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Papua New Guinea lacks data characterising the sexual health needs of younger key populations (KP): female sex workers (FSW) and commercially and sexually exploited girls (CSE), men who have sex with men (MSM), and transgender women (TGW). Biobehavioural surveys among KP were conducted in three cities. We conducted unweighted and weighted analysis for sample and population proportions, respectively. Variables associated with younger versus older age (15–24 versus ≥25 years) were included in the multivariable analysis. Younger FSW/CSEG had greater odds of having both Neisseria gonorrhoea and Chlamydia trachomatis (aOR:3.2, 95%CI 2.0–5.0), or having either infection (aOR:2.2, 95%CI 1.2–4.1) than older peers. They also had lower odds of having tested for HIV (aOR: 0.6, 95%CI 0.4–0.8). Younger MSM/TGW had greater odds of paying for sex in the <6 months (aOR:2.2, 95%CI: 1.5–3.1) and of having been paid for sex (aOR:1.6, 95%CI 1.1–2.4) than their older peers (≥25 years). Younger MSM/TGW had lower odds of having contact with a peer educator ≤12 months (aOR:0.6, 95%CI 0.4–0.9) and having tested for HIV (aOR:0.6, 95%CI: 0.4–0.9). All key populations have substantial sexual health needs, but those of younger members are greatest. Younger key populations would likely benefit from health services designed specifically for them. [ABSTRACT FROM AUTHOR]

Objective: The type of health education messages that communities and individuals seek to have communicated about the human papillomavirus (HPV) vaccine is important if vaccine programmes are to succeed, especially in settings such as Papua New Guinea (PNG), which have a high burden of cervical cancer, low health literacy and negative experiences of earlier vaccination programmes. This study sought to identify the health education messages that are viewed as most appropriate in such a context. Methodology: A qualitative study using gender-specific focus group discussions (N = 21) and semi-structured interviews (N = 82) was undertaken in three sites in PNG. Sites included both rural and urban locations in Milne Bay, Eastern Highlands and Western Highlands Provinces. Results: Two divergent discourses emerged. One group of participants, largely young people, felt communication messages should stress that HPV is a preventable sexually transmitted infection, which can cause cervical cancer. The other group, mainly members of the older population, believed that messaging should focus on the vaccine as a prevention strategy for cervical cancer. A small minority wanted both aspects of the vaccine discussed. Conclusion: Sensitivity needs to be taken when engaging with communities which have negative experiences of earlier infant immunisation programmes. Ensuring that the health communication needs and priorities of different sections of the populations are taken into account is key to the successful introduction and roll-out of HPV vaccination in this setting.

Background: Although global poverty rates have declined in the last decade, the fall in the Asia-Pacific region has been slow relative to the rest of the world. Poverty continues to be a major cause of poor maternal and newborn health, and a barrier to accessing timely antenatal care. Papua New Guinea has one of the highest poverty rates and some of the worst maternal and neonatal outcomes in the Asia-Pacific region. Few studies have investigated equity in antenatal care utilization in this setting. We explored equity in antenatal care utilization and the determinants of service utilization, which include a measure of multidimensional poverty in Papua New Guinea. Methods: To explore the association between poverty and antenatal care utilization this study uses data from a ten-cluster randomized controlled trial. The poverty headcount, average poverty gap, adjusted poverty headcount, and multidimensional poverty index of antenatal clinic attendees are derived using the Alkire-Foster method. The distribution of service utilization is explored using the multidimensional poverty index, followed by multivariate regression analyses to evaluate the determinants of service utilization. Results: The poverty headcount was 61.06%, the average poverty gap 47.71%, the adjusted poverty headcount 29.13% and the average multidimensional poverty index was 0.363. Further, antenatal care utilization was regressive with respect to poverty. The regression analyses indicated that older women; being a widow (small number of widows (n = 3) asserts interpreting result with caution); or formally employed increase the likelihood of accessing antenatal care more often in pregnancy. Travelling for over an hour to receive care was negatively associated with utilization. Conclusion: This study indicated high levels of multidimensional poverty in PNG and that ANC utilization was regressive; highlighting the need to encourage pregnant women, especially those who are economically more vulnerable to visit clinics regularly throughout pregnancy. [ABSTRACT FROM AUTHOR]

Introduction: Human papillomavirus (HPV) testing is transforming cervical screening globally. The World Health Organization (WHO) now recommends same-day HPV screen-and-treat for primary cervical screening in low- and middle-income countries (LMIC) but there is a lack of evidence on women's lived experience of testing positive for oncogenic HPV and receiving same-day treatment. This study aimed to address this knowledge gap among women participating in a same-day HPV screen-and-treat (HPV S&T) program in Papua New Guinea. Methods: As part of a larger qualitative study, this paper explores the lived experiences of 26 women who tested positive for oncogenic HPV and were treated the same day. We analysed the data using the interpretative phenomenological analysis method. All data were managed using Nvivo 12.5. Results: The interpretative phenomenological analysis led to three superordinate themes: 1) facing and alleviating initial worries, (2) transforming the disclosure process, and (3) connecting to their faith. Women's experiences of the same day HPV screen-and-treat were framed by initial emotional reactions to their positive HPV test result, and having access to treatment on the same day, which helped address their worries and fears, and transformed their experience of disclosing their test result and subsequent treatment to family and friends. Conclusion: This study shows that, while women experience similar initial emotional reactions, undergoing same day treatment quickly resolved the women's worries, making this program highly acceptable. Overall, women's engagement in the program confirmed its high acceptability and cultural congruence, leaving women feeling empowered and hopeful about their future, and the future of all Papua New Guinea women. [ABSTRACT FROM AUTHOR]

