Access to and utilization of COVID-19 antigen rapid diagnostic tests (Ag-RDTs) among people living with HIV (PLWH): A mixed methods study from Cambodia

Several COVID-19 antigen rapid diagnostic tests have been approved in Cambodia, but no evidence exists about the access to and utilization of these tests. This limits public health interventions to increase testing, especially among vulnerable populations such as people living with HIV (PLWH). We conducted a mixed method study among PLWH in Phnom Penh, Cambodia, between July and August 2022 to understand their current Ag-RDT access and utilization levels, as well as key barriers and drivers. We undertook a cross-sectional survey and focus group discussions among 280 and 10 PLWH, respectively, from five HIV treatment centres using a probability-proportional-to-size and simple random sampling approach. Access was defined as having received a COVID-19 Ag-RDT within the six months and utilization as having administered a COVID-19 Ag-RDT, either to oneself or to others, within the 12 months prior to the study. We calculated means, standard deviations and proportions for continuous and categorical variables, using a linear regression model with random effects to account for clustering. Additionally, we fitted a logistic model with random effects to assess factors associated with Ag-RDT access. For the qualitative data, we used thematic analyses to identify barriers/enablers of Ag-RDT access and utilization. About 35% (n = 101) of PLWH reported having had access to an Ag-RDT test in the past six months. About 11% (n = 32) of the study participants administered the Ag-RDT to themselves, 4% (n = 10) to others and 9% (n = 24) have done both, in the past 12 months. Age and education appeared to be associated with Ag-RDT access in the logistic models. Price and advice from pharmacists were commonly reported to be the main selection criteria for the brand of Ag-RDT chosen. Ag-RDTs are an important diagnostic tool for COVID-19 among PLWH in Cambodia, but familiarity of use and price could hinder better uptake, access and utilization.

Beyond patient delay, navigating structural health system barriers to timely care and treatment in a high burden TB setting in Papua New Guinea

Tuberculosis (TB) is a major public health issue in Papua New Guinea, with incidence rates particularly high in the South Fly District of Western Province. We present three case studies, along with additional vignettes, that were derived from interviews and focus groups carried out between July 2019 and July 2020 of people living in rural areas of the remote South Fly District depicting their challenges accessing timely TB diagnosis and care; most services within the district are only offered offshore on Daru Island. The findings detail that rather than 'patient delay' attributed to poor health seeking behaviours and inadequate knowledge of TB symptoms, many people were actively trying to navigate structural barriers hindering access to and utilisation of limited local TB services. The findings highlight a fragile and fragmented health system, a lack of attention given to primary health services, and undue financial burdens placed on people living in rural and remote areas associated with costly transportation to access functioning health services. We conclude that a person-centred and effective decentralised model of TB care as outlined in health policies is imperative for equitable access to essential health care services in Papua New Guinea.

Towards the elimination of cervical cancer in low-income and lower-middle-income countries: modelled evaluation of the effectiveness and cost-effectiveness of point-of-care HPV self-collected screening and treatment in Papua New Guinea

Introduction

WHO has launched updated cervical screening guidelines, including provisions for primary HPV screen-and-treat. Papua New Guinea (PNG) has a high burden of cervical cancer, but no national cervical screening programme. We recently completed the first field trials of a screen-and-treat algorithm using point-of-care self-collected HPV and same-day treatment (hereafter self-collected HPV S&T) and showed this had superior clinical performance and acceptability to visual inspection of the cervix with acetic acid (VIA). We, therefore, evaluated the effectiveness, cost-effectiveness and resource implications of a national cervical screening programme using self-collected HPV S&T compared with VIA in PNG.

Methods

An extensively validated platform (‘Policy1-Cervix’) was calibrated to PNG. A total of 38 strategies were selected for investigation, and these incorporated variations in age ranges and screening frequencies and allowed for the identification of the optimal strategy across a wide range of possibilities. A selection of strategies that were identified as being the most effective and cost-effective were then selected for further investigation for longer-term outcomes and budget impact estimation. In the base case, we assumed primary HPV testing has a sensitivity to cervical intraepithelial neoplasia 2 (CIN2+) + of 91.8% and primary VIA of 51.5% based on our earlier field evaluation combined with evidence from the literature. We conservatively assumed HPV sampling and testing would cost US$18. Costs were estimated from a service provider perspective based on data from local field trials and local consultation.

Results

Self-collected HPV S&T was more effective and more cost-effective than VIA. Either twice or thrice lifetime self-collected HPV S&T would be cost-effective at 0.5× gross domestic product (GDP) per capita (incremental cost-effectiveness ratio: US$460–US$656/life-years saved; 1GDPper-capita: US$2829 or PGK9446 (year 2019)) and could prevent 33 000–42 000 cases and 23 000–29 000 deaths in PNG over the next 50 years, if scale-up reached 70% coverage from 2023.

Conclusion

Self-collected HPV S&T was effective and cost-effective in the high-burden, low-resource setting of PNG, and, if scaled-up rapidly, could prevent over 20 000 deaths over the next 50 years. VIA screening was not effective or cost-effective. These findings support, at a country level, WHO updated cervical screening guidelines and indicate that similar approaches could be appropriate for other low-resource settings.

Point-of-care testing and treatment of sexually transmitted and genital infections during pregnancy in Papua New Guinea (WANTAIM trial): protocol for an economic evaluation alongside a cluster-randomised trial

INTRODUCTION

Left untreated, sexually transmitted and genital infections (henceforth STIs) in pregnancy can lead to serious adverse outcomes for mother and child. Papua New Guinea (PNG) has among the highest prevalence of curable STIs including syphilis, chlamydia, gonorrhoea, trichomoniasis and bacterial vaginosis, and high neonatal mortality rates. Diagnosis and treatment of these STIs in PNG rely on syndromic management. Advances in STI diagnostics through point-of-care (PoC) testing using GeneXpert technology hold promise for resource-constrained countries such as PNG. This paper describes the planned economic evaluation of a cluster-randomised cross-over trial comparing antenatal PoC testing and immediate treatment of curable STIs with standard antenatal care in two provinces in PNG.

METHODS AND ANALYSIS

Cost-effectiveness of the PoC intervention compared with standard antenatal care will be assessed prospectively over the trial period (2017-2021) from societal and provider perspectives. Incremental cost-effectiveness ratios will be calculated for the primary health outcome, a composite measure of the proportion of either preterm birth and/or low birth weight; for life years saved; for disability-adjusted life years averted; and for non-health benefits (financial risk protection and improved health equity). Scenario analyses will be conducted to identify scale-up options, and budget impact analysis will be undertaken to understand short-term financial impacts of intervention adoption on the national budget. Deterministic and probabilistic sensitivity analysis will be conducted to account for uncertainty in key model inputs.

ETHICS AND DISSEMINATION

This study has ethical approval from the Institutional Review Board of the PNG Institute of Medical Research; the Medical Research Advisory Committee of the PNG National Department of Health; the Human Research Ethics Committee of the University of New South Wales; and the Research Ethics Committee of the London School of Hygiene and Tropical Medicine. Findings will be disseminated through national stakeholder meetings, conferences, peer-reviewed publications and policy briefs.

