One size does not fit all: HIV prevalence and correlates of risk for men who have sex with men, transgender women in multiple cities in Papua New Guinea

Chlamydial and gonorrheal neglected sexually transmitted diseases among Pacific Islanders of the Western Pacific Region-A narrative review and call to action

The Pacific Island countries of the Western Pacific Region have some of the highest rates of sexually transmitted Chlamydia trachomatis and Neisseria gonorrhoeae infections in the world. Despite this, there are few research studies that include Pacific Islanders. We conducted a narrative review of original research and surveys, including World Health Organization and Pacific Community reports, to determine the prevalence, management, and treatment of C. trachomatis and N. gonorrhoeae compared to HIV and syphilis from 1980 to 2022. Available epidemiologic data on C. trachomatis and N. gonorrhoeae indicated an extremely high prevalence-approximately 30% and 13%, respectively-among Pacific Islanders during this timeframe. These neglected sexually transmitted infections represent a significant burden and health disparity. Robust epidemiologic research is needed to identify modifiable risk factors for designing interventions and control strategies. Appropriate policies along with regional and international advocacy and aid are required to improve reproductive health among these vulnerable, understudied populations to avert preventable infections and sequelae.

Sexual and reproductive health needs and practices of female sex workers in Papua New Guinea: findings from a biobehavioral survey Kauntim mi tu (‘Count me too’)

Background

Little research has explored the sexual and reproductive health (SRH) experience of female sex workers (FSW), including girls aged < 18 years who are commercially sexually exploited (CSE), in Papua New Guinea (PNG). This paper describes the SRH history of FSW and CSE girls and factors associated with their use of moderately or highly effective contraceptive methods in three settings in PNG.

Methods

From 2016 to 2017, respondent-driven sampling (RDS) surveys were conducted among FSW and CSE girls in Port Moresby, Lae, and Mt. Hagen. FSW and CSE girls who were born female, aged ≥12 years, sold or exchanged vaginal sex in the past 6 months, spoke English or Tok Pisin, and had a valid RDS study coupon were eligible to participate. Interviews were conducted face-to-face and participants were offered rapid routine HIV and syphilis testing. Survey logistic regression procedures were used to identify factors associated with the use of moderately or highly effective contraceptive methods. Weighted data analysis was conducted.

Results

A total of 2901 FSW and CSE girls (Port Moresby, 673; Lae, 709; and Mt. Hagen, 709) were enrolled. The proportion using moderately or highly effective contraceptive methods was 37.7% in Port Moresby, 30.9% in Lae, and 26.5% in Mt. Hagen. After adjusting for covariates, factors significantly associated with the use of moderately or highly effective contraceptive methods in Port Moresby were being age 20–24, being married, being divorced or separated, having one or more dependent children, being away from home for more than 1 month in the last 6 months, and having tested HIV negative. No factors were significantly associated in Lae or Mt. Hagen. ANC attendance amongst FSW and CSE girls who gave birth in last 3 years was highest in Port Moresby at 91.2%. HIV testing was inconsistently and inadequately offered at ANC across the three cities.

Conclusions

Kauntim mi tu provides much-needed insight into the SRH experiences of FSW and CSE girls in PNG, where their use of moderately or highly effective contraceptive methods is low. We hope to shed light on the complicated reality they face due to illegality of sex work and multitude of complex healthcare experiences.

Tuberculosis and HIV/AIDS-attributed mortalities and associated sociodemographic factors in Papua New Guinea: evidence from the comprehensive health and epidemiological surveillance system

OBJECTIVE

Tuberculosis (TB) and HIV/AIDS are public health concerns in Papua New Guinea (PNG). This study examines TB and HIV/AIDS mortalities and associated sociodemographic factors in PNG.

METHOD

As part of a longitudinal study, verbal autopsy (VA) interviews were conducted using the WHO 2016 VA Instrument to collect data of 926 deaths occurred in the communities within the catchment areas of the Comprehensive Health and Epidemiological Surveillance System from 2018 to 2020.InterVA-5 cause of deaths analytical tool was used to assign specific causes of death (COD). Multinomial logistic regression analyses were conducted to identify associated sociodemographic factors, estimate adjusted ORs (AOR), 95% CIs and p values.