Background: Little research has explored the sexual and reproductive health (SRH) experience of female sex workers (FSW), including girls aged < 18 years who are commercially sexually exploited (CSE), in Papua New Guinea (PNG). This paper describes the SRH history of FSW and CSE girls and factors associated with their use of moderately or highly effective contraceptive methods in three settings in PNG.Methods: From 2016 to 2017, respondent-driven sampling (RDS) surveys were conducted among FSW and CSE girls in Port Moresby, Lae, and Mt. Hagen. FSW and CSE girls who were born female, aged ≥12 years, sold or exchanged vaginal sex in the past 6 months, spoke English or Tok Pisin, and had a valid RDS study coupon were eligible to participate. Interviews were conducted face-to-face and participants were offered rapid routine HIV and syphilis testing. Survey logistic regression procedures were used to identify factors associated with the use of moderately or highly effective contraceptive methods. Weighted data analysis was conducted.Results: A total of 2901 FSW and CSE girls (Port Moresby, 673; Lae, 709; and Mt. Hagen, 709) were enrolled. The proportion using moderately or highly effective contraceptive methods was 37.7% in Port Moresby, 30.9% in Lae, and 26.5% in Mt. Hagen. After adjusting for covariates, factors significantly associated with the use of moderately or highly effective contraceptive methods in Port Moresby were being age 20-24, being married, being divorced or separated, having one or more dependent children, being away from home for more than 1 month in the last 6 months, and having tested HIV negative. No factors were significantly associated in Lae or Mt. Hagen. ANC attendance amongst FSW and CSE girls who gave birth in last 3 years was highest in Port Moresby at 91.2%. HIV testing was inconsistently and inadequately offered at ANC across the three cities.Conclusions: Kauntim mi tu provides much-needed insight into the SRH experiences of FSW and CSE girls in PNG, where their use of moderately or highly effective contraceptive methods is low. We hope to shed light on the complicated reality they face due to illegality of sex work and multitude of complex healthcare experiences. [ABSTRACT FROM AUTHOR]

Background: Quality maternal and newborn care is essential for improving the health of mothers and babies. Low- and middle-income countries, such as Papua New Guinea (PNG), face many barriers to achieving quality care for all. Efforts to improve the quality of maternal and newborn care must involve community in the design, implementation, and evaluation of initiatives to ensure that interventions are appropriate and relevant for the target community. We aimed to describe community members' perspectives and experiences of maternal and newborn care, and their ideas for improvement in one province, East New Britain, in PNG. Methods: We undertook a qualitative descriptive study in partnership with and alongside five local health facilities, health care workers and community members, using a Partnership Defined Quality Approach. We conducted ten focus group discussions with 68 community members (identified through church, market and other community-based groups) in East New Britain PNG to explore perspectives and experiences of maternal and newborn care, identify enablers and barriers to quality care and interventions to improve care. Discussions were transcribed verbatim. A mixed inductive and deductive analysis was conducted including application of the World Health Organisation (WHO) Quality Maternal and Newborn Care framework. Results: Using the WHO framework, we present the findings in accordance with the five experience of care domains. We found that the community reported multiple challenges in accessing care and facilities were described as under-staffed and under resourced. Community members emphasised the importance of good communication and competent, caring and respectful healthcare workers. Both women and men expressed a strong desire for companionship during labor and birth. Several changes were suggested by the community that could immediately improve the quality of care. Conclusions: Community perspectives and experiences are critical for informing effective and sustainable interventions to improve the quality of maternal and newborn care and increasing facility-based births in PNG. A greater understanding of the care experience as a key component of quality care is needed and any quality improvement initiatives must include the user experience as a key outcome measure. Plain English summary: Improving the care provided to, and experienced by, women and their families during pregnancy and childbirth is important for improving the health of mothers and babies. Community members should be involved in thinking about appropriate ways to improve care. Papua New Guinea (PNG) is a country in the Pacific which faces multiple challenges to improving care during pregnancy and birth. We aimed to understand what community members think about care provided and experienced during labour and birth in East New Britain, a rural province of PNG. We worked with five health facilities, health workers and community members in East New Britain to develop a qualitative research project. We carried out 10 focus group discussions with community members in East New Britain to understand what the provision and experience of care was like during labour and birth, and ways that it could be improved. We found that community members identified multiple challenges in getting to facilities and many facilities were found to have not enough supplies, equipment, or staff. Community members wanted staff that were good at their work but also caring and respectful. Women wanted to have support people present during labour and birth and many men wanted to be present too. Our results show that it is important to understand what the community thinks about the quality of care during labour and birth and this information is helpful to design effective activities to improve the care provided and experienced. [ABSTRACT FROM AUTHOR]

Background: Globally, 2.5 million babies die in the first 28 days of life each year with most of these deaths occurring in low- and middle-income countries. Early recognition of newborn danger signs is important in prompting timely care seeking behaviour. Little is known about women's knowledge of newborn danger signs in Papua New Guinea. This study aims to assess this knowledge gap among a cohort of women in East New Britain Province. Methods: This study assessed knowledge of newborn danger signs (as defined by the World Health Organization) at three time points from a prospective cohort study of women in East New Britain Province, factors associated with knowledge of danger signs after childbirth were assessed using logistic regression. This study includes quantitative and qualitative interview data from 699 pregnant women enrolled at their first antenatal clinic visit, followed up after childbirth (n = 638) and again at one-month post-partum (n = 599). Results: Knowledge of newborn danger signs was very low. Among the 638 women, only 9.4% knew three newborn danger signs after childbirth and only one knew all four essential danger signs defined by Johns Hopkins University 'Birth Preparedness and Complication Readiness' Index. Higher knowledge scores were associated with higher gravidity, income level, partner involvement in antenatal care, and education. Conclusion: Low levels of knowledge of newborn danger signs among pregnant women are a potential obstacle to timely care-seeking in rural Papua New Guinea. Antenatal and postnatal education, and policies that support enhanced education and decision-making powers for women and their families, are urgently needed. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: A field trial to evaluate a self-collect point-of-care HPV screen-and-treat (HPV S&T) program was implemented in two Well Women Clinics in Papua New Guinea (Papua New Guinea). Assessing the acceptability of a health intervention is a core element of evaluation. In this study, we examined women's acceptability of both self-collection and HPV S&T intervention in Papua New Guinea. Methods: Sixty-two semi-structured interviews were conducted with women who had undergone cervical screening in the same-day self-collected HPV screen-and-treat program in Madang and Western Highlands Provinces, Papua New Guinea. Data were thematically analysed using the Theoretical Framework of Acceptability (TFA) and managed using NVivo 12.5. Results: Most women agreed that self-collection was transformative: it helped circumvent the culturally embarrassing pelvic examination and increased their self-efficacy, especially due to the provision of health education, instructions, and pictorial aids. The availability of same-day results, and treatment if indicated, was particularly valued by the women because it reduced the financial and temporal burden to return to the clinic for results. It also meant they did not need to wait anxiously for long periods of time for their results. Women also appreciated the support from, and expertise of, health care workers throughout the process and spoke of trust in the HPV-DNA testing technology. Most women were willing to pay for the service to ensure its sustainability and timely scale-up throughout Papua New Guinea to support access for women in harder to reach areas. Conclusion: This study reported very high levels of acceptability from a field trial of self-collection and HPV same-day screen-and-treat. The program was deemed culturally congruent and time efficient. This innovative cervical screening modality could be the 'solution' needed to see wider and more immediate impact and improved outcomes for women in Papua New Guinea and other high-burden, low-resource settings. [ABSTRACT FROM AUTHOR]

