Angela Kelly-Hanku

Field Evaluation of Xpert HPV Point-of-Care Test for Detection of Human Papillomavirus Infection by Use of Self-Collected Vaginal and Clinician-Collected Cervical Specimens

ABSTRACT The World Health Organization has recommended that testing for high-risk human papillomavirus (HPV) (hrHPV) infection be incorporated into cervical screening programs in all settings worldwide. In many high-burden, low-income countries, it will not be feasible to achieve high cervical screening coverage using hrHPV assays that require clinician-collected samples. We conducted the first evaluation of self-collected vaginal specimens compared with clinician-collected cervical specimens for the detection of hrHPV infection using the Xpert HPV test. Women aged 30 to 54 years attending two well-woman clinics in Papua New Guinea were invited to participate and provided self-collected vaginal and clinician-collected cervical cytobrush specimens. Both specimen types were tested at the point of care by using the Xpert HPV test. Women were given their cervical test result the same day. Those with a positive hrHPV test and positive examination upon visual inspection of the cervix with acetic acid were offered same-day cervical cryotherapy. A total of 1,005 women were enrolled, with 124 (12.3%; 95% confidence interval [CI], 10.3%, 14.4%) being positive for any hrHPV infection. There was a 99.4% overall percent agreement (OPA) between vaginal and cervical tests for HPV-16 (95% CI, 98.9%, 99.9%), a 98.5% OPA for HPV-18/45 (95% CI, 97.7%, 99.3%), a 94.4% OPA for other hrHPV infections (95% CI, 92.9%, 95.9%), and a 93.4% OPA for all hrHPV types combined (95% CI, 91.8%, 95.0%). Self-collected vaginal specimens had excellent agreement with clinician-collected cervical specimens for the detection of hrHPV infection using the Xpert HPV test. This approach provides for the first time an opportunity to incorporate point-of-care hrHPV testing into clinical cervical screening algorithms in high-burden, low-income settings.

‘Mobile men with money’: HIV prevention and the erasure of difference

Mobile Men with Money is one of the latest risk categories to enter into HIV prevention discourse. Used in countries in Asia, the Pacific and Africa, it refers to diverse groups of men (e.g. businessmen, miners and itinerant wage labourers) who, in contexts of high population movement and economic disparity, find themselves at heightened risk of HIV as members of a ‘most-at-risk population’, or render others vulnerable to infection. How adequate is such a description? Does it make sense to develop HIV prevention programmes from such understandings? The history of the epidemic points to major weaknesses in the use of terminologies such as ‘sex worker’ and ‘men who have sex with men’ when characterising often diverse populations. Each of these terms carries negative connotations, portraying the individuals concerned as being apart from the ‘general population’, and posing a threat to it. This paper examines the diversity of men classified as mobile men with money, pointing to significant variations in mobility, wealth and sexual networking conducive to HIV transmission. It highlights the patriarchal, heteronormative and gendered assumptions frequently underpinning use of the category and suggests more useful ways of understanding men, masculinity, population movement, relative wealth in relation to HIV vulnerability and risk.

‘We call it a virus but I want to say it's the devil inside’: Redemption, moral reform and relationships with God among people living with HIV in Papua New Guinea

There is growing recognition of the importance of religion and religious beliefs as they relate to the experience of HIV, globally and in Papua New Guinea in particular. Based on 36 in-depth qualitative interviews conducted with people living with HIV receiving HIV antiretroviral therapy in 2008, this paper examines the cultural aetiology of HIV of in Papua New Guinea, the country with the highest reported burden of HIV in the Pacific. Narratives provided drew upon a largely moral framework, which viewed HIV acquisition as a consequence of moral failing and living an un-Christian life. This explanation for suffering viewed the individual as responsible for their condition in much the same way that neo-liberal biomedical discourses do. Moral reform and re-establishing a relationship with God were seen as key actions necessary to effect healing on the material body infected with HIV. Religious understandings of HIV drew upon a pre-existing cultural aetiology of dis-ease and misfortune widespread in Papua New Guinea. Understanding the centrality of Christianity to explanations of disease, and subsequently the actions necessary to bring about health, is essential in order to understand how people with HIV in receipt of antiretroviral therapies internalise biomedical perspectives and reconcile these with Christian beliefs.