TRIAL REGISTRATION NUMBER

ISRCTN37134032.

Loss to follow up of pregnant women with HIV and infant HIV outcomes in the prevention of maternal to child transmission of HIV programme in two high-burden provinces in Papua New Guinea: a retrospective clinical audit

INTRODUCTION

Despite early adoption of the WHO guidelines to deliver lifelong antiretroviral (ARV) regimen to pregnant women on HIV diagnosis, the HIV prevention of mother to child transmission programme in Papua New Guinea remains suboptimal. An unacceptable number of babies are infected with HIV and mothers not retained in treatment. This study aimed to describe the characteristics of this programme and to investigate the factors associated with programme performance outcomes.

METHODS

We conducted a retrospective analysis of clinical records of HIV-positive pregnant women at two hospitals providing prevention of mother to child transmission services. All women enrolled in the prevention of mother to child transmission programme during the study period (June 2012-June 2015) were eligible for inclusion. Using logistic regression, we examined the factors associated with maternal loss to follow-up (LTFU) before birth and before infant registration in a paediatric ARV programme.

RESULTS

763 of women had records eligible for inclusion. Demographic and clinical differences existed between women at the two sites. Almost half (45.1%) of the women knew their HIV-positive status prior to the current pregnancy. Multivariate analysis showed that women more likely to be LTFU by the time of birth were younger (adjusted OR (AOR)=2.92, 95% CI 1.16 to 7.63), were newly diagnosed with HIV in the current/most recent pregnancy (AOR=3.50, 95% CI 1.62 to 7.59) and were in an HIV serodiscordant relationship (AOR=2.94, 95% CI 1.11 to 7.84). Factors associated with maternal LTFU before infant registration included being primipara at the time of enrolment (AOR=3.13, 95% CI 1.44 to 6.80) and being newly diagnosed in that current/most recent pregnancy (AOR=2.49, 95% CI 1.31 to 4.73). 6.6% (50 of 763) of exposed infants had a positive HIV DNA test.

CONCLUSIONS

Our study highlighted predictors of LTFU among women. Understanding these correlates at different stages of the programme offers important insights for targets and timing of greater support for retention in care.

Evaluation of Commercially Available Viral Transport Medium (VTM) for SARS-CoV-2 Inactivation and Use in Point-of-Care (POC) Testing

Critical to facilitating SARS-CoV-2 point-of-care (POC) testing is assurance that viruses present in specimens are inactivated onsite prior to processing. Here, we conducted experiments to determine the virucidal activity of commercially available Viral Transport Mediums (VTMs) to inactivate SARS-CoV-2. Independent testing methods for viral inactivation testing were applied, including a previously described World Health Organization (WHO) protocol, in addition to a buffer exchange method where the virus is physically separated from the VTM post exposure. The latter method enables sensitive detection of viral viability at higher viral titre when incubated with VTM. We demonstrate that VTM formulations, Primestore® Molecular Transport Medium (MTM) and COPAN eNAT™ completely inactivate high-titre SARS-CoV-2 virus (>1 × 107 copies/mL) and are compatible with POC processing. Furthermore, full viral inactivation was rapidly achieved in as little as 2 min of VTM exposure. We conclude that adding certain VTM formulations as a first step post specimen collection will render SARS-CoV-2 non-infectious for transport, or for further in-field POC molecular testing using rapid turnaround GeneXpert platforms or equivalent.

Qualitative Evidence Synthesis on Self-Collection for Human Papillomavirus-Based Cervical Screening: Protocol for Systematic Review

Background

Cervical cancer is the fourth most common cancer affecting women worldwide. In the 1980s, it was found that the sexually transmitted disease human papillomavirus causes over 90% of all cervical cancer cases. Since that discovery, diagnostic technologies have been developed for the detection of human papillomavirus DNA in cervical samples. However, significant sociocultural and structural barriers remain. Considerable strides have taken place in recent years to address these barriers, such as the self-collection for human papillomavirus–based cervical screening method.

Objective

The purpose of this review is to synthesize qualitative evidence around the self-collection method and identify strategies to increase acceptability and feasibility in different settings. This qualitative synthesis will be used to better understand how to conceptualize and implement more effective, accessible, and socially and culturally acceptable cervical screening programs and policies globally.

Methods

A systematic search will be conducted in Global Health, Cochrane, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ProQuest, ScienceDirect, EMBASE, EMCARE, Medline (OVID), Scopus, and Web of Science. Published and peer-reviewed articles will be included. Two reviewers will independently screen and assess the studies. The data will be coded and analyzed using a thematic synthesis process. The socioecological model will be used to organize emergent themes at the micro and macro levels. The results will be presented in narrative and tabular form.

Results

The article search and data extraction were completed in May 2020. The data were analyzed in June 2020. The review will be submitted for publication in Fall 2020.

Conclusions

This review will present the global evidence of the perspectives and experiences of various key stakeholders and how these perspectives and experiences impact their decision-making process to perform or accept self-collection for human papillomavirus–based cervical screening. The review will provide guidance to implementation researchers as well as implications for future research.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42019109073; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=109073

International Registered Report Identifier (IRRID)

DERR1-10.2196/21093

Cost and cost-effectiveness of point-of-care testing and treatment for sexually transmitted and genital infections in pregnancy in low-income and middle-income countries: a systematic review protocol

INTRODUCTION

The economic and health burden of sexually transmitted and genital infections (henceforth, STIs) in low-income and middle-income countries (LMICs) is substantial. Left untreated, STIs during pregnancy may result in several adverse pregnancy and birth outcomes. Timely diagnosis and treatment at point-of-care (POC) can potentially improve these outcomes. Despite the availability and promotion of POC diagnostics for STIs as a key component of antenatal care in LMICs, their widespread use has been limited, owing to the high economic costs faced by individuals and health systems. To date, there have been no systematic reviews which explore the cost or cost-effectiveness of POC testing and treatment of STIs in pregnancy in LMICs. The objective of this protocol is to outline the methods that will compare, synthesise and appraise the existing literature in this domain.

METHODS AND ANALYSIS

We will conduct literature searches in MEDLINE, Embase and Web of Science. To find additional literature, we will search Google Scholar and hand search reference lists of included papers. Two reviewers will independently search databases, screen titles, abstracts and full texts; when necessary a third reviewer will resolve disputes. Only cost and cost-effectiveness studies of POC testing and treatment of STIs, including syphilis, chlamydia, trichomonas, gonorrhoea and bacterial vaginosis, in pregnancy in LMICs will be included. Published checklists will be used to assess quality of reporting practices and methodological approaches. We will also assess risk of publication bias. Interstudy heterogeneity will be assessed and depending on variation between studies, a meta-analysis or narrative synthesis will be conducted.

ETHICS AND DISSEMINATION

Ethical approval is not required as the review will use published literature. The results will be published in a peer-reviewed open source journal and presented at an international conference.

PROSPERO REGISTRATION NUMBER

CRD42018109072.

Health service delivery models for scaling use of point-of-care HPV 'test and treat' strategies in high-burden, low-income settings

Visual inspection of the cervix with acetic acid (VIA) has shown disappointing performance when used alone as part of screen and treat strategies for cervical cancer prevention in Papua New Guinea. Point-of-care testing with the Xpert® HPV assay (Cepheid, Sunnyvale, CA, USA) offers a new approach, enabling 'test and treat' services using self-collected specimens with same-day curative cervical ablation (cryotherapy or thermocoagulation).