Background: Papua New Guinea (PNG) has one of the highest burdens of HIV and syphilis in pregnancy in the Asia-Pacific region. Timely and effective diagnosis can alleviate the burden of HIV and syphilis and improve maternal and newborn health. Supply-side factors related to implementation and scale up remain problematic, yet few studies have considered their impact on antenatal testing and treatment for HIV and syphilis. This study explores health service availability and readiness for antenatal HIV and/or syphilis testing and treatment in PNG.Methods: Using data from two sources, we demonstrate health service availability and readiness. Service availability is measured at a province level as the average of three indicators: infrastructure, workforce, and antenatal clinic utilization. The readiness score comprises 28 equally weighted indicators across four domains; and is estimated for 73 health facilities. Bivariate and multivariate robust linear regressions explore associations between health facility readiness and the proportion of antenatal clinic attendees tested and treated for HIV and/or syphilis.Results: Most provinces had fewer than one health facility per 10 000 population. On average, health worker density was 11 health workers per 10 000 population per province, and approximately 22% of pregnant women attended four or more antenatal clinics. Most health facilities had a composite readiness score between 51% and 75%, with urban health facilities faring better than rural ones. The multivariate regression analysis, when controlling for managing authority, catchment population, the number of clinicians employed, health facility type and residence (urban/rural) indicated a weak positive relationship between health facility readiness and the proportion of antenatal clinic attendees tested and treated for HIV and/or syphilis.Conclusion: This study adds to the limited evidence base for the Asia-Pacific region. There is a need to improve antenatal testing and treatment coverage for HIV and syphilis and reduce healthcare inequalities faced by rural and urban communities. Shortages of skilled health workers, tests, and medicines impede the provision of quality antenatal care. Improving service availability and health facility readiness are key to ensuring the effective provision of antenatal care interventions. [ABSTRACT FROM AUTHOR]

This article explores socio-spatial dimensions of risk and how they can enhance understanding of a high burden tuberculosis (TB) context in the South Fly District of Papua New Guinea. We report on select findings from a qualitative study that included 128 semi-structured in-depth interviews and 10 focus group discussions with a wide range of South Fly District community members. Using the conceptual framework of 'riskscapes' to examine emic perspectives on risk, space and practice, we map key elements of TB riskscapes on Daru Island, South Fly District, along with solutions for navigating through these riskscapes. Overcrowding, lack of water, sanitation and hygiene, as well as food insecurity and undernutrition, were identified as common elements within participants' riskscapes, that compounded upon each other to create the perception of an assemblage of risk favourable to TB transmission. [ABSTRACT FROM AUTHOR]

Aim: To determine the causes of early neonatal death and the avoidable factors associated with these deaths among women participating in a cluster‐randomised crossover trial in Papua New Guinea. Methods: Early neonatal deaths were identified by retrospective chart review of the Women and Newborn Trial of Antenatal Interventions and Management study participants between July 2017 and January 2020. Causes of death and avoidable factors were identified using the Perinatal Problem Identification Program system. Results: There were 35 early neonatal deaths among 2499 livebirths (14 per 1000 births). Fifty‐seven percent (20/35) of deaths occurred on the first day of life. Idiopathic preterm birth was the leading obstetric cause of perinatal death (29%; 10/35). Extreme multi‐organ immaturity (23%; 8/35) and hypoxic ischaemic encephalopathy (17%; 6/35) were the most common final causes of neonatal death. Forty‐six avoidable factors were identified among 26 deaths, including delays in care‐seeking, insufficient resources at health facilities, poor intrapartum care and immediate care of the newborn, including neonatal resuscitation. Conclusion: In this study, potentially preventable causes and avoidable factors were identified in the majority of early neonatal deaths. Addressing these factors will require health system strengthening, particularly the upskilling of primary level health staff, as well as targeted health education of women and the community. [ABSTRACT FROM AUTHOR]

Objective: To undertake a retrospective perinatal death audit and assessment of avoidable factors associated with stillbirths among a cohort of women in two provinces in Papua New Guinea. Methods: We used data from an ongoing cluster‐randomized crossover trial in 10 sites among 4600 women in Papua New Guinea (from 2017 to date). The overarching aim is to improve birth outcomes. All stillbirths from July 2017 to January 2020 were identified. The Perinatal Problem Identification Program was used to analyze each stillbirth and review associated avoidable factors. Results: There were 59 stillbirths among 2558 births (23 per 1000 births); 68% (40/59) were classified "fresh" and 32% as "macerated". Perinatal cause of death was identified for 63% (37/59): 30% (11/37) were due to intrapartum asphyxia and traumatic breech birth and 19% (7/37) were the result of pre‐eclampsia. At least one avoidable factor was identified for 95% (56/59) of stillbirths. Patient‐associated factors included lack of response to reduced fetal movements and delay in seeking care during labor. Health personnel‐associated factors included poor intrapartum care, late diagnosis of breech presentation, and prolonged second stage with no intervention. Conclusion: Factors associated with stillbirths in this setting could be avoided through a package of interventions at both the community and health‐facility levels. Among 59 stillbirths, we identified 127 possible avoidable factors, including poor response to reduced fetal movement, delay in seeking care in labor, and poor intrapartum monitoring. [ABSTRACT FROM AUTHOR]

