Sexual & Reproductive Health Research

Project Overview
Pregnancy among young people is a major public health concern in PNG, the Asia-Pacific, and other low and middle income countries (LMICs). It is identified as a priority in the Sustainable Development Goals by the United Nations , and the Lancet Commission for Adolescent Health . Young women aged 15-19 years account for 11% of all births worldwide; 95% occur in LMICs. There are 70000 annual deaths of adolescent girls due to pregnancy and childbirth, and risk of maternal death for girls <16 years is double that of adult women. Adverse health outcomes from pregnancy among young people are severe. They include increased risk of maternal mortality and morbidity, and poor perinatal outcomes (e.g. low birth weight, preterm birth, stillbirth, neonatal mortality). Socio-economic outcomes include school drop-out and limited livelihood opportunities, which perpetuate gender inequality and poverty. Despite priority given to pregnancy among young people in national and global health strategies, there is scarce information about young people’s experiences of pregnancy, and the social and cultural contexts of these pregnancies. This knowledge gap in Asia-Pacific settings hinders the development of effective policies and health programs.

Local setting
Papua New Guinea (PNG) has one of the highest adolescent fertility rates in the Asia Pacific and also one of the highest maternal mortality ratios in the world, and the highest in the Oceania region. Sepsis due to unsafe abortion is a leading cause of maternal mortality. The legal and policy environment inhabits the provision of safe abortion services to women due to criminal legislation reducing induced abortion. Most abortions are unsafe and there are no National level abortion data available. Furthermore, there are no in-depth qualitative data about young people’s experiences of pregnancy and the social context in which they occur available in the country as well as many Asia-Pacific countries; also there is limited data on young people’s contraception use in the country.

This is a three- year qualitative study commencing this year (2019); it will examine the experiences of pregnancy among young married and unmarried Papua New Guineans between the ages of 15-24. The overall aim of this study will be to guide the development of youth-centred health promotion strategies to prevent and mitigate the impact of pregnancy among young people of this age group and associated adverse health outcomes.
Other specific objectives include:

• Document young women and men’s perceptions and experiences of pregnancy.
• Examine young people’s socio-sexual behaviours and social, religious, cultural and service based context that influence risk of pregnancy and adverse health outcomes among young people.
• Analyse the strategies that young people use to prevent and mitigate the impact of pregnancy.
• Identify successes and gaps in the government and community responses to pregnancy among young people.
• Develop context-appropriate health promotion service- and community based strategies to prevent and mitigate the impact of pregnancy among young people.

The study will be conducted in three sites, Kagamuga in the Western Highlands, Bena in the Eastern Highlands and Port Moresby. These three sites offer a vast variety in terms of health service structures and facilities in Urban, peri-urban and rural settings.

Principal Advisors
Dr Stephen Bell –The Kirby Institute, UNSW Sydney
Associate Professor Angela Kelly-Hanku – PNG Institute of Medical Research

Study Co-ordinator
Sophie Ase- PNG Institute of Medical Research

Project Title: Understanding global biomedical technologies in local realities. The case of couples with mixed HIV status in Papua New Guinea. Yumi Serodiscordance Study

Duration of Study:  4 year study and we started qualitative data collection in 2017 and is on going

Collaborators on the study:  PNG Institute of Medical Research and University of New South Wales, Sydney

Investigators

Principal Investigator: Associate Prof Dr Angela Kelly – Hanku

Co-Investigators: Ms Agnes Mek, Dr Steven Bell, Asha Pearson, Heather Worth

Overview

We are doing this study to understand the life experiences of couples where one is HIV positive and the other is HIV negative (couples with mixed HIV status). More work is needed to understand how HIV impacts in the lives of couples with mixed HIV status. We also need to know how things associated with HIV such as HIV treatment, condoms and CD4 cell count testing impacts on their experience of HIV. Sometimes these things are referred to as biomedical technologies.

Objective

As an anthropological study of biomedicine it has the following aims:

• To generate culturally enriched understandings of the constitutive effects of new HIV biomedical technologies in the sexual and everyday lives of Serodiscordant couples in PMG.
• To bring an innovative, theoretically informed understanding to the ways in which HIV biomedical technologies intersect with culturally specific practices and meanings around gender, sexuality, illness and contagion/pollution.
• To provide knowledge of local usages and interpretations of global biomedical HIB prevention and treatment technologies (antiretroviral therapy, condoms, CD4 cell count testing, post exposure prophylaxis) in PNG

To examine and theorise how the intersection between socio-sexual cultures and practices impact on a therapeutic economy of HIV in the Melanesian society with the greatest burden of HIV.

We have been working in Western Highlands Province and Port Moresby. These places have a lot of people living with HIV and are likely to have more couples of mixed HIV status. 