A reliable and easy to transport quality control method for chlamydia and gonorrhoea molecular point of care testing

Quality control (QC) is an essential component of point-of-care testing programs. In the context of a randomised-controlled trial (TTANGO) using GeneXpert (Xpert) Chlamydia trachomatis and Neisseria gonorrhoeae (CT/NG) point-of-care testing in remote areas of Australia, we aimed to develop and utilise a stable positive control material. Bacterial cultures of CT and NG were resuspended together to provide cycle threshold (C_t) values of approximately 25 cycles for both CT and NG when tested on the Xpert CT/NG assay. These positive control suspensions were dried in aliquots, heat inactivated, and then provided to 12 participating health services as research-only QC samples in kit form. At each service, a QC sample was resuspended and tested each month on the Xpert. QC results, including Xpert C_t values, were analysed from each site over 30 months and we calculated costs per QC sample. Overall, at 12 health services there were 89 QC samples tested (average of 8 tests per site per year). Mean C_t values for the 89 controls samples were 25.25 cycles (SD = 1.15) for CT, 24.04 cycles (SD = 1.400) for one NG target and 23.35 cycles (SD = 1.55) for the other NG target. No significant differences in C_t value for CT or NG controls were observed over a trial period of 30 months. Positive QC samples for research use in a trial of a molecular point-of-care assay were inexpensive to produce and stable when stored at 2-8°C. For routine use, additional requirements such as meeting National Association of Testing Authority (NATA) regulations and Therapeutic Goods Administration (TGA) approval will need to be achieved.

Re-establishing safer medical-circumcision-integrated initiation ceremonies for HIV prevention in a rural setting in Papua New Guinea. A multi-method acceptability study

Background

Efforts to stem the spread of Human Immunodeficiency Virus (HIV) in Papua New Guinea (PNG) are hampered by multiple interrelated factors including limited health services, extreme diversities in culture and language and highly prevalent gender inequity, domestic violence and poverty. In the rural district of Yangoru-Saussia, a revival of previously ceased male initiation ceremonies (MICs) is being considered for a comprehensive approach to HIV prevention. In this study, we explore the local acceptability of this undertaking including replacing traditional penile cutting practices with medical male circumcision (MMC).

Methods

A multi-method study comprising three phases. Phase one, focus group discussions with male elders to explore locally appropriate approaches to HIV prevention; Phase two, interviews and a cross-sectional survey with community men and women to assess views on MICs that include MMC for HIV prevention; Phase three, interviews with cultural leaders and a cross sectional survey to assess the acceptability of replacing traditional penile bleeding with MMC.

Results

Cultural leaders expressed that re-establishing MICs was locally appropriate for HIV prevention given the focus on character building and cultural preservation. Most surveyed participants (81.5%) supported re-establishing MICs and 92.2% supported adapting MICs with MMC. Changes to penile bleeding emerged as a contentious and contested issue given its cultural significance in symbolizing initiates’ transition from childhood to adulthood. Participants were concerned about potential clash with modern education, introduced religious beliefs and limited government support in leadership and funding.

Conclusions

Most people in this study in Yangoru-Saussia support re-establishing MICs and replacing traditional penile bleeding with MMC. This culturally-sensitive alignment of MMC (and HIV prevention) with revived MICs responds to a national health priority in PNG and acts as an example of providing culturally-sensitive male circumcision for HIV prevention recommended by WHO/UNAIDS. However, the implementation of this undertaking will require considerable effort, especially when modern pursuits in education and religion must be factored and when there is expectation for local authorities to lead and provide funding.

Transgressive women don't deserve protection: young men's narratives of sexual violence against women in rural Papua New Guinea

Sexual violence against women and girls is commonplace in Papua New Guinea (PNG). While the experiences of women are rightly given central place in institutional responses to sexual violence, the men who perpetrate violence are often overlooked, an oversight that undermines the effectiveness of prevention efforts. This paper draws on interviews conducted with young men as part of a qualitative longitudinal study of masculinity and male sexuality in a rural highland area of PNG. It explores one aspect of male sexuality: men's narratives of sexual violence. Most striking from the data is that the collective enactment of sexual violence against women and girls is reported as an everyday and accepted practice amongst young men. However, not all women and girls were described as equally at risk, with those who transgress gender roles and roles inscribed and reinforced by patriarchal structures, at greater risk. To address this situation, efforts to reduce sexual violence against women and girls require an increased focus on male-centred intervention to critically engage with the forms of patriarchal authority that give license to sexual violence. Understanding the perceptions and experiences of men as perpetrators of sexual violence is a critical first step in the process of changing normative perceptions of gender, a task crucial to reducing sexual violence in countries such as PNG.

A novel point-of-care testing strategy for sexually transmitted infections among pregnant women in high-burden settings: results of a feasibility study in Papua New Guinea

Background

Sexually transmitted and genital infections in pregnancy are associated with an increased risk of adverse maternal and neonatal health outcomes. High prevalences of sexually transmitted infections have been identified among antenatal attenders in Papua New Guinea. Papua New Guinea has amongst the highest neonatal mortality rates worldwide, with preterm birth and low birth weight major contributors to neonatal mortality. The overall aim of our study was to determine if a novel point-of-care testing and treatment strategy for the sexually transmitted and genital infections Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Trichomonas vaginalis (TV) and Bacterial vaginosis (BV) in pregnancy is feasible in the high-burden, low-income setting of Papua New Guinea.

Methods

Women attending their first antenatal clinic visit were invited to participate. CT/NG and TV were tested using the GeneXpert platform (Cepheid, USA), and BV tested using BVBlue (Gryphus Diagnostics, USA). Participants received same-day test results and antibiotic treatment as indicated. Routine antenatal care including HIV and syphilis screening were provided.

Results

Point-of-care testing was provided to 125/222 (56 %) of women attending routine antenatal care during the three-month study period. Among the 125 women enrolled, the prevalence of CT was 20.0 %; NG, 11.2 %; TV, 37.6 %; and BV, 17.6 %. Over half (67/125, 53.6 %) of women had one or more of these infections. Most women were asymptomatic (71.6 %; 47/67). Women aged 24 years and under were more likely to have one or more STI compared with older women (odds ratio 2.38; 95 % CI: 1.09, 5.21). Most women with an STI received treatment on the same day (83.6 %; 56/67). HIV prevalence was 1.6 % and active syphilis 4.0 %.

Conclusion

Point-of-care STI testing and treatment using a combination of novel, newly-available assays was feasible during routine antenatal care in this setting. This strategy has not previously been evaluated in any setting and offers the potential to transform STI management in pregnancy and to prevent their associated adverse health outcomes.

The Association Between Cervical Human Papillomavirus Infection and Subsequent HIV Acquisition in Tanzanian and Ugandan Women: A Nested Case-Control Study

OBJECTIVE

This study was performed to analyze the associations between cervical human papillomavirus (HPV) infection and human immunodeficiency virus (HIV) acquisition, using cervical samples from previous studies in Tanzania and Uganda.