Much about the range of pathogens, frequency of coinfection, and clinical effects of reproductive tract infections (RTIs) among pregnant women remains unknown. We report on RTIs (Mycoplasma genitalium, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Treponema pallidum subspecies pallidum, bacterial vaginosis, and vulvovaginal candidiasis) and other reproductive health indicators in 699 pregnant women in Papua New Guinea during 2015-2017. We found M. genitalium, an emerging pathogen in Papua New Guinea, in 12.5% of participants. These infections showed no evidence of macrolide resistance. In total, 74.1% of pregnant women had >1 RTI; most of these infections were treatable. We detected sexually transmitted infections (excluding syphilis) in 37.7% of women. Our findings showed that syndromic management of infections is greatly inadequate. In total, 98.4% of women had never used barrier contraception. These findings will inform efforts to improve reproductive healthcare in Papua New Guinea. [ABSTRACT FROM AUTHOR]

Background: In Papua New Guinea (PNG) members of key populations, including female sex workers (FSW), men who have sex with men (MSM) and transgender women (TGW), have higher rates of HIV compared to the general adult population and low engagement in HIV care. This paper examines the socio-ecological factors that encourage or hinder HIV treatment initiation and adherence among HIV positive members of key populations in PNG.Methods: As part of a larger biobehavioural survey of key populations in PNG, 111 semi-structured interviews were conducted with FSW, MSM and TGW, of whom 28 identified as living with HIV. Interviews from 28 HIV positive participants are used in this analysis of the influences that enabled or inhibited HIV treatment initiation and treatment adherence.Results: Enablers included awareness of the biomedical benefits of treatment; experiences of the social, familial and health benefits of early treatment initiation and adherence; support provided by family and friends; and non-judgmental and supportive HIV service provision. Factors that inhibited treatment initiation and adherence included perception of good health and denial of HIV diagnosis; poor family support following positive diagnosis; and anonymity and stigma concerns in HIV care services.Conclusion: Exploring health promotion messages that highlight the positive health impacts of early treatment initiation and adherence; providing client-friendly services and community-based treatment initiation and supply; and rolling out HIV viral load testing across the country could improve health outcomes for these key populations. [ABSTRACT FROM AUTHOR]

Background: Timely diagnosis and early initiation of life-saving antiretroviral therapy are critical factors in preventing mortality among HIV-infected infants. However, resource-limited settings experience numerous challenges associated with centralised laboratory-based testing, including low rates of testing, complex sample referral pathways and unacceptably long turnaround times for results. Point-of-care (POC) HIV testing for HIV-exposed infants can enable same-day communication of results and early treatment initiation for HIV-infected infants. However, complex operational issues and service integration can limit utility and must be well understood prior to implementation. We explored and documented the challenges and enabling factors in implementing the POC Xpert® HIV-1 Qual test (Cepheid, Sunnyvale, CA, USA) for early infant diagnosis (EID) as part of routine services in four public hospitals in Myanmar.Methods: This sub-study was part of a randomised controlled stepped-wedge trial (Australian and New Zealand Clinical Trials Registry, number 12616000734460) designed to investigate the impact of POC testing for EID in Myanmar and Papua New Guinea. Infants recruited during the intervention phase underwent POC testing at the participating hospitals as part of routine care. Semi-structured interviews with 23 caregivers, 12 healthcare providers and 10 key informants were used to explore experiences of POC-EID testing. The research team and hospital staff documented and discussed implementation challenges throughout the study.Results: Overall, caregivers and healthcare workers were satisfied with the short turnaround time of the POC test. Occasional delays in POC testing were mostly attributable to late receipt of samples by laboratory technicians and communication constraints among healthcare staff. Hospital staff valued technical assistance from the research group and the National Health Laboratory. Despite staff shortages and infrastructure challenges such as unreliable electricity supply and cramped space, healthcare workers and caregivers found the implementation of the POC test to be feasible at pilot sites.Conclusions: As plans for national scale-up evolve, there needs to be a continual focus on staff training, communication pathways and infrastructure. Other models of care, such as allowing non-laboratory-trained personnel to perform POC testing, and cost effectiveness should also be evaluated. [ABSTRACT FROM AUTHOR]

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

There is a small but important body of literature on female sex workers' (FSWs) violence towards others, but little of that focused on low- and middle-income countries. Drawn from a larger biobehavioural study of FSWs in three cities in Papua New Guinea, we analyse the interviews from 19 FSWs who reported having perpetrated physical violence towards four major groups: (1) ex-husbands; (2) clients; (3) other sex workers and (4) other people (mainly women). Our study demonstrates that FSWs' use of violence arises from a complex set of social, material and gendered circumstances and cannot be addressed in isolation from other aspects of their lives. [ABSTRACT FROM AUTHOR]

Background In this paper, factors associated with HIV and syphilis infection in three cities in Papua New Guinea are explored.Methods: Respondent-driven sampling surveys among FSW in Port Moresby, Lae, and Mt. Hagen (2016-17) were conducted. FSW who were aged ≥12 years, who were born female, who spoke English or Tok Pisin and who had sold or exchanged vaginal sex in the past 6 months were eligible to participate. Participants were interviewed face-to-face and offered rapid HIV and syphilis testing. Survey logistic procedures were used to identify factors associated with HIV and syphilis infection, including modern contraception use, physical violence and having a casual male partner. Weighted data analysis was conducted.Results: Overall, 2901 FSW (Port Moresby, 673; Lae, 709; and Mt. Hagen, 709) were enrolled in the study. HIV prevalence was 15.2% in Port Moresby, 11.9% in Lae and 19.6% in Mt. Hagen. Factors associated with HIV varied by city; for example, use of modern contraception in Port Moresby, experiences of physical violence in Lae and ever having tested for HIV in Mt. Hagen. No one variable was associated with HIV in all cities. Prevalence of syphilis infection was 7.1%, 7.0%, and 3.0% in Port Moresby, Lae, and Mt. Hagen, respectively. Factors associated with syphilis infection also varied by city and were only significant in Lae.Conclusion: The different factors associated with HIV and syphilis infection in each city highlight the complex HIV and syphilis epidemics among FSW and the importance of conducting surveys in multiple locations and developing local interventions. [ABSTRACT FROM AUTHOR]