Outcome

• The study will generate culturally enriched understandings of the constitutive effects of new HIV biomedical technologies in the sexual and everyday lives of Serodiscordant couples in PNG
• The study hopes to bring theoretically informed understanding to the ways in which HIV biomedical technologies intersect with culturally specific practices and meanings around gender, sexuality and illness
• Will provide knowledge of local usages and interpretations of global biomedical HIV prevention and treatment technologies in PNG

Impacts

• This research will report how HIV biomedical technologies in PNG are being taken up in very specific ways amongst different people and in different places and will challenge and add to current debates on the ways in which these new technologies impact on the lives of Papua New Guineans and other.
• Our research will illustrate the need to view understandings as expressions of people’s attempts to make sense of biomedicine, however scientifically imperfect in locally meaningful ways.
• We will provide an easy to read report (English only) and fact sheet (English and Tok Pisin) will be launched at a national event in PNG and made available to stakeholders and interested parties throughout PNG and the wider Pacific, through regional networks and also at international conferences.
• Two strategic workshops, including a ‘Research to Action’ workshop which will bring together Serodiscordant couples and local services providers, NGOs and funding bodies in PNG to discuss the research results, develop significant recommendations, identify ways to translate the research findings into practice and set priorities for action.

Understanding the socio-cultural dimensions of tuberculosis in PNG

Knowledge to optimize public health solutions

Research Collaborators

Papua New Guinea Institute of Medical Research, National Department of Health, Burnet Institute, UNSW Sydney, University of Melbourne, Monash University, Sydney University, NCD and Western Provincial Health Authorities, Communities of people with TB and other stakeholders.

Study Investigators

The Chief Investigators: Associate Professor Angela Kelly-Hanku, Professor Steve Graham, Professor Andrew Vallely, Professor William Pomat, Dr. Stephen Bell, Dr. Suman Majumdar, Dr. Paul Mason.

Associate-Investigators: Dr. Dakulala, Dr. Paul Aia, Professor John Kaldor, Professor Guy Marks.

Research Team: Ruthy Neo-Boli, John Cowan, and Martha Kupul (Project Coordinator)

 Synopsis

Tuberculosis (TB) is preventable and curable, yet remains the leading infectious cause of death globally. Papua New Guinea (PNG) has amongthe highest TB incidence rates (417/100,000) in the world, with rates in particular areas considerably higher. PNG is one of only 14 countriesclassified by WHO as having the triple high burdens of TB, multi drug-resistant (MDR) TB and TB-HIV co-infection. Despite formal adoptionof international standards for clinical and public health management of TB, past strategies have repeatedly proven insufficient to respond to theepidemic in the context of a fragile, over-stretched health system and complex socio-cultural environments.The optimal utilisation of novel andcurrent biomedical innovations, such as rapid diagnostic testing and shorter regimens for the treatment and prevention of TB, requires sociallyembeddedpublic health approaches. The unprecedented TB emergency in PNG and poor performance of conventional TB control programs thatfocus on vertical approaches, requires the urgent consideration of more effective and efficient responses to control epidemic spread. The End TBStrategy recognises the complex interaction of socio-cultural factors in health and that multi-disciplinary approaches incorporating anunderstanding of the complex socio-cultural factors affecting health factors are required if strategies are to be implemented successfully. Using aqualitative research design that is recognised in biomedical and public health research, this three-year project will examine the socio-culturalcontext of TB, including TB diagnosis, prevention and care programs in two distinct area of PNG, NCD and South Fly District of Western Province where TB emergencies have been declared.This is the first study of its kind in PNG designed specifically to inform TB control responses in high burden MDR-TB areas and the scaling upof treatment of infection. Both the process and outcomes of this study will have significance beyond the borders of PNG.

Study Title:  A rapid assessment of criminal law, HIV, sex work and male-to-male sex in Papua New   Guinea: HIV and other public health impacts

Study Overview

In PNG, there are a number of laws which regulate and criminalise sex work, male-to-male sex and the wilful and negligent transmission of HIV. This study was concerned with how these laws does or doesn’t impact the access to and experiences of HIV testing, prevention, treatment and care for people involved in sex work and men who have sex with men (including transgender). 

In the 2013 meeting of the Pacific Consultation on Legal and Policy Barriers to Accessing HIV Services for PLHIV and Key Affected Populations in Fiji, the PNG Team noted that work in the area of HIV and the law had slowed considerably and that renewed attention and energy was needed. In the action plan developed for Papua New Guinea by Papua New Guineans and other stakeholders identified that a small research project was required to inform future work in the area of HIV and the law.

There is substantial international evidence pertaining to the importance of decriminalization of sex work and male-to-male sex in order to improve public health outcomes, particularly HIV testing, prevention, treatment and care. What is missing in the current field is literature specific to PNG to inform these debates and identify what are the likely public health impacts if current PNG laws are left unchanged compared to the expected benefits if HIV related legal reform occurs.

Aim and objectives

The main aim of the study is to undertake a rapid assessment of the impact of criminal law on HIV testing, prevention, treatment and care of sex workers and men who have sex with men.