METHODS

A total of 161 adult women who acquired HIV infection during follow-up and 464 individually matched HIV-seronegative controls were selected from 5 cohorts of women working in bars and recreational facilities. Stored cervical samples were tested for 37 HPV genotypes, using a polymerase chain reaction assay (Roche Linear Array genotyping assay). Multivariate matched analysis using conditional logistic regression was performed to evaluate HPV infection, persistence, and clearance as predictors of HIV acquisition.

RESULTS

HIV seroconverters were significantly more likely than controls to frequently drink alcohol and to be infected with Chlamydia trachomatis, Neisseria gonorrhoeae, or herpes simplex virus type 2. There was no evidence of an association between HIV acquisition and any detectable HPV at the visit prior to HIV seroconversion (adjusted odds ratio, 1.02; 95% confidence interval, .66-1.57) or between HIV acquisition and persistent HPV infection (defined as 2 positive HPV genotype-specific test results at least 6 months apart), cleared HPV infection (defined as a positive HPV test result followed by negative HPV genotype-specific test result), or newly acquired HPV infection, compared with HPV-negative women.

CONCLUSIONS

There was no evidence of association between HPV infection status and subsequent HIV acquisition. These results stand in contrast to other observational studies.

Feasibility and acceptability of clean birth kits containing misoprostol for self-administration to prevent postpartum hemorrhage in rural Papua New Guinea

OBJECTIVE

To determine the feasibility and acceptability of providing clean birth kits (CBKs) containing misoprostol for self-administration in a rural setting in Papua New Guinea.

METHODS

A prospective intervention study was conducted between April 8, 2013, and October 24, 2014. Eligible participants were women in the third trimester of pregnancy who attended a prenatal clinic in Unggai Bena. Participants received individual instruction and were then given a CBK containing 600μg misoprostol tablets for self-administration following an unsupervised birth if they could demonstrate their understanding of correct use of items in the CBK. Data regarding the use and acceptability of the CBK and misoprostol were collected during postpartum follow-up.

RESULTS

Among 200 participants, 106 (53.0%) had an unsupervised birth, and 99 (93.4%) of these women used the CBK. All would use the CBK again and would recommend it to others. Among these 99 women, misoprostol was self-administered by 98 (99.0%), all of whom would take the drug again and would recommend it to others.

CONCLUSION

The findings strengthen the case for community-based use of misoprostol to prevent postpartum hemorrhage in remote communities. Large-scale interventions should be planned to further evaluate impact and acceptability.

A cluster-randomised controlled trial integrating a community-based water, sanitation and hygiene programme, with mass distribution of albendazole to reduce intestinal parasites in Timor-Leste: the WASH for WORMS research protocol

INTRODUCTION

There is limited evidence demonstrating the benefits of community-based water, sanitation and hygiene (WASH) programmes on infections with soil-transmitted helminths (STH) and intestinal protozoa. Our study aims to contribute to that evidence base by investigating the effectiveness of combining two complementary approaches for control of STH: periodic mass administration of albendazole, and delivery of a community-based WASH programme.

METHODS AND ANALYSIS

WASH for WORMS is a cluster-randomised controlled trial to test the hypothesis that a community-based WASH intervention integrated with periodic mass distribution of albendazole will be more effective in reducing infections with STH and protozoa than mass deworming alone. All 18 participating rural communities in Timor-Leste receive mass chemotherapy every 6 months. Half the communities also receive the community-based WASH programme. Primary outcomes are the cumulative incidence of infection with STH. Secondary outcomes include the prevalence of protozoa; intensity of infection with STH; as well as morbidity indicators (anaemia, stunting and wasting). Each of the trial outcomes will be compared between control and intervention communities. End points will be measured 2 years after the first albendazole distribution; and midpoints are measured at 6 months intervals (12 months for haemoglobin and anthropometric indexes). Mixed-methods research will also be conducted in order to identify barriers and enablers associated with the acceptability and uptake of the WASH programme.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the human ethics committees at the University of Queensland, Australian National University, Timorese Ministry of Health, and University of Melbourne. The results of the trial will be published in peer-reviewed journals presented at national and international conferences, and disseminated to relevant stakeholders in health and WASH programmes. This study is funded by a Partnership for Better Health--Project grant from the National Health and Research Council (NHMRC), Australia.

TRIAL REGISTRATION NUMBER

ACTRN12614000680662; Pre-results.

Factors associated with antiretroviral treatment uptake and adherence: a review. Perspectives from Australia, Canada, and the United Kingdom

International focus on reducing onward HIV transmission emphasizes the need for routine HIV testing and early uptake of antiretroviral treatment (ART). Strategic targets have been set for 2020 to achieve the goal of 90% of people infected with HIV diagnosed, 90% of identified cases on treatment, and 90% of persons on treatment virally suppressed (90-90-90). It is vital to understand the complexity of factors influencing a person's treatment decisions over time and the context which may enable better adherence. In this paper we present findings from the review of published and gray literature (2003-2013) on the documented factors associated with treatment initiation and adherence in the general adult population of Australia, Canada, and the UK. A framework developed by Begley, McLaws, Ross, and Gold [2008. Cognitive and behavioural correlates of non-adherence to HIV anti-retroviral therapy: Theoretical and practical insight for clinical psychology and health psychology. Clinical Psychologist, 12(1), 9-17] in Australia was adapted to summarize the findings. A systematic database search using keywords and a set of inclusion criteria yielded 17 studies (Australia = 6; Canada = 8; UK = 3). In addition 11 reports were included in the review. We found that a person's abilities and motivations (intrapersonal factors, reported in 7 studies) to start and continue ART are influenced by a host of interconnected factors spanning relationship (interpersonal, 3 studies) and broader structural (extrapersonal, 15 studies) factors that are situated within social determinants of health. People therefore evaluate various costs and benefits of starting and staying on treatment, in which biomedical concerns play an important yet often subsidiary role. In this review the economic barriers to care were found to be significant and under-reported, highlighting the persistent health inequities in terms of access to services. Our understanding of the context around people's use of ART remains poor. Qualitative social research within HIV-positive communities is urgently needed to capture people's lived experiences and may address some of this deficit in understanding.

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.

Factors impacting HIV testing: a review--perspectives from Australia, Canada, and the UK

With the current global focus on strengthening HIV prevention through greater testing and treatment uptake, it is increasingly salient to identify and address barriers to testing. A review of the published, peer-reviewed literature and national reports from Australia, Canada, and the UK (2003-2013) on barriers to HIV testing was conducted to provide new information relevant to Australia and to complement earlier reviews from Canada and the UK. A systematic database search using keywords and a set of inclusion criteria yielded 36 studies (Australia = 13; Canada = 6; and the UK = 17). In addition 17 unpublished reports were included in the review. Our study uses a novel, comprehensive framework to describe barriers to HIV testing, and thus contributes to moving beyond the traditional patient-provider-system categorization. Within that framework, barriers are categorized as either intrapersonal (reported in 15 studies), interpersonal (21), or extrapersonal (16) and conceptualized within wider sociocultural and structural contexts. People's abilities and motivations to test (intrapersonal factors) are influenced by a host of interconnected factors spanning relationship (interpersonal) and broader socioeconomic, political and cultural (extrapersonal) factors. We suggest that the relative effects of interventions targeting barriers to HIV testing at the intrapersonal and interpersonal levels are limited by the extent to which the social determinants of health are addressed. The framework may also lend itself to thinking about the enabling factors for HIV testing, and future research may investigate the application of that framework for strategizing the most effective response. Future studies should also capture the lived experiences of barriers to HIV testing experienced by patients, especially in populations which are hard to reach based on social and geographic distance. Context-specific studies to evaluate the feasibility and effectiveness of various interventions proposed in the literature to address barriers to HIV testing are needed.