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

Background: Papua New Guinea (PNG) has among the highest estimated burdens of cervical cancer globally but currently has no national cervical screening program. Visual inspection of the cervix with acetic acid (VIA) is a low‐cost screening strategy endorsed by the World Health Organization that has been adopted in many low‐resource settings but not previously evaluated in PNG. Aim: To evaluate the association between VIA examination findings and high‐risk HPV (hrHPV) infection; and the impact of concomitant genital Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis on the interpretation of VIA findings. Methods: A prospective clinical cohort study among women aged 30–59 years attending Well Woman Clinics in PNG. Main outcome measures were VIA examination findings and laboratory‐confirmed hrHPV, C. trachomatis, N. gonorrhoeae and T. vaginalis. Results: A total of 614 women were enrolled, of whom 87.5% (537/614) underwent VIA, and 12.5% (77/614) did not due to pre‐existing cervicitis or inability to visualise the transformation zone. Among the 537 women who underwent VIA, 21.6% were VIA positive, 63.7% VIA negative, and 14.7% had indeterminate findings. The prevalence of hrHPV infection (n = 614) was 14.7%; C. trachomatis, 7.5%; N. gonorrhoeae, 8.0%; and T. vaginalis, 15.0%. VIA positive women were more likely to have HPV16 (odds ratio: 5.0; 95%CI: 1.6–15.6; P = 0.006) but there was no association between HPV18/45, all hrHPV types (combined), C. trachomatis, N. gonorrhoeae or T. vaginalis. Conclusions: VIA positivity was associated with HPV16, but not with other hrHPV infections, nor with genital C. trachomatis, N. gonorrhoeae or T. vaginalis in this setting. [ABSTRACT FROM AUTHOR]

Objectives: Within their local realities, people experience and interpret disease in diverse ways that do not necessarily correlate or converge with Western biomedical interventions. In the high cervical cancer burden setting of Papua New Guinea, understanding how people experience and interpret cervical cancer is necessary for effective intervention. Drawing on work by Street on the production of unstable biomedical knowledge, we explored how ambiguity and uncertainty, coupled with cultural taboos and linguistic limitations, affect what and how people ‘know’ about women’s reproductive organs and their associated disease. Design: A qualitative research approach was used to explore and understand how people in PNG articulate matters of health and disease as they relate to cervical cancer and HPV infection. Specifically, how unstable biomedical knowledge is produced and sustained. We employed a mixed-methods approach in collecting data from 208 (147 women) participants between 2011 and 2012 across 3 provinces in PNG. Results: We found that knowledge and awareness about cervical cancer were poor. Five thematic areas emerged in our analysis, which included the gendered knowledge of women’s reproductive health, the burden of cervical cancer in the community and the role (or limitation) of language. We further identified four ways in which ambiguity and uncertainty operate on both sociocultural and biological levels, and in the intersection between to produce unstable biomedical knowledge. These included poor knowledge of where the cervix is located and the uncertainty or unreliability of (lay) diagnoses of disease. Conclusion: Local understandings of cervical cancer reflected the limitations of Tok Pisin as a lingua franca as well as the wider uncertain biomedical environment where diagnoses are assembled and shared. There is a clear need to improve understanding of the female reproductive organs in order that people, women in particular, can be better informed about cervical cancer and ultimately better receptive to intervention strategies. [ABSTRACT FROM AUTHOR]

Background Papua New Guinea (PNG) is estimated to have among the highest prevalences of HIV and sexually transmissible infections (STIs) of any Asia-Pacific country, and one of the highest burdens of maternal syphilis globally. The prevalence of curable STIs, such as Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV), among pregnant women in PNG is relatively unknown.Methods: A cross-sectional bio-behavioural survey to investigate the epidemiology of CT, NG, TV and other STIs among pregnant women in three provinces of PNG was undertaken. Women aged 18-35 years attending their first antenatal clinic visit were invited to participate. Participants completed a short interview and provided self-collected vaginal specimens for CT, NG and TV laboratory-based nucleic acid amplification tests and a venepuncture specimen for laboratory testing for syphilis and Herpes simplex virus type-2 (HSV-2) serology. Routine antenatal assessment was conducted according to national guidelines, including HIV counselling and testing and point-of-care syphilis screening.Results: A total of 765 women were enrolled. Overall, 43% (95% confidence interval (CI): 39.2-46.4) had one or more of CT, NG or TV infection. CT was the most prevalent STI (22.9%, 175/765; 95% CI: 19.9-25.9), followed by TV (22.4%, 171/765; 95% CI: 19.4-25.4), and NG (14.2%, 109/765; 95% CI: 11.7-16.7). The prevalence of active syphilis was 2.2% (17/765; 95% CI: 1.2-3.3), HSV-2 was 28.0% (214/765; 95% CI: 24.8-31.2) and HIV, 0.8% (6/765; 95% CI: 0.2-1.4). Prevalences were highest among primigravid women, women aged <25 years, and among those in Central Province.Conclusion: High prevalences of curable genital STIs were observed among women attending routine antenatal clinic services in PNG. These infections have been associated with adverse pregnancy outcomes and could be important contributors to poor maternal and neonatal health in this setting. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction: Various forms of penile foreskin cutting are practised in Papua New Guinea. In the context of an ecological association observed between HIV infection and the dorsal longitudinal foreskin cut, we undertook an investigation of this relationship at the individual level. Methods: We conducted a cross-sectional study among men attending voluntary confidential HIV counselling and testing clinics. Following informed consent, participants had a face-to-face interview and an examination to categorize foreskin status. HIV testing was conducted on site and relevant specimens collected for laboratory-based Herpes simplex type-2 (HSV-2), syphilis, Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV) testing. Results: Overall, 1073 men were enrolled: 646 (60.2%) were uncut; 339 (31.6%) had a full dorsal longitudinal cut; 72 (6.7%) a partial dorsal longitudinal cut; and 14 (1.3%) were circumcised. Overall, the prevalence of HIV was 12.3%; HSV-2, 33.6%; active syphilis, 12.1%; CT, 13.4%; NG, 14.1%; and TV 7.6%. Compared with uncut men, men with a full dorsal longitudinal cut were significantly less likely to have HIV (adjusted odds ratio [adjOR] 0.25, 95%CI: 0.12, 0.51); HSV-2 (adjOR 0.60, 95%CI: 0.41, 0.87); or active syphilis (adjOR 0.55, 95%CI: 0.31, 0.96). This apparent protective effect was restricted to men cut prior to sexual debut. There was no difference between cut and uncut men for CT, NG or TV. Conclusions: In this large cross-sectional study, men with a dorsal longitudinal foreskin cut were significantly less likely to have HIV, HSV-2 and syphilis compared with uncut men, despite still having a complete (albeit morphologically altered) foreskin. The protective effect of the dorsal cut suggests that the mechanism by which male circumcision works is not simply due to the removal of the inner foreskin and its more easily accessible HIV target cells. Exposure of the penile glans and inner foreskin appear to be key mechanisms by which male circumcision confers protection. Further research in this unique setting will help improve our understanding of the fundamental immunohistologic mechanisms by which male circumcision provides protection, and may lead to new biomedical prevention strategies at the mucosal level. [ABSTRACT FROM AUTHOR]

