Figure 1: Estimated HIV prevalence,

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1 Total population (thousands) 6,331 (27) [1] Annual population growth rate 1.8% (2-21) [1] Population aged 1-29 (thousands) 3,197 (27) [1] Percentage of population in urban areas 14% (27) [1] Crude birth rate (births per 1, population) 3.1(27) [1] Under- mortality rate (per 1, live births) 73 (26) [2] Source: Human development Index (HDI) Rank/Value 149/.3 (28) [3] Life expectancy at birth (years) 62 (26) [2] Adult literacy rate 7 (26) [2] Ratio of girls to boys in primary and secondary education (%) No data GDP per capita (PPP, $US) 2,63 (2) [3] Per capita total health expenditure (Int. $) 172 (2) [2] Surveillance is lacking, and there are ongoing problems with unreturned and incomplete notification forms for all new diagnoses of HIV [4]; In 26, the sex was unknown for 9% of all newly notified cases of HIV. Meanwhile, 18% of notifications had no age, % failed to document the person s province of origin, and 3% did not list the possible mechanisms of exposure []; A number of community based surveys have been conducted that tested participants for HIV, however none employed fully representative sampling strategies []; While numerous community-based behavioral surveys have been conducted among populations who are not considered high risk, few have employed representative sampling methodologies making them essentially incomparable []. After the first case of HIV was detected in 1987, the number of HIV infections has increased drastically. In 24, Papua New Guinea became the fourth country in the Asia-Pacific region to declare a generalized HIV & AIDS epidemic. As of 28, it has the highest HIV prevalence in the Asia-Pacific region at 1.%. Cases of HIV from Papua New Guinea in turn constitute an increasing proportion of the total cases detected in the Pacific - from 21% of all cases in , to over 98% in 2-27 []. This upwards trend is expected to continue in coming years (figure 1). Figure 1: Estimated HIV prevalence, Percent Source: NACS and NDOH, 27 cited by the PNG National AIDS Secretariat and Partners in UNGASS Country Progress Report: PNG (January 26- December 27), 31 January 28 At the end of 27, UNAIDS estimated that 4, people were living with HIV (an increase of more than 4% from 21) [6]. Of this number, 21, (39%) are estimated to be women and 1,1 children [7]. The predominant means of HIV transmission is unprotected heterosexual sex 1 with multiple sexual partners.

2 HIV has now been diagnosed in every province. Since the Port Moresby Hospital was the only site providing testing for HIV in PNG for almost 1 years, over % of all reported HIV infections come from the National Capital District (figure 2) [8]. Figure 2: Percentage (%) distribution of HIV cases by province, 26 A 26 survey in 1 communities revealed that HIV prevalence amongst men was 2.2% and amongst women was 3% [9]. Urban areas, however, demonstrated higher rates for both men (3%) and women (4%). Rates were particularly high among young urban females (.8%) aged 1-24, indicating that the HIV epidemic in PNG is becoming feminized and taking on a younger face (figure 3). Figure 3: HIV prevalence in 1 communities by sex and urban-rural setting National Capital District 19. Western Highland Province Source: PNG National AIDS Secretariat and Partners in UNGASS Country Progress Report: PNG (January 26-December 27), 31 January 28 9 Morobe 2 Other provinces Males Females Urban male Urban female Rural male Rural female Urban young man Urban young female Source: Toole M. The HIV situation in Papua New Guinea: What we can deduce from surveillance and special studies. Center for International Health. Presentation at ASHM Conference, Melbourne, October HIV positive (per cent) 4.8 Gender disparity compounds women s and especially adolescent girls risks of contracting STIs, including HIV. Violence against women persists and heightens their vulnerability to HIV infection given that they are often unable to negotiate the terms of sexual contact (including protection measures). The illegality of commercial sex work makes female sex workers particularly hard to reach with interventions and to sample []; Low condom use among the general populations, particularly in rural areas []; High rates of sexually transmitted diseases; A wide range of risk behaviors taken by youths, including multiple sex partners and early first sex; High incidence of rape, sexual aggression and other forms of violence against women [1]. In the first round of Behavioral Surveillance Surveys (BSS) undertaken in 26, adult male workers in private industries were amongst the population groups surveyed (n= 1,38). Among them were truck drivers, sugar workers, port workers and military personnel. Figure 4 summarizes the survey findings amongst these groups. Figure 4: Risk behaviors amongst adult male workers in selected occupations, 26 had forced sex with a woman had male-to-male sex reported consistent condom use at last sex with regular partners % with non-commercial sex partners % paying women for sex in past 12 months Truck drivers Ramu sugar workers Lae port workers Military personnel NACS and NHASP, 27 cited by PNG National AIDS Secretariat and Partners in UNGASS Country Progress Report: PNG (January 26- December 27), 31 January 28 2