RESULT

TB and HIV/AIDS were the leading CODs from infectious diseases, attributed to 9% and 8% of the total deaths, respectively.Young adults (25-34 years) had the highest proportion of deaths from TB (20%) and the risk of dying from TB among this age group was five times more likely than those aged 75+ years (AOR: 5.5 (95% CI 1.4 to 21.7)). Urban populations were 46% less likely to die from this disease compared rural ones although the difference was not significant (AOR: 0.54 (95% CI 0.3 to 1.0)). People from middle household wealth quintile were three times more likely to die from TB than those in the richest quintile (AOR: 3.0 (95% CI 1.3 to 7.4)).Young adults also had the highest proportion of deaths to HIV/AIDS (18%) and were nearly seven times more likely to die from this disease compared with those aged 75+years (AOR: 6.7 (95% CI 1.7 to 25.4)). Males were 48% less likely to die from HIV/AIDS than females (AOR: 0.52 (95% CI 0.3 to 0.9)). The risk of dying from HIV/AIDS in urban population was 54% less likely than their rural counterparts (AOR: 0.46 (95% CI 0.2 to 0.9)).

CONCLUSION

TB and HIV/AIDS interventions are needed to target vulnerable populations to reduce premature mortality from these diseases in PNG.

A socio-ecological analysis of factors influencing HIV treatment initiation and adherence among key populations in Papua New Guinea

BACKGROUND

In Papua New Guinea (PNG) members of key populations, including female sex workers (FSW), men who have sex with men (MSM) and transgender women (TGW), have higher rates of HIV compared to the general adult population and low engagement in HIV care. This paper examines the socio-ecological factors that encourage or hinder HIV treatment initiation and adherence among HIV positive members of key populations in PNG.

METHODS

As part of a larger biobehavioural survey of key populations in PNG, 111 semi-structured interviews were conducted with FSW, MSM and TGW, of whom 28 identified as living with HIV. Interviews from 28 HIV positive participants are used in this analysis of the influences that enabled or inhibited HIV treatment initiation and treatment adherence.

RESULTS

Enablers included awareness of the biomedical benefits of treatment; experiences of the social, familial and health benefits of early treatment initiation and adherence; support provided by family and friends; and non-judgmental and supportive HIV service provision. Factors that inhibited treatment initiation and adherence included perception of good health and denial of HIV diagnosis; poor family support following positive diagnosis; and anonymity and stigma concerns in HIV care services.

CONCLUSION

Exploring health promotion messages that highlight the positive health impacts of early treatment initiation and adherence; providing client-friendly services and community-based treatment initiation and supply; and rolling out HIV viral load testing across the country could improve health outcomes for these key populations.

HIV, syphilis and hepatitis B prevalence, related risk behaviours and correlates of condom use among transgender women in two cities in Sri Lanka: findings from respondent-driven sampling surveys

Background Biobehavioural data on transgender women (TGW) are limited globally.

METHODS

We used data collected as part of the 2017-18 National Integrated HIV Biobehavioural Survey, which included 254 TGW in Colombo and 252 in Jaffna, for structured questionnaire interviews and biological testing. We performed multivariable logistic regression analysis to explore factors associated with condom use.

RESULTS

We found low HIV prevalence in Colombo (0.6%) and no HIV infections in Jaffna. TGW in Colombo had higher positivity on the Treponema pallidum-particle agglutination test (2.5%) compared with TGW in Jaffna (0.4%). We found no hepatitis B infections. In both cities, <25% of TGW have comprehensive knowledge about HIV prevention. In Colombo 54.4%, but only 21.4% of TGW in Jaffna, have ever been tested for HIV. Drug-injecting behaviours are uncommon in both cities (prevalence <1%), whereas 7.4% reported sharing equipment for injecting feminising hormones in Colombo. Greater proportions of TGW in Colombo compared with Jaffna used condom at last sex (82.3% vs 37.7%). Multivariable analysis showed lower odds of condom use at last sex in TGW aged >30 years and those who did not test for HIV in the past 12 months in Colombo, and for TGW with higher income in Jaffna, TGW not visiting outdoor sites to find partners, and TGW who sold sex.

