HIV/AIDS in Papua New Guinea: An unfolding disaster?

See also pp. 359–62 In 2004 I spent 3 months working at the Port Moresby General Hospital (PMGH) on a pilot programme to introduce antiretroviral drugs. A confirmed HIV diagnosis was required for patients to be considered for treatment and they had to be well enough to attend our outpatient clinic. Several times a week I attended ward rounds with the medical team. In the wards and in the ED we saw many patients in whom a diagnosis of HIV was clinically obvious and there were many others for whom the diagnosis was considered possible (Fig. 1). Why weren’t these patients being tested? I soon realized that things we take for granted in Australia – private spaces where we can talk to patients, assurance of confidentiality, lack of fear and stigma, and laboratory turnaround times measured in hours, not days – were real barriers to achieving accurate diagnoses. A doctor attends a patient with HIV/AIDS in the Emergency Department of the Port Moresby General Hospital. The patient died 5 days later. Photograph taken by Dr Carolyn Annerud. The HIV epidemic in Papua New Guinea (PNG) commenced in 1987, but it was not until the mid-1990s that the recorded number of cases began to increase in an exponential fashion. By late 2003 there were about 8200 officially recognized cases but estimates of the true number of cases range up to 28 000. In 2001 there was an estimated adult seroprevalence of 0.7%.1 Limited studies have hinted at the growing problem of HIV/AIDS in the country since then. In 2003 1.4% of pregnant women at antenatal clinics in Port Moresby, and 2.5% of pregnant women in the regional centre of Lae were infected with HIV.2,3 Small surveys have reported that 15–19% of inpatients with tuberculosis (TB) (Dr Paison Dakulalu, pers. comm.), 17% of female sex workers and 9% of patients attending clinics for sexually transmissible infections are HIV-positive.1,4 At the PMGH, HIV/AIDS is now the second most common admission diagnosis after TB and the most common cause of death (Dr Goa Tau, pers. comm.). We can now add the findings by Curry et al. in this issue of the Journal to support the view that PNG has entered an accelerated phase of HIV transmission.5 Curry et al. undertook opportunistic testing of 300 serum samples collected in the ED for HIV antibodies. Many comments could be made about the study design and potential confounders, but these do not change the bottom line, which is that the prevalence of HIV in this group was 18%. The diseases observed in association with HIV seropositivity included respiratory illnesses, particularly TB, diarrhoea and oral thrush. It is safe to assume that many of the illnesses observed were a result of HIV-related immunosuppression. What are the implications of this study? First, they tell us that HIV prevalence in the country is well on the way to reaching the levels seen in Sub-Saharan Africa, as predicted by the World Bank.1 Second, it illustrates the parlous state of health care in the country. The PMGH is the flagship of the public hospital system in PNG, yet as Curry et al. describe, there are no accurate statistics kept of patient attendances, blood sampling tubes were often unavailable, gloves are in short supply and there are no isolation facilities. Patients with open TB lie in close proximity to those, as yet, uninfected. Needlestick injuries are an exceptional hazard for staff and have contributed to concerns about staff safety. One positive development since the paper was written is that antiretroviral drugs have become available for postexposure prophylaxis. Third, the study highlights how important it is to now move on from the laboratory-based diagnosis of HIV and to adopt the voluntary counselling and testing (VCT) stategy promoted by bodies such as the World Health Organization. Voluntary testing (with point of care tests), which is linked to counselling, can provide the same quality of information the current study has provided, but with the positive consequences that flow from having patients aware of their diagnosis and the means to prevent transmission.6 Having a VCT service in the ED should be an urgent priority. Fourth, the findings of Curry et al. hint at the way that the HIV will play out clinically. There has been a significant increase in the incidence of TB coincident with the HIV epidemic. The national incidence of TB has risen from 51 to 236/100 000 between 1999 and 2003. Cambodia, with an HIV prevalence of 2.7%, has a TB incidence of 585/100 000.1 How is PNG responding to this epidemic? Economic projections for the impact of HIV on the economy include reductions in the workforce of between 13 and 38% by 2020 and negative economic growth.7 Antiretroviral drugs offer some hope to those already infected and there is some evidence that care and support reduces fear and stigma.8 Antiretroviral therapy is needed to support the expansion of VCT.9 There are approximately 100 patients who have accessed treatment through the pilot antiretroviral programme. The Global Fund to Fight AIDS, TB and Malaria has approved funding for a plan to significantly improve the access to treatment as part of the World Health Organizations’‘3 by 5’ programme to have 3 million people on antiretroviral treatment by 2005. The success of this programme in PNG will require significant increases in trained staff and significant improvements in the health infrastructure. Provision of antiretroviral therapy, however, is only a small component of the overall response to HIV, which is focused on prevention and education. Australia has pledged $A600m to 2010 to fight the disease in the region. The challenge now is to ensure that the financial commitments make a real difference not only in places like the PMGH, but also for the estimated 85% of the population living outside the urban centres. None declared.