3 Many men (ranging from 18% to %) had forced sex with a woman, adding to the body of evidence that there is a high incidence of violence committed against women in PNG. Risk behaviors were high amongst truck drivers, military personnel and port workers: many of them engaged in unprotected sex both with commercial and non-commercial partners. Sexually transmitted infections (STIs) are highly prevalent in PNG. A recent survey in 1 communities found that 4% of the surveyed populations testing positive for at least one STI. Fourteen percent of women and 16% of men tested positive for syphilis. Amongst those who tested positive for HIV, 43% of menand29%ofwomenalsotested positive for syphilis (figure ) [9] Figure : Level of sexually transmitted infections and syphilis amongst men and women, 2 4 Tested at least one STI 14 Syphilis (women) Source: Toole M. The HIV situation in Papua New Guinea: What we can deduce from surveillance and Special studies. Center for International Health. Presentation at ASHM Conference, Melbourne, October Syphilis (men) 43 Syphilis (men with HIV) 29 Syphilis (women with HIV) A 26 study of 3,47 men and women in urban and rural areas found that condom use at last sex with a non-regular, non-commercial partner was low in both regions. Specifically, in rural Wewak, results were 18% among males and 11% among females. In the capital city of Port Moresby, figures were 16-24% among males and 12-13% among females [11]. In 27, condom use was reportedly 88.% among MSM and 94% among FSWs [8]. The Institute of Medical Research (IMR) in PNG conducted surveys amongst female sex workers (FSWs) in Port Moresby and Goroka from 2 (baseline) to 27 (end of project interventions) [12]. High levels of consistent condom use with non-paying sex partners and with clients could be observed amongst FSWs in Port Moresby. The opposite was true amongst FSWs in Goroka, where despite an increase between 2 and 27 condom use remained quite low (figure 6). Figure 6: Percentage of female sex workers reporting condom use in Goroka and Port Moresby, 2 and 27 Reported consistent condom use over past month with client, Goroka Reported consistent condom use over past month with client, POM Reported consistent condom use with nonpaying partners, Goroka Reported consistent condom use with nonpaying partners, POM Had non-paying sexual partners, POM Source: Maibani-Michie, 27 cited by the PNG National AIDS Secretariat and Partners in UNGASS Country Progress Report: PNG (January 26-December 27), 31 January 28 In 27, 47% of FSWs received an HIV test and received their results [13]. In terms of comprehensive knowledge as of 27, 3% of FSWs can both correctly identify ways of preventing the sexual transmission of HIV and reject major misconceptions about HIV 3 transmission [13].