Copyright of Culture, Health & Sexuality is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objective: To examine the correlation between HIV prevalence and male circumcision and other foreskin cutting practices across the four regions of Papua New Guinea (PNG).Design: An ecological substudy using unique data from an interdisciplinary research programme to evaluate the acceptability, sociocultural context and public health impact of male circumcision for HIV prevention in PNG.Methods: Published data describing (a) self-reported circumcision status by region from the 'Acceptability and Feasibility of Male Circumcision for HIV prevention in PNG' study and (b) HIV prevalence by region from PNG National Department of Health were used to correlate male circumcision and other foreskin cutting practices and HIV prevalence. Maps were constructed to visually represent variations across the four regions of PNG.Results: Regions of PNG with the highest HIV prevalence had the lowest prevalence of male circumcision and other forms of foreskin cutting and vice versa. Male circumcision and dorsal longitudinal cuts were strongly associated with HIV prevalence and able to explain 99% of the observed geographical variability in HIV prevalence in PNG (p<0.01).Conclusions: The regional prevalence of HIV infection in PNG appears to be closely correlated with the regional distribution of male circumcision and dorsal longitudinal foreskin cuts. Further research is warranted to investigate causality of this correlation as well as the potential of dorsal longitudinal cuts to confer protection against HIV acquisition in heterosexual men. [ABSTRACT FROM AUTHOR]

Copyright of Culture, Health & Sexuality is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: In Papua New Guinea induced abortion is restricted under the Criminal Code Law. Unsafe abortions are known to be widely practiced and sepsis due to unsafe abortion is a leading cause of maternal mortality. Methods: We undertook a six month, prospective, mixed methods study at the Eastern Highlands Provincial Hospital. Semi structured and in depth interviews were undertaken with women presenting following induced abortion. This paper describes the reasons why women resorted to unsafe abortion, the techniques used, decision to seek post abortion care and women's reflections post abortion. Results: 28 women were admitted to hospital following an induced abortion. Reasons for inducing an abortion included: wanting to continue with studies, relationship problems and socio-cultural factors. Misoprostol was the most frequently used method to end the pregnancy. Physical and mechanical means, traditional herbs and spiritual beliefs were also reported. Women sought care post abortion due to excessive vaginal bleeding, and severe abdominal pain with some afraid they would die if they did not seek help. Conclusion: In the absence of contraceptive information and services to avoid, postpone or space pregnancies, women in this setting are resorting to unsafe means to end an unwanted pregnancy, putting their lives at risk. Women need access to safe, effective means of abortion. [ABSTRACT FROM AUTHOR]

Background: In Papua New Guinea abortion is restricted under the Criminal Code Act. While safe abortions should available in certain situations, frequently they are not available to the majority of women. Sepsis from unsafe abortion is a leading cause of maternal mortality. Our findings form part of a wider, mixed methods study designed to identify complications requiring hospital treatment for post abortion care and to explore the circumstances surrounding unsafe abortion. Methods: Through a six month prospective study we identified all women presenting to the Eastern Highlands Provincial Hospital following spontaneous and induced abortions. We undertook semi-structured interviews with women and reviewed individual case notes, extracting demographic and clinical information. Findings: Case notes were reviewed for 56% (67/119) of women presenting for post abortion care. At least 24% (28/119) of these admissions were due to induced abortion. Women presenting following induced abortions were significantly more likely to be younger, single, in education at the time of the abortion and report that the baby was unplanned and unwanted, compared to those reporting spontaneous abortion. Obtained illegally, misoprostol was the method most frequently used to end the pregnancy. Physical and mechanical means and traditional herbs were also widely reported. Conclusion: In a country with a low contraceptive prevalence rate and high unmet need for family planning, all reproductive age women need access to contraceptive information and services to avoid, postpone or space pregnancies. In the absence of this, women are resorting to unsafe means to end an unwanted pregnancy, putting their lives at risk and putting an increased strain on an already struggling health system. Women in this setting need access to safe, effective means of abortion. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM PUBLISHER]