Prevalence and risk factors for Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis infection in pregnant women in Papua New Guinea

OBJECTIVE

To determine the prevalence of, and risk factors associated with, Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis infection in pregnant women in Madang, Papua New Guinea (PNG).

METHODS

A cross-sectional survey was conducted among 400 pregnant women presenting to antenatal clinics. Sociodemographic and behavioural data were collected and real-time PCR diagnostic methods were used to detect the presence of chlamydia, gonorrhoea and trichomonas in self-collected vaginal swabs. The relationships between symptoms, sociodemographic and behavioural factors and infection were assessed.

RESULTS

The prevalence of C. trachomatis was 11.1%, N. gonorrhoeae was 9.7% and T. vaginalis was 21.3%. One-third of women (33.7%) had at least one infection. The most common symptom was abdominal pain (48.0%), but only abnormal vaginal discharge was consistently associated with infection (p<0.001). Women diagnosed with vaginal discharge syndrome were more likely to have at least one treatable infection (50.0% (47/94)  vs 26.8% (68/254), p<0.001), yet 59.1% of women with infection would have been missed by the current clinically-based syndromic diagnosis. Risk factors included having a partner at perceived risk of infection, maternal extramarital intercourse, early sexual debut, lack of formal education, urban residence and smoking. 78.8% of women reported never using condoms.

CONCLUSIONS

The prevalences of T. vaginalis, C. trachomatis and N. gonorrhoeae were high among pregnant women in coastal PNG. The poor performance of clinically based syndromic diagnosis suggests that alternative strategies are urgently required to improve detection and reduce the burden of sexually transmitted infections and their associated adverse pregnancy outcomes in this population.

Male Circumcision and HIV Transmission; What Do We Know?

Male circumcision (MC) has been shown to be protective against heterosexual HIV transmission and is being explored in some parts of the world as a means of combating the epidemic. The World Health Organization (WHO) recommends that MC be considered as an important component of HIV prevention in high prevalence settings.

We review evidence that demonstrates that the inner foreskin is likely to be the main portal of entry for the HIV virus in males. Whether removal of the inner foreskin accounts for all the protection afforded by circumcision is yet to be established.

The proposed mechanisms of protection range from inherent immunohistological factors of foreskin such as difference in thickness of keratin layer and density of target cells for HIV between inner and outer foreskin to physiological mechanisms that follow male circumcision such as drying of secretions underneath foreskin after sexual intercourse, loss of microbiome that attract target cells to the genital mucosa and lack of priming the genital mucosa with less abundant sexual transmitted infections among circumcised men.

The aim of this review is to give an updated account on the mechanisms proposed so far on the demonstrated 50-70% protection from HIV transmission through heterosexual intercourse, by male circumcision.

High prevalence and incidence of HIV, sexually transmissible infections and penile foreskin cutting among sexual health clinic attendees in Papua New Guinea

Background Papua New Guinea (PNG) has one of the highest prevalences of HIV and sexually transmissible infections (STIs) in the Asia-Pacific region, and one of the highest burdens of maternal syphilis and cervical cancer globally. Despite this disease burden, only limited clinical research in sexual and reproductive health has been conducted in PNG.

METHODS

A longitudinal clinical cohort study was conducted at two sexual health clinics. Participants completed a behavioural interview, clinical assessment and genital examination at baseline, and at 12, 24 and 50 weeks, including specimen collection for STI diagnostics.

RESULTS

In total, 154 people attended a screening visit. Reattendance at 12, 24 and 50-weeks was 87%, 78% and 80% respectively. At baseline, HIV prevalence was 3.3%; chlamydia (Chlamydia trachomatis), 29.2%; gonorrhoea (Neisseria gonorrhoeae), 22.1%; Trichomonas vaginalis 15.6%; herpes simplex type-2 (HSV-2), 46.1%; active syphilis, 11.7%. Multiple infections were common particularly among women. The incidence of chlamydia was 27 per 100 person-years (PY); gonorrhoea, 15 out of 100 PY; T. vaginalis, 29 out of 100 PY; HSV-2, 12 out of 100 PY; syphilis, 8 out of 100 PY. No incident HIV cases were recorded. At baseline, 39% of men in Mt Hagen and 65% in Port Moresby had a penile foreskin cut, with a dorsal slit being the most common. Two men underwent penile cutting during the follow-up period.

CONCLUSIONS

The prevalence and incidence of STIs, HIV and penile cutting were high among sexual health clinic attendees. High retention figures suggest that this population may be suitable for future interventions research and clinical trials.

Comparative performance of the Kalon and HerpeSelect enzyme-linked immunosorbant assays to determine the prevalence of herpes simplex virus type 2 in Papua New Guinea

Background Infection with herpes simplex virus type 2 (HSV-2) is common worldwide and an important risk factor for HIV infection. Aetiological diagnosis of HSV-2 is typically determined with the use of commercially available type-specific enzyme-linked immunosorbent assays (ELISAs). This study aimed to determine the prevalence of HSV-2 among people attending sexual health clinics in the Highlands of Papua New Guinea. The study also aimed to compare the performance of two type-specific ELISA assays, the Kalon and HerpeSelect glycoprotein G2 assays, in this context.

METHODS

Participants were recruited as part of a longitudinal sexual health study. Participants attended four appointments over a 12-month period and had blood taken for HSV-2 serology at each time point. Both the Kalon and HerpeSelect assays were performed as per manufacturer's instructions.

RESULTS

A total of 132 participants were tested for HSV-2 using the Kalon and HerpeSelect ELISAs. HSV-2 prevalence was 52% (95% CI, 43-60) and 61% (95% CI, 52-69) with Kalon and HerpeSelect assays respectively. There was high concordance (87%, ?=0.75, P<0.001, n=115) between the two assays at the manufacturer recommended index value cut-offs. For participants with discordant results at baseline, (n=16), three sero-conversions were observed over the 12-month period when sequential sera was tested.

CONCLUSIONS

A high HSV-2 prevalence was observed in this clinic-based population. Our longitudinal data indicate the higher prevalence of HSV-2 detected with the HerpeSelect ELISA was likely due to false positives rather than a higher sensitivity in the early stages of infection.

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

Background

Papua 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.

Methods

We 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.

Results

There 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.

Conclusions

Our 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.