4 While heterosexual sex is currently the predominant mode of HIV transmission in Papua New Guinea, a rather high proportion of men are classified as men who have sex with men (MSM). Specifically, 26 studies have shown that up to 13% of men in high risk occupations (truckers, sugar workers, port workers, military) (n=148) and 12% of out of school young men (n=788) have sex with other men [14]. HIV prevalence (26) [24] Selected behaviors (27) [8, 13] National response [13, 2] MSM make up.1% of the total number of reported HIV infections. 41% of MSM had an HIV test and got the results; 71% of MSM had comprehensive HIV knowledge; 42% of MSM in Port Moresby had sex with a one-time male paying client in the past month; 47% had sex with a regular paying male client in the past month; 84% had sex with a non-paying male sex partner; 63% had sex with a female in the past month; Consistent condom use was 71% with regular paying male clients; 77% with one-time male paying clients; 68% with nonpaying sex partners and 8% with females. MSM is illegal in Papua New Guinea; MSM are not formally organized; 1% of MSM were reached by HIV prevention programmes in 27; There is no specific program line for MSM in the national HIV plan; There is no specific budget line for MSM in the national HIV plan. The abovementioned IMR surveys also captured data on MSM in Port Moresby [12]. While the proportions of MSM who had sex with a non-paying male sex partner, with non-paying female sex partner, and with regular paying male clients decreased from 2 to 27, the levels of consistent condom use increased (figure 7). Figure 7: Percentage of men who have sex with men reporting sexual partners and condom use in Port Moresby, 2 and 27 Reported consistent condom use with regular paying male clients Had regular paying male clients in past month Reported consistent condom use with one-time male paying clients Had sex with one-time male paying clients Reported consistent condom use with non-paying female sex partner Had sex with non-paying female sex partner over past month Reported consistent condom use with non-paying sex partner Had a non-paying male sex partner Source: Maibani-Michie, 27 cited by the PNG National AIDS Secretariat and Partners in UNGASS Country Progress Report: PNG (January 26-December 27), 31 January 28 Nationwide in 27, 42% of MSM received and HIV test and received their results [13]. In terms of comprehensive knowledge as of 27, 71% of MSM can both correctly identify ways of preventing the sexual transmission of HIV and reject major misconceptions about HIV transmission. A 26 BSS of out-of-school youth (n= 913 females; 788 males) revealed that % of married and 66% of unmarried young women exchanged sex for goods or money in the last year [1]. The same survey revealed that 46% of married and 42% of unmarried young men had had commercial sex. Condom use at last commercial sex was 7% among unmarried young men and 4% among married young men. Sexually transmitted infections were also found to be high among this sample: 38% among unmarried young women and 13% among married young men. In 26, the median age at first sex was 16 among both young men and young women. The proportion of youth with two or more partners was 2% and 37% among unmarried young women and men, respectively and 9% and 39% among married young women and men, respectively. 4

5 Comprehensive knowledge of HIV/AIDS that is, being able to correctly identify ways of preventing the sexual transmission of HIV and to reject major misconceptions about HIV transmission has been shown to be quite low among young people. Data from 2 reveals that only % of those living in rural settings and 7% of those in urban settings have comprehensive HIV knowledge (figure 8). 1 1 Figure 8: Percentage of comprehensive HIV knowledge among young people (1-24), Urban Rural Urban Rural Urban Rural Male Female Total Source: National AIDS Council Secretariat, Papua New Guinea. UNGASS Monitoring the declaration of commitment on HIV/AIDS, January 24-December Table 1: Projections of HIV epidemic in Papua New Guinea [Source: AusAID. Impacts of HIV & AIDS 2-22 in Papua New Guinea, Indonesia and East Timor Final report of HIV epidemiological modeling and impact study. February 26] According to the 26 estimates carried out by AusAID, by the end of 21, there will be almost 12, people living with HIV in Papua New Guinea with annual new infections of 26, people. The cumulative AIDS-related deaths will be almost 61, cases, and approximately 2, children will be AIDS-related orphans (table 1) [16]. In estimating the impact of HIV and AIDS, it is important to develop a baseline scenario based on assumptions regarding the epidemiological characteristics of HIV transmission, and projection of the future course of the HIV epidemic. Under the baseline scenario, HIV prevalence in Papua New Guinea is projected to increase up to almost 3% by 21, and.8% by 22. This level of increase will indeed have a substantial impact on individuals, families, communities, workplaces, and the nation as a whole. For example, under the baseline scenario, HIV prevalence is projected to reach.3% amongst 1-4 year olds by 21 and almost 11% by 22. Notably, this age group comprises much of the workforce and the reproductive segment of society [16]. Figure 9: Projected prevalence of HIV amongst the general population (1-49), (with available antiretroviral therapy) HIV positive (%) IDU FSWs Male clients of FSWs MSM Pediatric Adult 1-49 Total pop. Amongst high-risk groups, the most rapid increase in HIV prevalence is projected to occur among female sex workers. It is projected under the baseline scenario that by the end of 21, prevalence amongst FSWs in PNG will be 8% and by the end of 22, approximately 24% (figure 9) [16]. Source: AusAID. Impacts of HIV & AIDS 2-22 in Papua New Guinea, Indonesia and East Timor Final report of HIV epidemiological modeling and impact study. February 26

