How do you roll out an effective HIV prevention programme in Papua New Guinea (PNG) where 850 languages are spoken, cultures and sexual mores differ wildly, and much of the country is inaccessible?
Add to that headache the fact that in real terms AIDS funding has crashed: Australia, the largest donor, has seen its currency fall by 50 percent against the local Kina, effectively halving its spending. The PNG government has also pared down its already limited financing for AIDS work.
"Most NGOs and people who do implementation may be able to stretch their resources, some may struggle, but there will be absolutely no money to expand; that, I think, will be the primary challenge for everyone," Jacqui Badcock, resident coordinator of the UN system in PNG told IRIN/PlusNews.
Now is the time when scaling up is most needed. HIV prevalence is estimated at just over 2 percent, already the worst in the Asia-Pacific region, and is expected to rise to 5 percent within four years. Rural areas, where 85 percent of the population live, have overtaken urban centres as hotspots for the virus, complicating the response.
"There's need for an intensified effort in order to reverse the trend [of rural infections] – and that can only happen with really strong prevention programmes," said Tim Rwabuhemba, UNAIDS country coordinator. "But PNG is a different ball game; you can't come with pre-set ideas, you can't come with things that work elsewhere, PNG's context is very different."
Take access, for example. The capital, Port Moresby, is not connected by road to any other province. A rugged mountain range runs like a spine across the centre of the country, and in its folds are isolated hamlets and communities where people may well speak an entirely different language from those in the next valley, and whose culture and traditions may be equally distinct.
|PNG is a different ball game; you can't come with pre-set ideas, you can't come with things that work elsewhere|
There are a number of high-risk sexual practices that are common across PNG, according to a National AIDS Council report. These include: "early sexual debut; multiple premarital and extramarital sex partners; unprotected anal and vaginal sex between men and women and unprotected anal sex between men; inconsistent condom use during the exchange or sale of sex by female and male youth, men and women; sexual violence including gang rape; and in some areas the use of penile inserts or products which dry the vagina".
Poverty helps create the conditions for heightened risk – especially among the youth. A high drop-out rate from school, low job opportunities, alcohol abuse, migration and a lack of accurate sexual and reproductive health knowledge, serve to deepen vulnerability.
The authorities proclaim PNG a "Christian nation", but older traditions are also part of the fabric of people's existence, complicating the orthodox approach to HIV prevention: the ABC of Abstinence, Being faithful to a single partner and Condom use.
"Neither the churches nor the government has been able to integrate their demands for a Christian morality and a modern economy with the values, aspirations, and structures of PNG's societies. Continued impoverishment, especially of women, will contribute to further vulnerability and increased risk of exposure to HIV," Carol Jenkins wrote in an Asia Development Bank-funded study, Cultures and Contexts Matter: Understanding and Preventing HIV in the Pacific.
"The ABC model doesn't work, it's outdated. A human being needs sex; you can be faithful, but what about your partner? And condoms are just talk in rural areas, where most of the people live; they are not available," Agnes Mek of the Rebiamul voluntary counselling and testing centre in Mount Hagen, Western Highlands, told IRIN/PlusNews.
Photo: Obinna Anyadike/IRIN
|Air is the only way to reach much of PNG|
Polygamy is waning, but male autonomy within marriage remains, and sexual networks can be broad and complicated - especially as people increasingly leave their home areas in search of work. Researcher Holly Wardlow describes a masculine subculture among labour migrants where extramarital sex is almost inevitable, and wives left at home are "more likely to have sexual relations in exchange for money".
Labels can be an uneasy fit in PNG. Indentifying commercial sex workers (CSW), a target of standard AIDS responses, presents a dilemma. "CSW are just as likely to be clerks, betel-nut sellers, collectors of firewood, struggling single mothers, girls doing Grade 8, or women trying to marry the expatriate boyfriends they meet in night-clubs," Lawrence Hammar wrote in the Papua New Guinea Medical Journal.
Sexual identity is another vague area. In a culture where initiation rituals can involve male sodomy and oral sex, same-sex activity by young men is not uncommon, and few languages have distinct terms for heterosexual, bisexual or homosexual, complicating AIDS responses aimed at HIV-vulnerable gay men.
What makes all the permutations of sexual contact in PNG high risk is that condoms are not widely and consistently used. The UN system's Badcock argues that if it were merely a question of supply, then condom marketing could adopt the model used by Coca-Cola, and PNG's very own SP Breweries, who have succeeded in getting their beverages into the villages.
But condoms carry a host of associations with promiscuity - a marketing disaster. Rwabuhemba points out that condoms have received less than wholehearted support from churches and some traditional leaders also take a dim view of the intervention of latex in the sex act. Meanwhile, women typically have little power to negotiate condom use with their partners.
Corlis Gamoga is a youth peer adviser with Marie Stopes, a UK-based sexual and reproductive health NGO. He insists he uses condoms, and tries to encourage his friends to do the same, but acknowledges it’s a hard sell. And if any woman they knew pulled out her own rubber, she would instantly be labelled a “trupla meri”- a loose woman.
What can be done? "You need strong leadership at all levels, matching the rhetoric with action on the ground," said Rwabuhemba. "You also need to make the money that's available work, especially for the vulnerable populations."
Until recently PNG limped along without a robust national AIDS body capable of coordinating the AIDS effort. The public health service, the frontline of HIV care and treatment, has also struggled with the legacy of political instability in the 1990s, which encouraged a debilitating brain drain of professional staff.
Although training is being rolled out, and until recently generous amounts of donor money was made available to the government for AIDS programming, the perception among some medical staff is that they are being asked to do more with less.
"HIV presents a difficult challenge, it's another additional health problem, and it's exposing some of the failings that were already there [in the health system]," one nursing sister in Mount Hagen told IRIN/PlusNews.
Ask the people
Social scientists argue that to make headway against the epidemic, PNG's response must go beyond behaviour change messages drafted in Port Moresby or donor capitals, and start understanding and engaging with local communities.
Jenkins emphasises that in most PNG societies, community-wide decisions are reached by consensus, providing a mechanism and platform to win agreement on prevention and care approaches, and address the stigma that still surrounds AIDS.
"We need a lot more community-based training of volunteers. They don't need to be formally well educated, but to have good communication skills," said Badcock.
Dr Petronia Kaima helps those whom prevention efforts have failed: she runs the Tinanga HIV clinic at Mount Hagen general hospital, providing antiretroviral therapy (ART). "I'm trying my best here; we've registered 2,000 patients and I've got 900 patients on ART," she told IRIN/PlusNews.
But she is frustrated, and wants more aggressive preventative action. "There needs to be a law that forces people to wear condoms!" was her heartfelt assessment.