for. As a result of the profound changes that AIDS dementia makes to the ways the person with HIV acts, the life of significant others is similarly altered. Drawing on the metaphor of “the game” from Bourdieu’s work on habitus, I explore how the onset and subsequent diagnosis of AIDS dementia comes to signify for significant others a moment in which life is permanently altered, whereby they no longer have the feel for the game. With AIDS dementia, life (“the game”) is altered. Significant others feel that AIDS dementia is not a normal or acceptable AIDS illness: fears are contested, secrets managed and disclosed, and relations strained. This change in play further marginalizes significant others, and increases their sense of alterity from others living with and affected by HIV alone, because dementia is not the socially acceptable way of being ill with HIV.