6 Over the next 2 years, in the absence of a strong HIV response, Papua New Guinea may not only face a rapidly increasing HIV prevalence but also increasingly high death rates due to AIDSrelated illness [16]. Under the baseline scenario, by 21 almost 6, people will have died due to AIDS-related causes, rising to over 4, by the end of 22. Deaths will occur mostly in the 1-49 age group, which considerably skews the population pyramid. Of these deaths, one-third will be amongst adult women. There will also be a potential loss in reproductive capacity if women become less willing or unable to have children because of their HIV status [16]. The analysis of the potential impacts of HIV and AIDS on the macro economy has been examined with the use of two major indicators: (1) potential reduction in GDP growth; and (2) decrease in the workforce [16]. Potential reduction in GDP growth: The International Labour Organization (ILO) has developed a model of the relationship between HIV prevalence andthereductioningdpandgdpper capita by analyzing data from 41 countries including Papua New Guinea (figure 1). Under the baseline scenario, HIV will potentially cause a reduction in annual GDP growth reaching 1.3% in 22. Under a more optimistic medium response scenario, the reduction in annual GDP growth is estimated at about 1% by 22, and for the high response scenario it is about.6% [16]. Figure 1: Percentage reductions in annual GDP per capita based on projections of HIV prevalence baseline scenario Source: AusAID. Impacts of HIV/AIDS 2-22 in Papua New Guinea, Indonesia and East Timor Final report of HIV epidemiological modeling and impact study. February 26 Table 2: Reduction in the size of the workforce Note: Assumes 8.6 year time lag between infection and death. Source: AusAID. Impacts of HIV & AIDS 2-22 in Papua New Guinea, Indonesia and East Timor Final report of HIV epidemiological modeling and impact study. February 26 Reduction in the size of workforce: Table 2 shows the projection of different scenarios on reduction in thesizeoftheworkforce.apotentiallossofcloseto 13% of the workforce by 22 is projected under the baseline scenario, and under mid-and-high response scenarios, the workforce size is reduced by 1% and 9% in 22, respectively. The reduction in size of the workforce translates to an economic cost because of the early death of those in the economically active age group and decreased productivity in their final years of life [16]. Increases in HIV-related morbidity and mortality will impact severely on the health sector by reducing the capacity of the health system itself through the loss of trained staff whilst demands for services increase. While it is difficult to determine the economic impact of HIV on the health sector, the modeling team made some assumptions to illustrate the potential differences between the baseline and high response scenarios. If the epidemic continues without an increased prevention effort, the costs of caring for those with opportunistic infections and providing antiretroviral therapy (ART) will continue to rise, and the health sector will be placed under significant strain. 6

7 In particular, by 22: costs of opportunistic treatment, health care and hospital admissions would rise up to US$ 18 million per annum; medical hospital beds would be over 7% capacity with AIDS patients; even when assuming limited availability, costs of antiretroviral drugs would climb to be over US$24 million per annum; and doctor to HIV and AIDS patient ratios would reach 1:26 [16]. Legal issues relating to HIV and AIDS in Papua New Guinea include the following: The HIV/AIDS Management and Prevention Act contains provisions regarding discrimination against people living with HIV, confidentiality, issues of prevention, counselling, care and treatment and provides avenues for redress for infringements to these rights and services [17]; The minimum legal age for accessing sexual and reproductive health services is 18 (yet girls between the ages of 14 and 17 are usually not denied these services if they try to access them) [18]; The Constitution guarantees protection for equal rights for all, but stigma and discrimination against all people living with HIV remains high [19]; Sex work is illegal and attempts by FSWs to formally organize themselves have resulted in violence and police harassment [2]. The Government has undertaken several significant steps to combat HIV and AIDS in the country, among which include the following: Establishment of national structures to manage and carry out HIV & AIDS policies and programmes: -The National AIDS Council (NAC) and the National AIDS Council Secretariat (NACS) in 1997; -Special Parliamentary Committee on HIV/AIDS in 24. Development of key policies to guide the national response to HIV and AIDS in the country: -HIV and AIDS Management and Prevention (HAMP) Act 23 that provides legal framework for addressing discrimination, stigmatization and mandatory screening with respect to HIV; -PNG Medium-Term Development Strategy (MTDS) 2-21, which includes HIV and AIDS as one of the 6 expenditure priorities of the Government; -National HIV and AIDS Strategic Plan (26-21), and followed by annual operational plans; -National Gender Policy and Plan on HIV and AIDS 26-21; -National Leadership Strategy in 27; -National Education Plan Establishment of national strategies and programmes on HIV & AIDS: - 3 x initiative to introduce ART in PNG in 24; -High Risk Setting Strategy implemented by civil society groups under the management of Burnett Institute in 2; -Provider-initiated HIV testing and counseling to scale up HIV testing in health sector in 27; -National Surveillance Plan with substantial support from bilateral and multilateral partners and research institutions. Strengthening of institutional and human resource capacity in HIV monitoring and evaluation, and HIV surveillance. 7