CONCLUSIONS

Current burden of HIV, syphilis and hepatitis B among TGW in Sri Lanka is low. Although risk behavioural patterns vary between the cities, a substantial sexually transmitted infection vulnerability is a common denominator, calling for strengthening of the capacity to respond to specific TGW needs.

Gaps in HIV Testing and Treatment Among Female Sex Workers in Lae and Mt. Hagen, Papua New Guinea

We conducted biobehavioral surveys among female sex workers (FSW) in Lae and Mt. Hagen, Papua New Guinea (January-December 2017). Respondent-driven sampling was used to recruit FSW aged ≥ 12 years, who were assigned female sex at birth, who spoke English or Tok Pisin, and who sold or exchanged sex for money, goods, or services in the last 6 months. When adjusted for viral suppression, 48.9% of FSW Lae and 61.9% in Mt. Hagen were aware of their HIV positive status. Of these women, 95.3% in Lae and 98.9% in Mt. Hagen were on antiretroviral therapy, and of these, 83.5% in Lae and 87.0% in Mt. Hagen had suppressed viral load. Renewed efforts are needed to increase HIV testing among FSW and provide support to FSW on treatment in both cities to attain viral suppression.

Strategic options for syphilis control in Papua New Guinea- impact and cost-effectiveness projections using the syphilis interventions towards elimination (SITE) model

Objectives

Papua New Guinea (PNG) has among the highest rates of sexually transmitted infections (STIs) globally and is committed to reducing their incidence. The Syphilis Interventions Towards Elimination (SITE) model was used to explore the expected impact and cost of alternative syphilis intervention scale-up scenarios.

Methods

SITE is a dynamical model of syphilis transmission among adults 15-49 years. Individuals are divided into nine groups based on sexual behaviour and into six stages of infection. The model was calibrated to PNG using data from routine surveillance, bio-behavioural surveys, research studies and program records. Inputs included syphilis prevalence, risk behaviours, intervention coverage and service delivery unit costs. Scenarios compared different interventions (clinical treatment, contact tracing, syphilis screening, and condom promotion) for incidence and cost per infection averted over 2021-2030.

Results

Increasing treatment coverage of symptomatic primary/secondary-stage syphilis cases from 25-35% in 2020 to 60% from 2023 onwards reduced estimated incidence over 2021-2030 by 55%, compared to a scenario assuming constant coverage at 2019-2020 levels. The introduction of contact tracing in 2020, assuming 0.4 contacts per symptomatic person treated, reduced incidence over 2021-2030 by 10%. Increasing screening coverage by 20-30 percentage points from the 2019-2020 level reduced incidence over 2021-2030 by 3-16% depending on the target population. Scaling-up clinical, symptom-driven treatment and contact tracing had the lowest cost per infection averted, followed by condom promotion and periodic screening of female sex workers and men who have sex with men.

Conclusions

PNG could considerably reduce its syphilis burden by scaling-up clinical treatment and contact tracing alongside targeted behavioural risk reduction interventions. SITE is a useful tool countries can apply to inform national STI programming and resource allocation.

High Prevalence of Chlamydia and Gonorrhea and the Need for Sexually Transmitted Infection Testing Among Men Who Have Sex With Men and Transgender Women in Papua New Guinea

BACKGROUND

Papua New Guinea has among the highest prevalence of sexually transmitted infections in the world but no estimates of Chlamydia trachomatis, Neisseria gonorrhoeae, or hepatitis B virus (HBV) are available among men who have sex with men (MSM) or transgender women (TGW).

METHODS

We conducted respondent-driven sampling surveys among MSM and TGW in Port Moresby, Lae, and Mt Hagen (2016-2017) to characterize the prevalence of these infections. Eligibility criteria were as follows: aged ≥12 years, born male, could speak English or Tok Pisin, and had oral or anal sex with another person born male in the past 6 months. Participants were surveyed face-to-face and offered testing for anorectal and genital chlamydia and gonorrhea, syphilis, HIV, and HBV. All results are respondent-driven sampling weighted.