The degree to which adult medical male circumcision (MC) programs can reduce new HIV infections in a moderate HIV prevalence country like Papua New Guinea (PNG) are uncertain especially given the widespread prevalence of longitudinal foreskin cuts among adult males. We estimated the likely impact of a medical MC intervention in PNG using a mathematical model of HIV transmission. The model was age-structured and incorporated separate components for sex, rural/urban, men who have sex with men and female sex workers. Country-specific data of the prevalence of foreskin cuts, sexually transmitted infections, condom usage, and the acceptability of MC were obtained by our group through related studies. If longitudinal foreskin cutting has a protective efficacy of 20% compared to 60% for MC, then providing MC to 20% of uncut males from 2012 would require 376,000 procedures, avert 7,900 HIV infections by 2032, and require 143 MC per averted infection. Targeting uncut urban youths would achieve the most cost effective returns of 54 MC per HIV infection averted. These numbers of MC required to avert an HIV infection change little even with coverage up to 80% of men. The greater the protective efficacy of longitudinal foreskin cuts against HIV acquisition, the less impact MC interventions will have. Dependent on this efficacy, increasing condom use could have a much greater impact with a 10 percentage point increase averting 18,400 infections over this same period. MC programs could be effective in reducing HIV infections in PNG, particularly in high prevalence populations. However the overall impact is highly dependent on the protective efficacy of existing longitudinal foreskin cutting in preventing HIV. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Interventions to prevent mother to child transmission of human immunodeficiency virus (HIV) during childbirth and breastfeeding can reduce HIV infections in infants to less than 5% in low and middle income countries. The World Health Organization (WHO) recommends all mothers, regardless of their HIV status, practice exclusive breastfeeding for the first six months of an infant's life. In line with these recommendations and to protect, promote and support breastfeeding, in 2009 the PNG National Department of Health revised their National HIV infant feeding guidelines, reinforcing the WHO recommendation of exclusive breastfeeding for the first six months followed by the introduction of other food and fluids, while continuing breastfeeding. The overall aim of this paper is to explore health care workers' knowledge regarding infant feeding options in PNG, specifically as they relate to HIV exposed infants. Methods: As part of a study investigating women's and men's experiences of prevention of mother to child transmission (PMTCT) services in two sites in PNG, 28 key informant interviews were undertaken. This paper addresses one theme that emerged from thematic data analysis: Health care workers' knowledge regarding infant feeding options, specifically how this knowledge reflects the Papua New Guinea National HIV Care and Treatment Guidelines on HIV and infant feeding (2009). Results: Most informants mentioned exclusive breastfeeding, the majority of whom reflected the most up-to-date National Guidelines of exclusive breastfeeding for six months. The importance of breastfeeding continuing beyond this time, along with the introduction of food and fluids was less well understood. The most senior people involved in PMTCT were the informants who most accurately reflected the national guidelines of continuing breastfeeding after six months. Conclusion: Providing advice on optimal infant feeding in resource poor settings is problematic, especially in relation to HIV transmission. Findings from our study reflect those found elsewhere in identifying that key health care workers are not aware of up-to-date information relating to infant feeding, especially within the context of HIV. Greater emphasis needs to be placed on ensuring the most recent feeding guidelines are disseminated and implemented in clinical practice in PNG. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Male circumcision (MC) significantly reduces the risk of HIV acquisition in men. The geographical, linguistic and cultural diversity of Papua New Guinea (PNG) makes issues of acceptability and implementation complex, and culturally appropriate HIV and Sexually Transmissible Infection (STI) prevention strategies are crucial in this setting. A modified Delphi approach was conducted with sexual health specialists to document and classify variants of penile cutting as part of a programme of research being carried out to investigate the acceptability and potential epidemiological impact of MC for HIV prevention in PNG, and options for future roll-out. Three broad categories were identified: circumcision, longitudinal incisions (including dorsal slit procedures) and incisions that did not alter the profile of penis or foreskin. The typology provides a universal language for health practitioners and policy makers that will inform future sexual health deliberations. The popularity of dorsal slit procedures in PNG has significant implications due to its procedural simplicity and limited resource requirements, making it an attractive provider option compared to medical circumcision. Further research is urgently required to examine the effectiveness of dorsal slit procedures for HIV prevention in PNG, the prevalence of various forms of penile cutting and the extent to which health staff are currently engaged in dorsal slit procedures. [ABSTRACT FROM AUTHOR]

Background: The potential for an expanded HIV epidemic in Papua New Guinea (PNG) demands an effective, evidencebased and locally-appropriate national response. As sexually transmitted infections (STIs) may be important co-factors in HIV transmission nationally, it is timely to conduct a systematic review of STI prevalences to inform national policy on sexual health and HIV/STI prevention. Methodology/Principal Findings: We undertook a systematic review and meta-analysis of HIV and STI prevalences in PNG, reported in peer-reviewed and non-peer-reviewed publications for the period 1950-2010. Prevalence estimates were stratified by study site (community or clinic-based), geographic area and socio-demographic characteristics. The search strategy identified 105 reports, of which 25 studies (10 community-based; 10 clinic-based; and 5 among self-identified female sex workers) reported STI prevalences and were included in the systematic review. High prevalences of chlamydia, gonorrhoea, syphilis and trichomonas were reported in all settings, particularly among female sex workers, where pooled estimates of 26.1%, 33.6%, 33.1% and 39.3% respectively were observed. Pooled HIV prevalence in community-based studies was 1.8% (95% CI:1.2-2.4) in men; 2.6% (95% CI:1.7-3.5) in women; and 11.8% (95% CI:5.8-17.7) among female sex workers. Conclusions/Significance: The epidemiology of STIs and HIV in PNG shows considerable heterogeneity by geographical setting and sexual risk group. Prevalences from community-based studies in PNG were higher than in many other countries in the Asia-Pacific. A renewed focus on national STI/HIV surveillance priorities and systems for routine and periodic data collection will be essential to building effective culturally-relevant behavioural and biomedical STI/HIV prevention programs in PNG. [ABSTRACT FROM AUTHOR]