Building social currency with foreskin cuts: a coping mechanism of Papua New Guinea health workers and the implications for new programmes

BACKGROUND

Recent research as part of a multi-disciplinary investigation on the acceptability and impact of male circumcision for HIV prevention in Papua New Guinea (PNG) has shown that health workers (HWs) undertake unauthorized forms of penile cutting practices in public health facilities or in community settings, at times within a traditional context. Participation in these activities shares common features with coping mechanisms, strategies used by HWs to alleviate the burden of unsatisfactory living and working conditions. Coping mechanisms, however, are typically described as motivated by economic advantage, but in PNG evidence exists that the behaviours of HWs are also influenced by opportunities for social capital.

METHODS

Twenty-five in-depth interviews (IDIs) were completed with a variety of HWs from 2009 until 2011 and were triangulated with findings from 45 focus group discussions and 82 IDIs completed with community members as part of a wider qualitative study. Thematic analysis examined HW participation in unauthorized penile cutting services.

RESULTS

The emergence of unauthorized practices as a coping mechanism in PNG is compelled by mutual obligations and social capital arising from community recognition and satisfaction of moral, professional and cultural obligations. Using the example of unauthorized penile cutting practices amongst HWs in PNG, the research shows that although economic gains are not explicitly derived, evidence exists that they meet other community and socio cultural responsibilities forming a social currency within local traditional economies.

CONCLUSIONS

Coping mechanisms create an opportunity to extend the boundaries of a health system at the discretion of the HW. Fragile health systems create opportunities for coping mechanisms to become institutionalized, pre-empting appropriate policy development or regulation in the introduction of new programmes. In order to ensure the success of new programmes, the existence of such practices and their potential implications must be addressed within programme design, and in implementation and regulation.

Listening to diverse community voices: the tensions of responding to community expectations in developing a male circumcision program for HIV prevention in Papua New Guinea

BACKGROUND

The success of health programs is influenced not only by their acceptability but also their ability to meet and respond to community expectations of service delivery. The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have recommended medical male circumcision (MC) as an essential component of comprehensive HIV prevention programs in high burden settings. This study investigated community-level perceptions of MC for HIV prevention in Papua New Guinea (PNG), a setting where diverse traditional and contemporary forms of penile foreskin cutting practices have been described.

METHODS

A multi-method qualitative study was undertaken in four provinces in two stages from 2009 to 2011. A total of 82 in-depth interviews, and 45 focus group discussions were completed during Stage 1. Stage 2 incorporated eight participatory workshops that were an integral part of the research dissemination process to communities. The workshops also provided opportunity to review key themes and consolidate earlier findings as part of the research process. Qualitative data analysis used a grounded theory approach and was facilitated using qualitative data management software.

RESULTS

A number of diverse considerations for the delivery of MC for HIV prevention in PNG were described, with conflicting views both between and within communities. Key issues included: location of the service, service provider, age eligibility, type of cut, community awareness and potential shame amongst youth. Key to developing appropriate health service delivery models was an appreciation of the differences in expectations and traditions of unique cultural groups in PNG. Establishing strong community coalitions, raising awareness and building trust were seen as integral to success.

CONCLUSIONS

Difficulties exist in the implementation of new programs in a pluralistic society such as PNG, particularly if tensions arise between biomedical knowledge and medico-legal requirements, compared to existing socio-cultural interests. Community participatory approaches offer important opportunities to explore and design culturally safe, specific and accessible programs.

A high-resolution geospatial surveillance-response system for malaria elimination in Solomon Islands and Vanuatu

Background

A high-resolution surveillance-response system has been developed within a geographic information system (GIS) to support malaria elimination in the Pacific. This paper examines the application of a GIS-based spatial decision support system (SDSS) to automatically locate and map the distribution of confirmed malaria cases, rapidly classify active transmission foci, and guide targeted responses in elimination zones.

Methods

Customized SDSS-based surveillance-response systems were developed in the three elimination provinces of Isabel and Temotu, Solomon Islands and Tafea, Vanuatu. Confirmed malaria cases were reported to provincial malaria offices upon diagnosis and updated into the respective SDSS as part of routine operations throughout 2011. Cases were automatically mapped by household within the SDSS using existing geographical reconnaissance (GR) data. GIS queries were integrated into the SDSS-framework to automatically classify and map transmission foci based on the spatiotemporal distribution of cases, highlight current areas of interest (AOI) regions to conduct foci-specific targeted response, and extract supporting household and population data. GIS simulations were run to detect AOIs triggered throughout 2011 in each elimination province and conduct a sensitivity analysis to calculate the proportion of positive cases, households and population highlighted in AOI regions of a varying geographic radius.

Results

A total of 183 confirmed cases were reported and mapped using the SDSS throughout 2011 and used to describe transmission within a target population of 90,354. Automatic AOI regions were also generated within each provincial SDSS identifying geographic areas to conduct response. 82.5% of confirmed cases were automatically geo-referenced and mapped at the household level, with 100% of remaining cases geo-referenced at a village level. Data from the AOI analysis indicated different stages of progress in each province, highlighting operational implications with regards to strategies for implementing surveillance-response in consideration of the spatiotemporal nature of cases as well as logistical and financial constraints of the respective programmes.

Conclusions

Geospatial systems developed to guide Pacific Island malaria elimination demonstrate the application of a high resolution SDSS-based approach to support key elements of surveillance-response including understanding epidemiological variation within target areas, implementing appropriate foci-specific targeted response, and consideration of logistical constraints and costs.

Sociocultural and individual determinants for motivation of sexual and reproductive health workers in Papua New Guinea and their implications for male circumcision as an HIV prevention strategy

BACKGROUND

The motivation of health workers (HWs) to deliver services in developing countries has been described as a critical factor in the success of health systems in implementing programmes. How the sociocultural context of Papua New Guinea (PNG) affects the values, motivation and actions of HWs involved in sexual and reproductive health services is important for policy development and programme planning. With interest in male circumcision (MC) as an HIV prevention option in PNG, this study explored the perceptions and motivations of HWs involved in sexual and reproductive health services in PNG, examining their implications for the possible future roll out of a national MC programme.

METHODS

A multi-method qualitative study was conducted with HWs across a range of health care professions working in sexual health facilities. A total of 29 in-depth interviews and one focus group discussion were completed. Qualitative thematic analysis of the transcripts and field notes was undertaken using a social constructivist approach and complemented by documentary organizational, programme and policy analysis.

RESULTS AND DISCUSSIONS

Introduction of new health programmes, such as a MC programme for HIV prevention, are likely to impact upon one or more of the many motivational determinants. Social-cultural and individual factors influencing HW motivation to be involved in sexual and reproductive health services in PNG included community expectation and concern, sense of accomplishment and religious conviction. Strong links to community responsibility outweighed organizational ties. Faced with an often dysfunctional work environment, HWs perceived themselves as responsible to compensate for the failed health system. The impact of community influence and expectation needs to be considered when introducing a MC programme, particularly to communities in PNG where penile foreskin cutting is a common and accepted practice.

CONCLUSIONS

The potential contribution to the success of a MC programme that HWs may have means that taking into account the differing needs of communities as well as the motivational influences on HWs that exist within the sociocultural environment is important. These findings will assist not only in programme planning for MC, but also in the expansion of other existing sexual and reproductive health services.