Factors Influencing Antiretroviral Adherence and Virological Outcomes in People Living with HIV in the Highlands of Papua New Guinea

Adherence to antiretroviral therapy (ART) is paramount for virological suppression and positive treatment outcomes. ART has been rapidly scaled up in Papua New Guinea (PNG) in recent years, however clinical monitoring of HIV+ individuals on ART is limited. A cross-sectional study was conducted at two major sexual health clinics in high HIV prevalence provinces in the Highlands Region of PNG to assess ART adherence, factors affecting adherence and the relationship between ART adherence and virological outcomes. Ninety-five HIV+ individuals were recruited and administered a questionnaire to gather demographic and ART adherence information whilst clinical data and pill counts were extracted from patient charts and blood was collected for viral load testing. Bivariate analysis was performed to identify independent predictors of ART adherence. Fourteen percent (n = 12) of participants showed evidence of virological failure. Although the majority of participants self-reported excellent ART adherence in the last seven days (78.9%, 75/91), pill count measurements indicated only 40% (34/84) with >95% adherence in the last month. Taking other medications while on ART (p = 0.01) and taking ART for ≥1 year (p = 0.037) were positively associated with adherence by self-report and pill count, respectively. Participants who had never heard of drug resistance were more likely to show virological failure (p = 0.033). Misconception on routes of HIV transmission still persists in the studied population. These findings indicate that non-adherence to ART is high in this region of PNG and continued education and strategies to improve adherence are required to ensure the efficacy of ART and prevent HIV drug resistance.

A systematic review of heterosexual anal intercourse and its role in the transmission of HIV and other sexually transmitted infections in Papua New Guinea

BackgroundPapua New Guinea (PNG) has a high burden of sexually transmitted infections (STIs) and the highest adult HIV prevalence in the Pacific region. Despite this burden of disease, heterosexual anal intercourse (HAI) has rarely been considered. Given the increasing number of, and interest in, behavioural surveys in PNG and the changing nature of PNG’s HIV epidemic, it is timely to conduct a systematic review of HAI in PNG order to improve sexual health.MethodsWe performed a systematic review of HAI in PNG as reported in peer-reviewed and non-peer-reviewed publications for the period 1950–May 2012. The search strategy identified 475 publications. After screening by geographical location, topic and methodology, we identified 23 publications for full text review, following which 13 publications were included in the final review. Using data from the review, we performed a risk equation analysis to demonstrate the potential impact of HAI on HIV acquisition and incidence in PNG.ResultsThere is a paucity of well-informed behavioural research on HAI in PNG. Inconsistency in key questions on HAI made it impossible to conduct a meta-analysis. The data available on HAI shows that it is practiced in all geographical areas and among all populations. Of those who reported HAI, rates varied from as low as 8% to as high as 77% depending on the recall period and partner type. Condom use during HAI was consistently low. Our risk equation analysis indicates that even if only 20% of females engage in HAI, and only 10% of sex acts involve HAI, the total number of new HIV infections among females would be 40% greater than if vaginal intercourse only occurred.ConclusionsOur findings of indicate that HAI may be an important driver of the HIV epidemic in PNG. In order to improve the sexual health of Papua New Guineans, efforts are required to improve behavioural surveillance of HAI as well as develop national HIV/STI programing and policy to better address the risks associated with unprotected HAI.

Presence of HIV drug resistance in antiretroviral therapy-naive and -experienced patients from Papua New Guinea

OBJECTIVES The optimal benefits of antiretroviral therapy (ART) can be compromised by the emergence of HIV drug resistance (HIVDR) resulting in treatment failure. ART was introduced in Papua New Guinea (PNG) in 2004, yet biological data on HIVDR are lacking. The aim of the study was to investigate levels of HIVDR in ART-naive and -experienced patients in PNG. METHODS We recruited, interviewed and collected blood from 108 ART-naive and 102 ART-experienced patients from two Highlands provinces of PNG. Dried blood spots were tested for HIVDR from all patients with detectable plasma viral load of ≥200 copies/mL using established in-house assays. RESULTS The PCR amplification success was 90.6% (n = 96) and 66.7% (n = 12) using dried blood spots from ART-naive and -experienced patients, respectively. Transmitted drug resistance was detected in 2.1% (n = 2) of samples from ART-naive patients; acquired drug resistance was detected in 50% (n = 6) of samples from ART-experienced individuals. CONCLUSIONS Our data showed that transmitted drug resistance in PNG is low and acquired drug resistance is higher with 12.7% of the ART-experienced patients failing treatment. As ART access is rapidly expanding in PNG, monitoring of drug resistance is paramount for early detection of treatment failure.

Whenever they cry, I cry with them: Reciprocal relationships and the role of ethics in a verbal autopsy study in Papua New Guinea.

