Response to "The HIV/AIDS Crisis in Papua New Guinea"

The report titled The HIV/AIDS Crisis in Papua New Guinea by Miranda Darling Tobias which was released on 8 February by The Centre for Independent Studies is conceptually and methodologically problematic in its analysis of the impact of the HIV epidemic in Papua New Guinea (PNG).

This report displays negligence on behalf of the author in its attempt to understand, describe and analyse the complex dimensions of the HIV epidemic facing PNG. She fails to account for the ways Papua New Guineans and its government have responded to the epidemic and continue to face unique challenges which contribute to the spread of the virus. The PNG epidemic is its own and while there may be some similarities with the Southern African epidemic she focuses too much on these and not on what is specific to PNG.

From the outset of the Executive Summary (18 pages), Tobias writes a report which makes gross generalizations regarding PNG's epidemic. She uses statistical data which are not referenced and which by all accounts are disproportionately high, and quotes sources which have been superseded. Concerned with Australia's interest in PNG, she fails to even reference or engage with the most recent AusAID report on the impacts of HIV in PNG – the HEMI Report (HIV Epidemiological Modelling and Impact Study) (Feb 2006), which was provided to her in November 2006.

There is much which can be criticized about this report. For the sake of a speedy response, we will confine our comments to four areas which we believe, as researchers in the field of HIV in PNG, need urgent rebuttal. These are conceptual and methodological issues, the use of statistical data, the role of the government in responding to the epidemic, and finally the condescending and patronizing tone of the report.

There is very limited critical or analytical thinking on part of the author. The report lacks rigorous research. She uses out of date STI data which have been superseded by more recent works by Lupiwa, Hammar, Gare and others which makes her argument problematic. No where in her article does she engage with the increasing social and behavioural research on HIV in PNG conducted by Lepani, Eves, Wardlow, Jenkins, Hughes, Hammar, Lupiwa, Maibani, Worth and Henderson, and Koczberski. Her lack of current data is reflected further where she quotes Dr Clement Malau (from another article) from June 2002. When Malau made his comments, as Director of the PNG National AIDS Council, the government was in their first National Strategic Plan. Five years later they are well into a second.

Tobias' uncritical thinking and simplistic understanding of PNG is further revealed in her comments of HIV education and the use of billboards. She writes that billboards in PNG are ‘prone to misinterpretation in a barely literate society' failing to understand that the society she writes about are oral, not reading, cultures. Literacy is not a measure of ability to understand HIV messages but rather the messages must be relevant and culturally specific.

Tobias makes simple and uncritical comments. She states that strong economic growth can transform societal norms, specifically in relation to the status of women. This in and of itself does not challenge, address nor change the structures of violence which make women, in particular young married women, vulnerable to HIV, let alone change the position of women in a patriarchal society. While she writes that young women are most vulnerable to HIV, it is in fact young MARRIED women. In a recent study conducted by the PNG IMR 60% of females infected with HIV were married women. She also writes that leisure is a contributing factor for high HIV infections without adequate explanation of her comment. What she does is incorrectly conflate unemployment and subsequent poverty with leisure.

Tobias makes a claim that 120,000 people are infected with HIV. However, unlike the HEMI report which used a mathematical model to simulate HIV transmission and progression to AIDS, this report fails to justify the statistics it offers. These figures are also substantially greater than other recent studies which suggest that HIV infection is 1.7% (PNG IMR 2007) and 1.8% (HEMI 2006) thus the figure of people infected with HIV would be between 53,500 and 64,000 not the 120,000 figure the report suggests.

HIV reporting in PNG has not been inherently fraught because of the slow progression of HIV to AIDS when symptoms appear, as Tobias suggests. In fact HIV testing has been limited in PNG because of few VCT centres, something that the government has begun to address with the rapid spread of such centres. Furthermore, why would people voluntarily come for HIV testing in a country where previously treatment was non existent, where comprehensive care and support after a diagnosis was not in place and where discrimination and stigma were widespread? To date there has been no specific notification process for AIDS related deaths. Therefore, all figures speculating infection rates of HIV and deaths due to AIDS should be treated with caution, something that Tobias does not acknowledge nor advise her readers to do with hers.

As long as any country has people living with HIV and there are new infections, there is always something more that a government can do. To claim that there is no commitment by the government of PNG to address the HIV epidemic is misleading and inaccurate. Commitment to the epidemic has been seen in a number of ways, ways in which Tobias does not mention. For example, the National AIDS Council was established by an Act of Parliament in December 1997. In all provinces there are Provincial AIDS Councils and more recently a decision has been made to implement a District AIDS Committee and a coordinator. In the Eastern Highlands, to date this has been successfully implemented in at least half of the districts. Each district now has a strategic plan. For example, in Daulo, a district of the Eastern Highlands Province, three wards have been identified on the grounds of geography and language and projections have been made by the District AIDS Committee for HIV awareness and education. Daulo's five year district plan has been presented to the Provincial Government. Thus, while there is commitment and action at the level of the National and Provincial Governments, this has also permeated local governments and communities. Last year the Department of Education launched a national HIV education curriculum to be implemented in government run schools. Teachers have already begun to attend workshops to be able to teach the curriculum.