Intravaginal practices and microbicide acceptability in Papua New Guinea: implications for HIV prevention in a moderate-prevalence setting

BACKGROUND

The acceptability of female-controlled biomedical prevention technologies has not been established in Papua New Guinea, the only country in the Pacific region experiencing a generalised, moderate-prevalence HIV epidemic. Socio-cultural factors likely to impact on future product uptake and effectiveness, such as women's ability to negotiate safer sexual choices, and intravaginal hygiene and menstrual practices (IVP), remain unclear in this setting.

METHODS

A mixed-method qualitative study was conducted among women and men attending a sexual health clinic in Port Moresby. During in-depth interviews, participants used copies of a hand-drawn template to indicate how they wash/clean the vulva and/or vagina. Interviewers pre-filled commercially available vaginal applicators with 2-3mL KY Jelly® to create a surrogate vaginal microbicide product, which was demonstrated to study participants.

RESULTS

A total of 28 IDIs were conducted (women=16; men=12). A diverse range of IVP were reported. The majority of women described washing the vulva only with soap and water as part of their daily routine; in preparation for sex; and following sexual intercourse. Several women described cleaning inside the vagina using fingers and soap at these same times. Others reported cleaning inside the vagina using a hose connected to a tap; using vaginal inserts, such as crushed garlic; customary menstrual 'steaming' practices; and the use of material fragments, cloth and newspaper to absorb menstrual blood. Unprotected sex during menstruation was common. The majority of both women and men said that they would use a vaginal microbicide gel for HIV/STI protection, should a safe and effective product become available. Microbicide use was considered most appropriate in 'high-risk' situations, such as sex with non-regular, transactional or commercial partners. Most women felt confident that they would be able to negotiate vaginal microbicide use with male sexual partners but if necessary would be prepared to use product covertly.

CONCLUSIONS

Notional acceptability of a vaginal microbicide gel for HIV/STI prevention was high among both women and men. IVP were diverse in nature, socio-cultural dimensions and motivators. These factors are likely to impact on the future acceptability and uptake of vaginal microbicides and other biomedical HIV prevention technologies in this setting.

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

Background

Male 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.

Methods

Fourteen 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.

Results

Obstacles 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.

Conclusions

In 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.

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

Background

Male 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.

Methods

A 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.

Results

Of 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.

Conclusions

The 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.

Assessment of the burden of human African trypanosomiasis by rapid participatory appraisal in three high-risk villages in Urambo District, Northwest Tanzania

BACKGROUND

The public health and socio-economic burden of Human African Trypanosomiasis (HAT) in East Africa is not well documented. Understanding the epidemiology and impact of HAT in such settings is difficult due to a lack of robust surveillance and reporting systems, restricting evidence-based policy development and contributing to the continued neglect of this disease.

OBJECTIVE

To investigate the burden of HAT in Urambo District, Tanzania in order to inform future public health policy.

METHODS

A rapid participatory appraisal (RPA) using a combination of qualitative and quantitative methods was conducted, that included key informant interviews, hospital record analysis, and tools adapted from participatory learning and action.

RESULTS

Three villages adjacent to Ugala Game Reserve appeared to be the most affected. High levels of under-reporting were noted due to a lack of diagnostic tools at peripheral health care facilities and limited access to specialist services. Community stakeholders perceived the health and socio-economic burden of HAT to be similar to that of malaria.

CONCLUSION

The burden of HAT in remote rural communities is difficult to capture through routine surveillance systems alone. The RPA represents an efficient mechanism for engaging communities in public health action for trypanosomiasis control in northwest Tanzania.

Operational research to inform a sub-national surveillance intervention for malaria elimination in Solomon Islands

Background

Successful reduction of malaria transmission to very low levels has made Isabel Province, Solomon Islands, a target for early elimination by 2014. High malaria transmission in neighbouring provinces and the potential for local asymptomatic infections to cause malaria resurgence highlights the need for sub-national tailoring of surveillance interventions. This study contributes to a situational analysis of malaria in Isabel Province to inform an appropriate surveillance intervention.

Methods

A mixed method study was carried out in Isabel Province in late 2009 and early 2010. The quantitative component was a population-based prevalence survey of 8,554 people from 129 villages, which were selected using a spatially stratified sampling approach to achieve uniform geographical coverage of populated areas. Diagnosis was initially based on Giemsa-stained blood slides followed by molecular analysis using polymerase chain reaction (PCR). Local perceptions and practices related to management of fever and treatment-seeking that would impact a surveillance intervention were also explored using qualitative research methods.

Results

Approximately 33% (8,554/26,221) of the population of Isabel Province participated in the survey. Only one subject was found to be infected with Plasmodium falciparum (Pf) (96 parasites/μL) using Giemsa-stained blood films, giving a prevalence of 0.01%. PCR analysis detected a further 13 cases, giving an estimated malaria prevalence of 0.51%. There was a wide geographical distribution of infected subjects. None reported having travelled outside Isabel Province in the previous three months suggesting low-level indigenous malaria transmission. The qualitative findings provide warning signs that the current community vigilance approach to surveillance will not be sufficient to achieve elimination. In addition, fever severity is being used by individuals as an indicator for malaria and a trigger for timely treatment-seeking and case reporting. In light of the finding of a low prevalence of parasitaemia, the current surveillance system may not be able to detect and prevent malaria resurgence.

Conclusion

An adaption to the malERA surveillance framework is proposed and recommendations made for a tailored provincial-level surveillance intervention, which will be essential to achieve elimination, and to maintain this status while the rest of the country catches up.

"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

BACKGROUND

Adult 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.

METHODS

A 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.

RESULTS

The 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.

CONCLUSION

This 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.

Health workers, health facilities and penile cutting in papua new guinea: implications for male circumcision as an HIV prevention strategy

There has been increasing interest in Papua New Guinea (PNG) in male circumcision (MC) for HIV (human immunodeficiency virus) prevention following compelling evidence from ecological studies and clinical trials in Africa, and the World Health Organization's recommendation in 2007 that MC be considered part of comprehensive HIV prevention programs in high-prevalence settings. Though no national policy has been established in PNG, East Sepik Province (ESP) commenced a formal program of MC in 2006, and there is evidence that PNG health workers are involved in other penile foreskin cutting activities in many areas. As part of a wider Male Circumcision Acceptability and Impact Study in PNG, we conducted an audit at a sample of PNG health facilities to assess their suitability for implementing a national MC program, and to identify issues that may arise in any future roll-out. The clinical audits demonstrated the difficulties with procurement and availability of equipment for general services around PNG, shortage of staff and capacity, and limitations of available clinical space. Results show that the ESP program has been successful; however, the success relies heavily on commitment from key workers to volunteer their time and services. A review of penile cutting activities by health care workers outside of the ESP program showed that the PNG health system is already involved in contemporary and traditional penile cutting practices via formal and informal arrangements: for example, by responding to complications from penile cuts performed by non-health workers, assisting community members to perform penile cutting through provision of equipment and advice, or providing regular penile foreskin cutting services for contemporary and traditional practices.

