HIV in Pregnancy: The PNG Experience

1. HIV in Pregnancy: The PNG Experience Professor Glen Mola Samoa, PSRH 2013

2. Historical Context • 1987 first case of HIV • 1991 100+ cumulative cases • 2007 5000+ new cases per year: plateaus and then in 2010 comes back to 3000 pa • 1988: 5000 ANs tested in Moresby = 0 cases • First AN cases 1994, prevalence 0.5% in 1998 • 2000 first national PPTCT plan • 2004 PPTCT programs in Pubic Health Systems – PMGH and catholic health services • Paediatric ART commenced in 2005 - PMGH

3. Trends from 1987 to 2007 • To begin with trends were exponential, exactly as occurred in sub-Saharan Africa • This was only to be expected in so far as sexuality in PNG is very like that of Africa, - albeit with marked tribal variation • To change the trend it was clear PNG had to do ‘things’ differently ‘Because once you get to 1%, the exponential upwards trend takes off.....’

4. A Typical prevalence curve of HIV over 15 years

6. There has been extensive mathematical modeling attempts to predict HIV prevalence The three factors which have been most extensively studied are: • Average number of partners per male • The effect of male circumcision • Epidemiology of partnering, - long term multiple partners are the most dangerous

7. Pick up an HIV +ve partner ~6/1000 transmission risk per coitus Therefore the first weekend (after sex x 10), - probability of becoming HIV+ve is 6% If she becomes the girlfriend, then after 3-4 months (ie after sex x 100), - probability of being HIV+ is 60%: But 100% seroconversion after 1 year If you are circumcised the figures are 2.5% (weekend), and 25% (if she has become the girlfriend): 100% seroconversion after 2 years If you use a CONDOM the figures are 0.006% (weekend), & 0.025% (girlfriend 3-4 months later): 0.5% after 2 years

8. 40 20 10 Prevalence of HIV 5 Number of partners Age at circumcision (years) Change in prevalence by partners and time (years). Power law network cut-off at 30 partners

9. Population-level effect of MC Ndola (East) Yaounde (West) • Increasing the proportion circumcised in Ndola results in an HIV epidemic similar to West African sites • Decreasing the proportion circumcised in Yaounde results in an HIV epidemic similar to East African sites 10% 0% 100% 100%

10. Not many success stories in PNG health, - and this one can’t be counted as a complete success just yet……….. Poster Courier newspaper 4.7.13

11. Political leadership • We have pushed the politicians into being politically correct, - have tests in public and put out the message that everyone needs to know their status • There have been no silly zenophobic statements or attitudes after the year of the first case in 1987

12. Community and Religious leadership • We have both archbishops holding hands with pastors of other churches on a poster advocating universal testing • Even the catholic church allows use of condoms when there is high risk of HIV transmission • We have the churches at the forefront of diagnosis and care (‘Anglicare Stopaids’ etc) • Whenever some fundamentalist group espouses prevention strategies causing promiscuity we do our best to ‘stamp’ on it by “enlisting Jesus’ help”

13. Using the HIV epidemic to break down taboos on sex education…………… • By using the emergency of the HIV epidemic we have been able to break down a lot of the taboos on discussion of sexual matters and sex education in the community • We even teach about the importance of (safer) sex in pregnancy in the ANC

14. Normalizing HIV testing (PICT) • WHO have really assisted in getting the attitude across that HIV testing is part of normal clinical care (PICT) • Using the ‘Opt Out’ strategy for testing in ANCs • Making HIV testing a common part of the evaluation of all very sick children and adults

15. Treatment availability makes discussion and control of HIV easier • When HAART treatment is available there makes assurance of benefit logical • Treatment prevents transmission too

16. What we are lagging with……….. • Disclosure to husbands/families: in the AN setting only 20-30% disclosure by delivery time. • Best way to achieve consent for disclosure is to emphasize benefit for husband, and whole family, - and at the same time mentioning the bad situation which can occur is disclosure does not happen……. • Implementation of Family Life Education curriculum: 1997, 2003 not implemented yet in 50+% schools……

17. But we are not there yet………… Mary 22, having third pregnancy Cross with husband in EHP Lufa village because he had been unfaithful Leaves him and the kids and comes to the national capital where she gets pregnant to someone else; but by the time she books in the ANC new boyfriend has left her. Husband in the village has married someone else. In ANC she is found to be HIV+ve, and is put on HAART Lives with distant relatives in a shanty town; no own means of support

18. Mary continued…… • Used ANC subsidy busfare money to come to the labor ward (by herself in labor) • Has a CS for Fetal distress • No relatives come to see her in hospital • She says that her parents are back in the village and she does not have a very good relationship with them because they did not approve of her leaving the husband Counseling issues: Where to now?? Issues: ARTs for life, contraception, guardianship, where to live, how to survive, ?going home, care of the baby, future relationships, etc…….

19. The Impact on health workers and health systems • You might spend 2-5 mins on a normal AN mother for review checks • But HIV mothers may need 20-50mins • A normal delivery may stay in the ward for 1-3 days, HIV mothers will need to stay in the ward for much longer • More and more very sick and socially challenged patients mean that health workers start suffering from “compassion fatigue”

20. Prevention, Prevention, Prevention • Condoms, Condoms, Condoms • Education • Talk out • Show leadership • Normalize this issue and stop making it so ‘special’; it is another chronic disease • Life-long treatment for everybody • All health workers to do it