8 The implementation of provider-initiated HIV testing and counselling in health-care settings resulted in a nine-fold increase in the use of testing in health-sector sites between 26 and 27 [13]. Forty-four percent (118 out of 27) of health facilities were providing HIV testing andcounselingasofdecember28[21]. Moreover, the number of people aged 1 years and older who received HIV testing and counseling and know their results was 17,61 (29,894 males; 77,721 females) [21]. In terms of prevention, as of 27, only 31% of FSWs and 1% of MSM were reached with HIV prevention programmes. Meanwhile, 2% of schools provided life skills-based HIV education in the last academic year [13]. Nineteen percent (2 out of 27) health facilities were offering ART as of December 28 [22]. Data from 26 and 27 show a rise in the percentage of adults and children with advanced HIV infection receiving ART (from 23% in 26 to 3% in 27) [8]. Over the same period, treatment among women rose from 2% to 33% while that among men rose from 22% to 39%. The 27 HIV Estimation and Projection Report indicates that, of the PLHIV needing treatment by the end of 27, treatment coverage was 36% for adults and for children is 29% (figure 11). Figure 11: Antiretroviral therapy coverage based on 27 HIV estimation and projection Adults Source: National AIDS Council Secretariat, Papua New Guinea. UNGASS Monitoring the declaration of commitment on HIV & AIDS, January 24-December Children In PNG, 7 out of 2 provinces provide prevention of mother-to-child transmission (PMTCT) services in health care facilities. The percentage of health facilities providing antenatal care (ANC) services that offer both HIV testing and antiretrovirals for PMTCT on site was 17% as of December 28 [23]. At the same time, 6% of health facilities offer pediatric ART [22]. In 28, 24% (44,8 of 18,) of pregnant women were tested for HIV and received their results) [21]. The estimated number of pregnant women who are HIV-positive reached 3,621 in 27, up from 2,848 in 26. While, the PMTCT programme coverage dipped from 3.% in 26 to 2.3% in 27, 6% of HIV-infected pregnant women received antiretrovirals (ARVs) to reduce the risk of mother-to-child transmission [23]. The Government of PNG has scaled up its funding for HIV and AIDS by more than 1%, from PNG Kina 7,12,6 (approximately US$2,7,) in 26 to K 18,, (US$6,9,) in 27. Prior to 24, government funding for HIV programs was sporadic [8]. In 2, PNG successfully applied for a GFATM grant of US$ 3 million over five years. Since 26, budgetary allocations have increased mainly through international donors. The Australian Government through AusAID has been the major Government funding agency for HIV and AIDS prevention treatment and care programs. Other major donors include the Asian 8

9 Development Bank, USAID, the UN system, and New Zealand AID. Other international donors include the Word Bank, the Clinton Foundation, the British High Commission and the European Union. Funds committed to the 28 National Strategic Plan are summarized in Table 3 [8]. Table 3: Summary of funds committed to the 28 National Strategic Plan, Implementation Plan Source: National AIDS Secretariat (PNG) and Partners in UNGASS Country Progress Report: PNG (January 26-December 27), 31 January 28. 9