Male circumcision for HIV prevention in Papua New Guinea: a summary of research evidence and recommendations for public health following a national policy forum

In 2005, a clinical trial in South Africa found that circumcision of young men could reduce their risk of acquiring HIV (human immunodeficiency virus) infection by over 60%. In the following year, two more trials in Africa confirmed this finding, leading the World Health Organization to recommend male circumcision as a public health strategy for HIV prevention in high-incidence countries. In order to inform public health policy in Papua New Guinea (PNG), two major research projects were initiated with the goals of investigating the status of penile cutting practices and assessing understandings, acceptability, feasibility and cost-effectiveness of male circumcision for HIV prevention. In addition, behavioural surveillance surveys systematically asked questions on penile cutting practices and an ethnographic literature review informed historical perspectives of penile cutting in PNG. Key findings from these research activities were presented at a National Policy Forum on Male Circumcision for HIV Prevention held in Port Moresby in November 2011. The Forum made three key recommendations: (1) the formation of a joint National Department of HealthlNational AIDS Council Secretariat Policy Committee on male circumcision; (2) the establishment of an integrated harm reduction program; and (3) that future policy on wide-scale roll-out of male circumcision for HIV prevention in PNG be informed by a combination of data from (a) male circumcision intervention pilot programs and (b) research on the potential protective effect of other forms of penile cutting.

Malaria elimination in Isabel Province, Solomon Islands: establishing a surveillance-response system to prevent introduction and reintroduction of malaria

Background

The Solomon Islands National Malaria Programme is currently focused on intensified control and progressive elimination. Recent control efforts in Isabel Province have reduced their malaria incidence to 2.6/1,000 population in 2009 [1] whereas most neighbouring provinces have much higher incidences. A malaria surveillance-response system that involves testing all travellers entering Isabel Province using rapid diagnostic tests (RDT) to prevent cases being imported had been proposed by local health authorities. This study provides information on the feasibility and acceptability of implementing a new approach of surveillance and response in the context of low levels of indigenous malaria transmission in Isabel Province.

Methods

A total of 13 focus group discussions (FGD) and 22 key informant interviews (KII) were conducted in Isabel Province, Solomon Islands. Key topics included: the travel patterns of people to, from and within Isabel Province; the acceptability, community perceptions, attitudes and suggestions towards the proposed surveillance programme; and management of suspected malaria cases. This information was triangulated with data obtained from port authorities, airlines and passenger ships travelling to and from Isabel Province in the preceding two years.

Results

Travel within Isabel Province and to and from other provinces is common with marked seasonality. The majority of inter-provincial travel is done on scheduled public transport; namely passenger ships and aircrafts. In Isabel Province there is a healthy community spirit as well as high concern regarding malaria and its importation and there is currently effective malaria passive case detection and management. Conducting malaria screening at ports and airports would be acceptable to the community.

Conclusion

A robust surveillance-response system is essential when moving towards malaria elimination. Many factors contribute positively towards the feasibility of an RDT based malaria surveillance system in Isabel Province. Due to financial and logistical restraints local health authorities have concluded that a system of community-based vigilance to identify new arrivals in villages and direct them to have malaria testing is more feasible than formal screening at ports and airports. A surveillance response system to prevent introduction of malaria into Isabel Province can be integrated into the National Malaria Control Programme provided the operational steps are carefully planned with regards to human and financial resources.

The architecture and effect of participation: a systematic review of community participation for communicable disease control and elimination. Implications for malaria elimination

BACKGROUND

Community engagement and participation has played a critical role in successful disease control and elimination campaigns in many countries. Despite this, its benefits for malaria control and elimination are yet to be fully realized. This may be due to a limited understanding of the influences on participation in developing countries as well as inadequate investment in infrastructure and resources to support sustainable community participation. This paper reports the findings of an atypical systematic review of 60 years of literature in order to arrive at a more comprehensive awareness of the constructs of participation for communicable disease control and elimination and provide guidance for the current malaria elimination campaign.

METHODS

Evidence derived from quantitative research was considered both independently and collectively with qualitative research papers and case reports. All papers included in the review were systematically coded using a pre-determined qualitative coding matrix that identified influences on community participation at the individual, household, community and government/civil society levels. Colour coding was also carried out to reflect the key primary health care period in which community participation programmes originated. These processes allowed exhaustive content analysis and synthesis of data in an attempt to realize conceptual development beyond that able to be achieved by individual empirical studies or case reports.

RESULTS

Of the 60 papers meeting the selection criteria, only four studies attempted to determine the effect of community participation on disease transmission. Due to inherent differences in their design, interventions and outcome measures, results could not be compared. However, these studies showed statistically significant reductions in disease incidence or prevalence using various forms of community participation. The use of locally selected volunteers provided with adequate training, supervision and resources are common and important elements of the success of the interventions in these studies. In addition, qualitative synthesis of all 60 papers elucidates the complex architecture of community participation for communicable disease control and elimination which is presented herein.

CONCLUSIONS

The current global malaria elimination campaign calls for a health systems strengthening approach to provide an enabling environment for programmes in developing countries. In order to realize the benefits of this approach it is vital to provide adequate investment in the 'people' component of health systems and understand the multi-level factors that influence their participation. The challenges of strengthening this component of health systems are discussed, as is the importance of ensuring that current global malaria elimination efforts do not derail renewed momentum towards the comprehensive primary health care approach. It is recommended that the application of the results of this systematic review be considered for other diseases of poverty in order to harmonize efforts at building 'competent communities' for communicable disease control and optimising health system effectiveness.

Community participation for malaria elimination in Tafea Province, Vanuatu: part II. Social and cultural aspects of treatment-seeking behaviour

BACKGROUND

Early diagnosis and prompt effective case management are important components of any malaria elimination strategy. Tafea Province, Vanuatu has a rich history of traditional practices and beliefs, which have been integrated with missionary efforts and the introduction of modern constructions of health. Gaining a detailed knowledge of community perceptions of malarial symptomatology and treatment-seeking behaviours is essential in guiding effective community participation strategies for malaria control and elimination.

METHOD

An ethnographic study involving nine focus group discussions (FGD), 12 key informant interviews (KII) and seven participatory workshops were carried out on Tanna Island, Vanuatu. Villages in areas of high and low malaria transmission risk were selected. Four ni-Vanuatu research officers, including two from Tanna, were trained and employed to conduct the research. Data underwent thematic analysis to examine treatment-seeking behaviour and community perceptions of malaria.

RESULTS

Malaria was perceived to be a serious, but relatively new condition, and in most communities, identified as being apparent only after independence in 1980. Severe fever in the presence of other key symptoms triggered a diagnosis of malaria by individuals. Use of traditional or home practices was common: perceived vulnerability of patient and previous experience with malaria impacted on the time taken to seek treatment at a health facility. Barriers to health care access and reasons for delay in care-seeking included the availability of health worker and poor community infrastructure.

CONCLUSION

Due to programme success of achieving low malaria transmission, Tafea province has been identified for elimination of malaria by 2012 in the Government of Vanuatu Malaria Action Plans (MAP). An effective malaria elimination programme requires interactions between the community and its leaders, malaria workers and health providers for success in diagnosis and prompt treatment. As malaria becomes more uncommon, utilizing unique motivators for communities to seek early diagnosis and treatment is important, particularly as other health conditions that cause fevers become increasingly more common. The design of these interventions are dependent upon robust understanding of community perceptions of disease, and the evolving nature of these perceptions.