Verbal autopsy (VA) methods usually involve an interview with a recently bereaved individual to ascertain the most probable cause of death when a person dies outside of a hospital and/or did not receive a reliable death certificate. A number of concerns have arisen around the ethical and social implications of the use of these methods. In this paper we examine these concerns, looking specifically at the cultural factors surrounding death and mourning in Papua New Guinea, and the potential for VA interviews to cause emotional distress in both the bereaved respondent and the VA fieldworker. Thirty one semi-structured interviews with VA respondents, the VA team and community relations officers as well as observations in the field and team discussions were conducted between June 2013 and August 2014. While our findings reveal that VA participants were often moved to cry and feel sad, they also expressed a number of ways they benefited from the process, and indeed welcomed longer transactions with the VA interviewers. Significantly, this paper highlights the ways in which VA interviewers, who have hitherto been largely neglected in the literature, navigate transactions with the participants and make everyday decisions about their relationships with them in order to ensure that they and VA interviews are accepted by the community. The role of the VA fieldworker should be more carefully considered, as should the implications for training and institutional support that follow.

Unsafe abortion requiring hospital admission in the Eastern Highlands of Papua New Guinea - a descriptive study of women’s and health care workers’ experiences

BackgroundIn Papua New Guinea induced abortion is restricted under the Criminal Code Law. Unsafe abortions are known to be widely practiced and sepsis due to unsafe abortion is a leading cause of maternal mortality.MethodsWe undertook a six month, prospective, mixed methods study at the Eastern Highlands Provincial Hospital. Semi structured and in depth interviews were undertaken with women presenting following induced abortion. This paper describes the reasons why women resorted to unsafe abortion, the techniques used, decision to seek post abortion care and women’s reflections post abortion.Results28 women were admitted to hospital following an induced abortion. Reasons for inducing an abortion included: wanting to continue with studies, relationship problems and socio-cultural factors. Misoprostol was the most frequently used method to end the pregnancy. Physical and mechanical means, traditional herbs and spiritual beliefs were also reported. Women sought care post abortion due to excessive vaginal bleeding, and severe abdominal pain with some afraid they would die if they did not seek help.ConclusionIn the absence of contraceptive information and services to avoid, postpone or space pregnancies, women in this setting are resorting to unsafe means to end an unwanted pregnancy, putting their lives at risk. Women need access to safe, effective means of abortion.

Childbirth in a rural highlands community in Papua New Guinea: A descriptive study

OBJECTIVES to explore mens and womens experiences, beliefs and practices surrounding childbirth in a rural highlands community in Papua New Guinea. DESIGN a qualitative study comprising focus group discussions, key informant and in depth interviews. SETTING the study was undertaken in a rural community in Eastern Highlands Province, Papua New Guinea. PARTICIPANTS 51 women and 26 men participated in 11 focus group discussions. Key informant and in depth interviews were undertaken with 21 women and five men. FINDINGS both women and men recognised the importance of health facility births, linking village births with maternal and newborn deaths. Despite this, many women chose to give birth in the community in circumstances influenced by cultural and customary beliefs and practices. Women giving birth in the community frequently gave birth in an isolated location. Traditional beliefs surrounding reasons for difficult births, including spiritual beliefs were reported along with the use of traditional methods used to help prolonged and difficult births. CONCLUSIONS while the importance of health facility births is recognised in this rural community many women continue to give birth in the village. Identifying and understanding local customs, beliefs and practices, particularly those that may be harmful to women and their newborn infants, is critical to the development of locally-appropriate community-based strategies for improving maternal and infant health in rural communities in PNG and other resource-limited, high burden settings.

Sex, violence and HIV on the inside: cultures of violence, denial, gender inequality and homophobia negatively influence the health outcomes of those in closed settings

To map the context of HIV in closed settings in Papua New Guinea (PNG), semi-structured interviews were undertaken with 56 prisoners and detainees and 60 key stakeholders. The nature of HIV-related risk differs for detained women and men, and reflects important gender-based issues present in PNG society more broadly. Women in detention are vulnerable to sexual violence and exploitation and at greatest risk of HIV while detained in police holding cells, where they are typically supervised by male officers, in contrast to prisons, where they have little contact with male staff. HIV risk for men in prison is associated with consensual and non-consensual sex; this risk is perpetuated by a pervasive culture of denial and institutionalised homophobia. The illegal nature of sodomy and male-to-male sex provides Correctional Services the legal grounds by which to refuse access to condoms for prisoners. Addressing HIV risk among detained men and women in PNG requires the reform of legislation, police and prison practices and an understanding of broader structural problems of gender-based violence and stigma and discrimination.