HIV in Pregnancy: The PNG Experience

Professor Glen MolaSamoa, PSRH 2013

Historical Context

1987 first case of HIV 1991 100+ cumulative cases 2007 5000+ new cases per year: plateaus and

then in 2010 comes back to 3000 pa 1988: 5000 ANs tested in Moresby = 0 cases First AN cases 1994, prevalence 0.5% in 1998 2000 first national PPTCT plan 2004 PPTCT programs in Pubic Health Systems

– PMGH and catholic health services Paediatric ART commenced in 2005 - PMGH

Trends from 1987 to 2007

To begin with trends were exponential, exactly as occurred in sub-Saharan Africa

This was only to be expected in so far as sexuality in PNG is very like that of Africa, - albeit with marked tribal variation

To change the trend it was clear PNG had to do ‘things’ differently

‘Because once you get to 1%, the exponential upwards trend takes off.....’

A Typical prevalence curve of HIV over 15 years

0.0

0.1

0.2

0.3

1990 1995 2000 2005

Prevalence of HIV and Syphillis in pregnant women PMGH 1990-2012

0.5

11.5

2

2.53

3.5

44.5

5

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012

Source: PMGH O&G 2012 Annual Report

Prev

alen

ce (%

)

Syphillis HIV

There has been extensive mathematical modeling attempts to predict HIV prevalence

The three factors which have been most extensively studied are:

Average number of partners per male

The effect of male circumcision Epidemiology of partnering, - long

term multiple partners are the most dangerous

Pick up an HIV +ve partner~6/1000 transmission risk per coitus

Therefore the first weekend (after sex x 10), - probability of becoming HIV+ve is 6%

If she becomes the girlfriend, then after 3-4 months (ie after sex x 100), - probability of being HIV+ is 60%:

But 100% seroconversion after 1 year

If you are circumcised the figures are 2.5% (weekend), and 25% (if she has become the girlfriend): 100% seroconversion after 2 years

If you use a CONDOM the figures are 0.006% (weekend), & 0.025% (girlfriend 3-4 months later): 0.5% after 2 years

Change in prevalence by partners and time (years). Power law network cut-off at 30 partners

Age at circumcision (years)

0.0

0.1

0.2

0.3

0.4

0 10 20 30

Pre

vale

nce

of H

IV

Number of partners

5

40

20

10

Population-level effect of MC

Impact of Proportion Circumcised - Ndola

0

10

20

30

40

1985 1990 1995 2000Year

Default - 10% Circumcised 0% Circumcised

50% circumcised 75% circumcised

100% Circumcised Data

Impact of Proportion Circumcised - Yaounde

0

10

20

30

40

1985 1990 1995 2000

Year

Ad

ult

(15

-49y

) H

IV

Pre

vale

nce

(%

)

Default - 100% Circumcised 0% Circumcised

25% Circumcised 50% Circumcised

75% Circumcised Data

Increasing the proportion circumcised in Ndola results in an HIV epidemic similar to West African sites

Decreasing the proportion circumcised in Yaounde results in an HIV epidemic similar to East African sites

Yaounde (West) Ndola (East)

10%

100% 100%

0%

Not many success stories in PNG health, - and this one can’t be counted as a complete success just yet………..

Poster Courier newspaper 4.7.13

Political leadership

We have pushed the politicians into being politically correct, - have tests in public and put out the message that everyone needs to know their status

There have been no silly zenophobic statements or attitudes after the year of the first case in 1987

Community and Religious leadership

We have both archbishops holding hands with pastors of other churches on a poster advocating universal testing

Even the catholic church allows use of condoms when there is high risk of HIV transmission

We have the churches at the forefront of diagnosis and care (‘Anglicare Stopaids’ etc)

Whenever some fundamentalist group espouses prevention strategies causing promiscuity we do our best to ‘stamp’ on it by “enlisting Jesus’ help”

Using the HIV epidemic to break down taboos on sex education……………

By using the emergency of the HIV epidemic we have been able to break down a lot of the taboos on discussion of sexual matters and sex education in the community

We even teach about the importance of (safer) sex in pregnancy in the ANC

Normalizing HIV testing (PICT)

WHO have really assisted in getting the attitude across that HIV testing is part of normal clinical care (PICT)

Using the ‘Opt Out’ strategy for testing in ANCs

Making HIV testing a common part of the evaluation of all very sick children and adults

Treatment availability makes discussion and control of HIV easier

When HAART treatment is available there makes assurance of benefit logical

Treatment prevents transmission too

What we are lagging with………..

Disclosure to husbands/families: in the AN setting only 20-30% disclosure by delivery time.

Best way to achieve consent for disclosure is to emphasize benefit for husband, and whole family, - and at the same time mentioning the bad situation which can occur is disclosure does not happen…….

Implementation of Family Life Education curriculum: 1997, 2003 not implemented yet in 50+% schools……

But we are not there yet…………

Mary 22, having third pregnancyCross with husband in EHP Lufa village because

he had been unfaithfulLeaves him and the kids and comes to the

national capital where she gets pregnant to someone else; but by the time she books in the ANC new boyfriend has left her.

Husband in the village has married someone else.In ANC she is found to be HIV+ve, and is put on

HAARTLives with distant relatives in a shanty town; no

own means of support

Mary continued……

Used ANC subsidy busfare money to come to the labor ward (by herself in labor)

Has a CS for Fetal distress No relatives come to see her in hospital She says that her parents are back in the

village and she does not have a very good relationship with them because they did not approve of her leaving the husband

Counseling issues: Where to now??Issues: ARTs for life, contraception, guardianship,

where to live, how to survive, ?going home, care of the baby, future relationships, etc…….

The Impact on health workers and health systems

You might spend 2-5 mins on a normal AN mother for review checks

But HIV mothers may need 20-50mins A normal delivery may stay in the ward

for 1-3 days, HIV mothers will need to stay in the ward for much longer

More and more very sick and socially challenged patients mean that health workers start suffering from “compassion fatigue”

Prevention, Prevention, Prevention

Condoms, Condoms, Condoms Education Talk out Show leadership Normalize this issue and stop

making it so ‘special’; it is another chronic disease

Life-long treatment for everybody All health workers to do it