10 [1] 27 UN Population Division cited in WHO, UNAIDS and UNICEF, Epidemiological Fact Sheet on HIV and AIDS: Papua New Guinea, July 28. [2] World Health Statistics 28, cited in WHO, UNAIDS and UNICEF, Epidemiological Fact Sheet on HIV and AIDS: Papua New Guinea, July 28. [3] UNDP, Human Development Report, 27/28. [4] National data managers workshop, Lae 27, as cited by Coghlan, B, Gouillou M et al, HIV in the Pacific: summary of surveillance data, Burnet Institute, 29. [] Coghlan, B, Gouillou M et al, HIV in the Pacific: summary of surveillance data, Burnet Institute, 29. [6] WHO, UNAIDS and UNICEF. Epidemiological fact sheet on HIV and AIDS: Papua New Guinea, July 28. [7] UNICEF, State of the World's Children 29. Maternal and Newborn Care. New York 29. Available online: < [8] National AIDS Secretariat (PNG) and Partners in UNGASS Country Progress Report: PNG (January 26-December 27), 31 January 28. [9] Toole M. The HIV situation in Papua New Guinea: What we can deduce from surveillance and special studies. Center for International Health. Presentation at ASHM Conference, Melbourne, October 26. [1] Cullen T, Cowan E, HIV/AIDS in Papua New Guinea: A reality check. Pacific Journalism Review, 26 12(1):13. [11] Hammar, L. (26). It s in Every Corner Now : results from a nationwide study of HIV, AIDS, STDs, and sexual health. National HIV/AIDS Support Project. Australian Agency for International Development. May 26. [12] Maibani-Michie, 27 cited by note 8. [13] UNAIDS/WHO, 28 Report on the global AIDS epidemic, July 28. [14] Millan J et al (26). HIV/AIDS Behavioural Surveillance Survey within High Risk Settings, Papua New Guinea: BSS Round 1. NACS and NHASP as cited by Coghlan, B, Gouillou M et al, HIV in the Pacific: summary of surveillance data, Burnet Institute, 29; Millan J, Yeka W, Obiero W, and Pantumari J (27). Report of the HIV/AIDS behavioural surveillance survey within high-risk settings, 26. National AIDS Council Secretariat and National HIV/AIDS Support Project. Port Moresby, PNG. September 27. [1] Family Health International, Behavioral Surveillance Survey. FHI, 26, as cited by National AIDS Secretariat (PNG) and Partners in UNGASS Country Progress Report: PNG (January 26-December 27), 31 January 28. [16] AusAID. Impacts of HIV & AIDS 2-22 in Papua New Guinea, Indonesia and East Timor Final report of HIV epidemiological modeling and impact study. February 26 [17] Independent State of Papua New Guinea, HIV/AIDS Management and Prevention Act, 23. No. 4 of 23; International Planned Parenthood Federation. Report Card: HIV prevention for girls and young women (Papua New Guinea). IPPF, 26. Available online: < E C1-8DFCC16EF//PNG.pdf >. [18] UNICEF, 27, Family Planning Policy in Papua New Guinea : Female gynaecologist, as cited by International Planned Parenthood Federation. Report Card: HIV prevention for girls and young women (Papua New Guinea). IPPF, 26. Available online: < >. [19] BBC NEWS, Asia-Pacific, 27 PNG AIDS victims Buried Alive as cited by International Planned Parenthood Federation. Report Card: HIV prevention for girls and young women (Papua New Guinea). IPPF, 26. Available online: < >. [2] Christine Stewart, Gender Relations Centre, research of School of Pacific and Asian Studies, the Australian National University, Working Paper 19 Prostitution and Homosexuality in Papua New guinea: Legal, Ethical and Human Rights Issues, as cited by International Planned Parenthood Federation. Report Card: HIV prevention for girls and young women (Papua New Guinea). IPPF, 26. Available online: < >. [21] National Department of Health, HIV Testing Database, 28, as cited by WHO, Universal Access Questionnaire, National Report (Papua New Guinea), 29.

11 [22] National Department of Health, ART Database, 28, as cited by WHO, Universal Access Questionnaire, National Report (Papua New Guinea), 29. [23] National Department of Health, PPTCT Database, 28, as cited by as cited by WHO, Universal Access Questionnaire, National Report (Papua New Guinea), 29. [24] van Griensven F, de Lind van Wijngaarden JW, et al, The global epidemic of HIV infection among men who have sex with men. Current Opinion in HIV and AIDS, 29 Jul;4(4):3-7. [2] Naz Foundation International, Male Sexual Health and HIV in Asia and the Pacific - International Consultation (Papua New Guinea). Available online: ibilities/country%2reports/png.pdf.