Background: Papua New Guinea (PNG) has a high prevalence of sexually transmitted infections (STIs). There is increasing evidence that anorectal STIs are important in terms of the dual epidemics of HIV and STIs in this setting. At the time of this study, anorectal STI testing was not possible, and there was no mechanism for self-collection of anorectal specimen among at risk 'key populations'. This paper documents the development of a culturally appropriate tool that has been used to facilitate self-collection of anorectal specimens with key populations in PNG.Methods: This qualitative study involved four focus groups conducted with a purposive sample of 35 participants, including female sex workers, men who have sex with men and transgender women in Port Moresby and Goroka in 2015. During focus groups, participants reviewed and provided critical feedback for the adaption of a previously piloted and published pictorial anorectal specimen collection tool for use with key populations in PNG.Results: The final instruction tools are presented in English language and Tok Pisin. To develop these, participants feedback resulted in six key areas of the existing instruction document being modified to ensure it was appropriate for use in PNG. These included translating complex words for sexual health issues (i.e. 'STIs', 'anorectal STIs', 'anus', 'anal sex'), biomedical instruments (i.e. 'specimen bottle', 'specimen packet' and 'swab'), and aspects of the clinical procedure (i.e. inserting the swab 3-4 cm into the anus to collect a specimen). The visual identity of the graphics was redesigned to localise the images for use in PNG.Conclusions: This paper describes the development of a culturally and linguistically appropriate tool for a biomedical and clinical intervention with key populations in PNG based around self-collection of anorectal specimens for molecular STI testing. The final tools have been used to facilitate the self-collection of anorectal specimens following a clear clinical protocol during a large bio-behavioural survey in PNG. [ABSTRACT FROM AUTHOR]

Despite persistent international attention, adolescent pregnancy remains a major public health concern in low- and middle-income countries, like Papua New Guinea (PNG), where health inequities related to social and cultural norms, gender power imbalance, education and socio-economic deprivation affect young and unmarried women in particular. In PNG - where there is high adolescent fertility, high early childbearing and high maternal mortality ratio, and evidence of high rates of unintended pregnancy and abortion among young women - adolescent pregnancy is a policy priority. Yet there are no youth-specific sexual, reproductive and maternal health services or community-based outreach programmes. There is limited in-depth qualitative data on young women's and young men's experiences of pregnancy, the social contexts within which these pregnancies occur, young people's contraception practices and experiences with existing sexual, reproductive and maternal health services. These issues inhibit the design and delivery of youth-friendly health services and outreach support programmes that could prevent or mitigate adverse health and social outcomes associated with adolescent pregnancy. In this commentary article, we propose the need for novel youth-centred research to inform the development of policies, health services and outreach programmes that pay honest and respectful attention to young people's lived experiences of pregnancy. Whilst we focus on the situation in PNG, these ideas are relevant to diverse low resource settings where the harmful impacts of health inequities among young people persist and are particularly detrimental. [ABSTRACT FROM AUTHOR]

Background: Papua New Guinea (PNG) has a tuberculosis (TB) case notification rate of 333 cases per 100,000 population in 2016 and is one of the 14 countries classified by the World Health Organization (WHO) as "high-burden" for TB, multi-drug-resistant TB (MDR-TB), and TB/HIV. HIV epidemic is mixed with a higher prevalence among key populations, female sex workers (FSW), men who have sex with men (MSM), and transgender women (TGW). Methods: We conducted a cross-sectional HIV biobehavioral survey (BBS) using respondent-driven sampling method among FSW, MSM, and TGW in Port Moresby, Lae, and Mt. Hagen (2016–2017). As part of the study, participants were screened for the four symptoms suggestive of TB infection using the WHO TB screening algorithm. Sputum and venous whole blood samples were collected and tested for pulmonary TB and HIV infection, respectively. Pulmonary TB testing was performed using GeneXpert®MTB/RIF molecular point-of-care test, and HIV testing was done following the PNG national HIV testing algorithm. All data discussed are weighted unless otherwise mentioned. Results: Among FSW, 72.6%, 52.0%, and 52.9% in Port Moresby, Lae, and Mt. Hagen, respectively, experienced at least one symptom suggestive of TB infection. Among MSM and TGW, 69% and 52.6% in Port Moresby and Lae, respectively, experienced at least one symptom suggestive of TB infection. Based on GeneXpert®MTB/RIF results, the estimated TB prevalence rate among FSW was 1200, 700, and 200 per 100,000 in Port Moresby, Lae, and Mt. Hagen, respectively. Among MSM and TGW, the estimated TB prevalence rate was 1000 and 1200 per 100,000 in Port Moresby and Lae, respectively. Co-prevalence of TB/HIV among FSW was 0.1% in Port Moresby and 0.2% in Lae. There were no co-prevalent cases among FSW in Mt. Hagen or among MSM and TGW in Port Moresby and Lae. Conclusions: Key populations have a higher estimated rate of pulmonary TB than the national rate of pulmonary and extra-pulmonary TB combined. This showed that screening key populations for TB should be integrated into HIV programs regardless of HIV status in PNG's national TB response. [ABSTRACT FROM AUTHOR]

To compare the performance of dual immunostaining of p16INK4a and Ki-67 proteins performed on self-collected vaginal specimens and clinician-collected cervical specimens, and to evaluate the performance of this technique in predicting high-grade disease. Women aged 30–59 years (n = 1005) were recruited at two well-women clinics in Papua New Guinea. Each woman provided both cervical and vaginal specimens that were tested for high-risk human papillomavirus (hrHPV) DNA using the Xpert HPV Test (Cepheid) at point of care. A subset of paired cervical and vaginal specimens (n = 243) were selected to undergo CINTec® PLUS (Roche) p16/Ki-67 dual-stain cytology and liquid-based cytology (LBC). Fifty-five pairs (22%) were excluded from further analysis because the smears were not assessable. Of the 189 remaining paired specimens, 74 pairs (39.1%) were positive for one or more hrHPV genotypes. When comparing results of the dual stain, the overall percent agreement, positive and negative percent agreements and κ value between the cervical and vaginal specimens were 87.8% (CI 82.3–92.1%), 64.6% (CI 49.5–77.8%), 95.7% (CI 91.0–98.0%) and 0.65 (CI 0.51–0.79%) respectively. The sensitivity of the dual stain performed on the cervical specimen to predict high-grade disease, determined by LBC, was superior to that of the dual stain performed on the vaginal specimen: 100% (CI 84.6–100%) versus 68.2% (CI 45.1–86.1%). Although further evaluation may be warranted, these findings indicate that dual-stain testing of vaginal specimens cannot be advocated as part of cervical screening programmes in low- and middle-income countries. However, dual-stain cytology performed on cervical specimens may have a role in quality assurance in such settings. [ABSTRACT FROM AUTHOR]