Date Published: June 27, 2013
Publisher: BioMed Central
Author(s): Wing Young Nicola Man, Angela Kelly, Heather Worth, Andrew Frankland, Patti Shih, Martha Kupul, Thiri Lwin, Agnes Mek, Barbara Kepa, Rebecca Emori, Frances Akuani, Brenda Cangah, Lucy Walizopa, Lawrencia Pirpir, Somu Nosi, Peter M Siba.
The prevention of intimate partner transmission of HIV remains an important component of comprehensive HIV prevention strategies. In this paper we examine the sexual practices of people living with HIV on antiretroviral therapy (ART) in Papua New Guinea (PNG).
In 2008, a total of 374 HIV-positive people over the age of 16 and on ART for more than two weeks were recruited using a non-probability, convenience sampling methodology. This accounted for around 18% of adults on ART at the time. A further 36 people participated in semi-structured interviews. All interviews were thematically analysed using NVivo qualitative data analysis software.
Less than forty per cent (38%) of participants reported having had sexual intercourse in the six months prior to the survey. Marital status was by far the most important factor in determining sexual activity, but consistent condom use during vaginal intercourse with a regular partner was low. Only 46% reported consistent condom use during vaginal intercourse with a regular partner in the last six months, despite 77% of all participants reporting that consistent condom use can prevent HIV transmission. Consistent condom use was lowest amongst married couples and those in seroconcordant relationships. The vast majority (91.8%) of all participants with a regular heterosexual partner had disclosed their status to their partner. Qualitative data reinforced low rates of sexual activity and provided important insights into sexual abstinence and condom use.
Considering the importance of intimate partner transmission of HIV, these results on the sexual practices of people with HIV on ART in PNG suggest that one-dimensional HIV prevention messages focussing solely on condom use fail to account for the current practices and needs of HIV-positive people, especially those who are married and know their partners’ HIV status.
Papua New Guinea (PNG) reported its first person diagnosed with HIV in 1987. Although more recent national adult prevalence estimates suggest the epidemic is progressing less rapidly than previously feared with less than 1% (0.9% 2009 estimate and 0.8% 2010 estimate) of the adult population currently estimated to be infected [1,2], HIV prevalence in PNG however remains among the highest in the Asia-Pacific Region. PNG’s HIV epidemic has been, and continues to be, heterosexually transmitted with more women than men diagnosed as HIV-positive . The epidemic exhibits substantial geographic heterogeneity, with nearly 90% of diagnoses coming from the seven Highlands provinces, the National Capital District and Morobe Province . It is widely recognised from within PNG and from international agencies that innovative strategies for the treatment and care of people living with HIV and of HIV prevention are urgently needed to address the complex public health issue that HIV poses in a country with unparalleled geographical, linguistic and cultural diversity . PNG is home to more culturally diverse groups and languages than any other country in the world; for example, it is reported that there are more than 800 living languages .
Table 1 presents the socio-demographic characteristics for the entire sample and for men and women separately. Of the 374 study participants, 147 (39%) were men and 227 (61%) were women. The majority (72%) of the sample was aged 35 years or younger, with a median age of 30 years, and a range from 16 to 69 years. The men in the study were significantly older than the women, with median ages of 35 and 28 respectively. Three-quarters of the sample reported having never been to school (21%), or been educated up to elementary (9%) or primary school only (43%). Overall, men reported having attained a higher level of education than women with a significantly greater proportion of men having completed secondary or higher education (39%) compared with women (19%). One-fifth of the overall sample (20%) reported that they drink alcohol, and significantly more men drink (27%) compared with women (17%).
Overall, the level of sexual activity amongst the sample in this study was low. The overall percentage of both women and men on ART who reported sexual activity (38%) is much lower than the proportions found by some studies in developing country contexts see for example [28-32]. For example, the proportion of women in this study reporting sexual activity in the last six months is lower than that found among women in a three-country study of Brazil, South Africa and Uganda  where almost half had sexual intercourse in the last month (46%).
Given that inconsistent condom use is more frequent in married and engaged relationships and in relationships where HIV status is undisclosed, structural prevention efforts that prioritise and increase access to couple testing and support safe HIV disclosure are likely to play an important role in the prevention of intimate partner transmission in PNG. As people’s health continues to improve on ART it may well be that people currently single or widowed may re-engage in sexual relationships and will need support and education to do so in a safe manner. Results from this study show that people living with HIV who are well-informed about ART are more consistent in their use of condoms. It thus appears that health care services play an important role as a structural facilitator for HIV prevention cf.  where health education during a person’s preparation with a health care worker to initiate ART plays an important role in the prevention of HIV through the use of condoms. Therefore, positive prevention needs to take a holistic view to preventing secondary transmission of HIV through wider HIV education such as ART rather than messages that simply chant to always use a condom. It also reinforces the wider health benefits of access to ART and good clinical education about the use of ART. Continuing to engage people with HIV in positive prevention, of discussing serostatus mixing and HIV disclosure will be important in preventing the secondary transmission of HIV in PNG and are likely to play a far greater role than a one-dimensional HIV prevention message of always using a condom. Moreover, as greater numbers of people are diagnosed with HIV; HIV-positive people are prescribed ART; survival rates increase and biomedical markers such as CD4 count and possibly viral load become part of standard clinical practice then, the sexual lives of PLHIV in PNG are likely to have changed and further research is warranted.
The data were collected as part of a mixed-method study undertaken in six provinces throughout PNG between February and July 2008. The purpose of the study was to explore the social experience of HIV-positive men and women on ART.
The authors declare that they have no competing interests.
WYNM led the analysis of quantitative data and drafting of the paper. AK designed the study, secured funding, oversaw data collection and data analysis, led the analysis of qualitative data, contributed to the drafting of the manuscript and revising it critically for important intellectual content and gave final approval of the version to be submitted. AF oversaw the first stages of data analysis of the study and contributed to the drafting of the manuscript. PS contributed to the drafting of the manuscript. HW assisted in securing funding for the study and overseeing the implementation of it and contributed to the drafting of the manuscript. MK, AM, BK, RE, FA, BC, LW, LP and SN collected data and participated in data analysis for the manuscript. TL assisted in data analysis for this manuscript. PMS assisted in securing funding for the study, oversaw the implementation of the study and contributed to the drafting of the manuscript. All authors read and approved the final manuscript.