The government has developed two national strategies on HIV/AIDS. The PNG National HIV/AIDS Medium Term Plan for 1998-2002 provided the multi-sectoral strategy framework for the national response to the HIV/AIDS epidemic. Following this, another national strategy (2004-2008) was developed with the goal to reduce the HIV/AIDS prevalence rate in the general population to below 1% and by at least 1% by 2008. It also has the goal to improve care for those infected and minimize the social and economic impact of the epidemic on individuals, families and communities. Initially the seven priority areas were: treatment, counselling, care and support; education and prevention; epidemiology and surveillance; social and behavioural change research; leadership, partnership and coordination; family and community support; and monitoring and evaluation. Recently though consultation an initiative of the government saw the further inclusion of gender as a priority area.

In 2006 the first National Summit on HIV Prevention was held. In a UNAIDS report on that summit it was written that ‘The highest level of political commitment was demonstrated at the Summit'. There is a Parliamentary Special Committee of HIV/AIDS chaired by Dr Banare Bun. In 2005 the HAMP (HIV AIDS Management and Prevention) Act was passed. This act covers for example the rights of people infected with HIV, pre and post test counselling, discrimination, and purposeful transmission of HIV. The government also funds the PNG IMR to conduct research into the area of HIV which the directive to inform practice. Furthermore, the link in PNG between research, policy and implementation is extremely well developed. This link is in part facilitated by the role of the Director of the PNG IMR being a member of the PNG Health Board along with the likes of the National Health Secretary.

Recently, on EM TV news Sir Peter Barter, the Minister for Health, was outspoken about the need for increased testing in rural and more remote areas of PNG and supporting the further development of VCT centres. Also, Dame Carol Kidu has spoken out about HIV both in her community/electorate, and in her position as Minister for Community Development she has been speaking of the issues facing her people as a result of HIV both at a national and international level. Other parliamentarians such as Dr Bun, Dr Puka Temu (a previous Minister for Health) have also spoken out about HIV.

Ten of the authors in this response are currently employed as HIV Social Science Research Cadets at the PNG IMR (a government funded research institute). They are part of an AusAID funded program between the University of New South Wales and PNG IMR to strengthen capacity of Papua New Guineans to conduct research into their own epidemic, drawing on indigenous knowledge. This is but one of the many AusAID funded programs which highlights that the government of PNG and its institutions are engaged in the HIV/AIDS epidemic.

There is not an absence of political commitment or effective leadership. Does more need to be done? Yes, there needs to be more commitment and leadership if the response is to be accelerated and further strengthened. A similar observation was made by the HEMI report which showed through a mathematical model why the government of PNG needs to scale up its current response. Again, this does not mean that the government of PNG is not doing anything in response to the epidemic but rather provides a model to support why the current efforts are important and why they need to be strengthened if PNG is to keep abreast of its epidemic. It is the belief of these authors that the people of PNG and its government need credit and support for their efforts in one of the most complex cultural and geographical countries. At the same time it is only by working together in an atmosphere of mutuality and hope that new and creative ways to respond further can be identified and implemented.

Like many countries, PNG was slow to realise the enormity of what HIV was to mean for its citizens and the development of it as a country. After coming to grips with the epidemic's potential, the government has been working in partnership with non-government organisations, aid agencies and faith based organisations. Previously the response was limited by a lack of adequate data and research. Today however, there is an emerging wealth of excellent works which are guiding the government and its partnerships to tailor an HIV response that is specific to PNG's epidemic and not those of any other. As this work has become available, the political has in turn grown and strengthened.

Overall, Tobias provides an unbalanced and poorly written report. It positions Papua New Guineans and its government as passive recipients of Australia's ‘compassion'. It is patronizing and condescending. In failing to write in a balanced manner Tobias has incited fear (and anger) rather than provide a document which people can usefully engage with in seeking to understand and respond to Papua New Guineas' epidemic in more complex ways. Thus, she has failed her own aim which was not to allocate blame but to provide practical ways forward.

Response written by Angela Kelly, Pamela Toliman, Kritoe Keleba, Rebecca Emori, Somu Nosi, Lawrencia Pirpir, Frances Akuani, Barbara Kepa, Martha Kupul, Brenda Peter Canagh, Lucy Walizopa, Agnes Mek, Peter Siba and Heather Worth.