RESULTS

We enrolled 400 participants in Port Moresby, 352 in Lae, and 111 in Mt Hagen. Chlamydia prevalence rates in the 3 cities regardless of anatomical site were 19.9%, 19.2%, and 24.3%, respectively. Gonorrhea prevalence rates regardless of anatomical site were 10.3%, 9.4%, and 9.6%, respectively. Hepatitis B virus prevalence rates were 11.7%, 13.8%, and 13.6%, respectively. In multivariable analysis, syphilis was associated with having either chlamydia or gonorrhea in Port Moresby (adjusted odds ratio, 4.0; 95% confidence interval, 2.0-7.9) and Lae (adjusted odds ratio, 2.4; 95% confidence interval, 1.2-5.0).

CONCLUSIONS

There is a large unmet need among MSM and TGW in Papua New Guinea for chlamydia and gonorrhea detection and treatment. The high prevalence of HBV reinforces the importance of ensuring introduction and scale-up of HBV treatment and immunization. Urgent efforts are needed to introduce laboratory-based diagnosis for chlamydia and gonorrhea to ensure these populations have access to much needed treatment services.

High prevalence of pulmonary tuberculosis among female sex workers, men who have sex with men, and transgender women in Papua New Guinea

Background

Papua New Guinea (PNG) has a tuberculosis (TB) case notification rate of 333 cases per 100,000 population in 2016 and is one of the 14 countries classified by the World Health Organization (WHO) as “high-burden” for TB, multi-drug-resistant TB (MDR-TB), and TB/HIV. HIV epidemic is mixed with a higher prevalence among key populations, female sex workers (FSW), men who have sex with men (MSM), and transgender women (TGW).

Methods

We conducted a cross-sectional HIV biobehavioral survey (BBS) using respondent-driven sampling method among FSW, MSM, and TGW in Port Moresby, Lae, and Mt. Hagen (2016–2017). As part of the study, participants were screened for the four symptoms suggestive of TB infection using the WHO TB screening algorithm. Sputum and venous whole blood samples were collected and tested for pulmonary TB and HIV infection, respectively. Pulmonary TB testing was performed using GeneXpert®MTB/RIF molecular point-of-care test, and HIV testing was done following the PNG national HIV testing algorithm. All data discussed are weighted unless otherwise mentioned.

Results

Among FSW, 72.6%, 52.0%, and 52.9% in Port Moresby, Lae, and Mt. Hagen, respectively, experienced at least one symptom suggestive of TB infection. Among MSM and TGW, 69% and 52.6% in Port Moresby and Lae, respectively, experienced at least one symptom suggestive of TB infection. Based on GeneXpert®MTB/RIF results, the estimated TB prevalence rate among FSW was 1200, 700, and 200 per 100,000 in Port Moresby, Lae, and Mt. Hagen, respectively. Among MSM and TGW, the estimated TB prevalence rate was 1000 and 1200 per 100,000 in Port Moresby and Lae, respectively. Co-prevalence of TB/HIV among FSW was 0.1% in Port Moresby and 0.2% in Lae. There were no co-prevalent cases among FSW in Mt. Hagen or among MSM and TGW in Port Moresby and Lae.

Conclusions

Key populations have a higher estimated rate of pulmonary TB than the national rate of pulmonary and extra-pulmonary TB combined. This showed that screening key populations for TB should be integrated into HIV programs regardless of HIV status in PNG’s national TB response.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41182-020-00293-w.

Confidential, accessible point-of-care sexual health services to support the participation of key populations in biobehavioural surveys: Lessons for Papua New Guinea and other settings where reach of key populations is limited

To achieve the UNAIDS 90-90-90 targets at a national level, many countries must accelerate service coverage among key populations. To do this, key population programs have adopted methods similar to those used in respondent-driven sampling (RDS) to expand reach. A deeper understanding of factors from RDS surveys that enhance health service engagement can improve key population programs. To understand the in-depth lives of key populations, acceptance of expanded point-of-care biological testing and determine drivers of participation in RDS surveys, we conducted semi-structured interviews with 111 key population participants (12-65 years) were purposefully selected from six biobehavioral surveys (BBS) in three cities in Papua New Guinea. Key populations were female sex workers, men who have sex with men, and transgender women. Four reasons motivated individuals to participate in the BBS: peer referrals; private, confidential, and stigma-free study facilities; "one-stop shop" services that provided multiple tests and with same-day results, sexually transmitted infection treatment, and referrals; and the desire to know ones' health status. Biobehavioral surveys, and programs offering key population services can incorporate the approach we used to facilitate key population engagement in the HIV cascade.