Specific objectives are to:

1. Assess the impacts of the criminalization of sex work and male-to-male sex on this populations access to and experiences of HIV testing, treatment, prevention and care;
2. Identify what impacts, if any, decriminalization of sex work and or male-to-male sex could have on access to and experiences of HIV testing, treatment, prevention and care;
3. Investigate the impacts that the criminalization of willful or negligent transmission of HIV (see HAMP Act) has on access to and experiences of HIV treatment, care and prevention amongst and;
4. Identify priorities areas for creating an enabling legal environment for access to HIV services (ie. working with police, legal reform and legal literacy programs)

Outputs

This study has been commissioned in order to directly feedback into the work activities of key PNG and international agencies working in PNG, which work in the area of HIV and the law. Depending on the findings and its subsequent recommendations, this study is expected to inform work to change aspects of the PNG law as it pertains to sex work and male-to-male sex and revisions of the HAMP Act. And to ensure that the legal and policy barriers to HIV testing, prevention treatment and care in PNG are at the fore of HIV advocacy in the country.

Specific outputs:

• Short report with recommendations written in consultation with key affected populations and key stakeholders
• Conference presentation and academic peer reviewed publications.

Current status of the study

This study was initially planned to be conducted in 2015, however due to shortfall of funding, there were delays.  And the data collection has recently been completed at the end of March, 2019.  The study was done in the National Capital District, Morobe and Eastern Highlands provinces of PNG. The study team is in the process of transcribing and translating the raw data for analysis. 

Semi structured in-depth interviews were carried out among;

1. Key Populations (FSW, MSM, TG)
2. Key Informants involved in Funding, designing and implementing HIV prevention, treatment and care programs and Advocating for and/or designing HIV related law reform in PNG.

Title: Prospective cohort study to evaluate point-of-care HPV-DNA testing for the early detection and treatment of cervical pre-cancer in high-burden, low-resource settings.

Background information:
Women in low-resource countries have an extremely high burden of cervical cancer: Of the estimated 528,000 new cervical cancer cases and 266,000 deaths worldwide in 2012, around 90% occurred in developing countries 1,2. PNG has among the highest estimated burdens of cervical
cancer, with incidence 6.3 times that of Australia and New Zealand (age standardized rates 34.5 vs
5.5/100,000), and mortality 13.5 times greater (21.7 vs 1.6/100,000). Cervical cancer is the most common cancer among women in PNG and results in an estimated 1,500 deaths per year. Human papillomavirus is the cause of cervical cancer: It has been recognized for several decades that persistent genital human papillomavirus (HPV) infection is the necessary cause of squamous and adenocarcinomas of the cervix, which constitute over 99% of all cervical cancers. There are
over 120 types of HPV, around 40 of which infect the anogenital tract through sexual contact.

These have been categorized into high-risk or low-risk types based on their ability to cause cervical cancer. Infection with high-risk HPV types (hrHPV) causes the histologically defined condition known as cervical intraepithelial neoplasia (CIN). The highest grade of CIN, designated CIN3, is known to be a ‘pre-cancer’ lesion, which can progress to invasive cancer if untreated. In high income
settings, the cytology-based Papanicolaou (Pap) test, involving the collection of exfoliated cells from the cervix, has been used to screen for pre-cancer, and led to large reductions in cervical cancer incidence in mortality in many countries, including Australia.
HPV 16 and 18 are the types most commonly associated with both CIN3 and cervical cancer, and estimated to be responsible for around 70% of all cervical cancers worldwide, with types 31, 33, 45, 52, and 58 responsible for an additional 20%.

Surveys of HPV prevalence among women in many countries have demonstrated a peak in infection under 25 years followed by a decline with age,8-10 explained by high incidence in younger women who have recently become sexually active,
followed by clearance of infection in the majority of those infected. The time lag between first infection and the development of CIN3 can be just a few years, but progression to cancer is
usually several decades. Although a variety of factors increase the likelihood that persistent HPV and CIN3 will progress to cervical cancer, including cigarette smoking and sexually transmitted infections (STIs), it is universally accepted that persistent infection with high risk HPV types is the necessary cause.

Our group recently completed the first HPV prevalence surveys in PNG and found high prevalence of infection and biological co-factors associated with disease progression among 1800 women attending well woman, antenatal and sexual health clinics. Around 24% of women aged 30-59 years (n=614) had one or more hrHPV infection and the
prevalence of chlamydia, gonorrhoea, trichomonas and herpes simplex virus type-2 (HSV-2) were 5.5%, 6.4%, 11.5% and 59.6% respectively. Members of our group also recently analysed cervical
biopsies from 70 women diagnosed with cervical cancer in PNG, and found HPV 16, 18, 33 and 31 the most prevalent high-risk types (57%, 26%, 10% and 4% respectively). 

Population: 3400 women aged 30-59 years in Papua New Guinea.

Trial Design: Non-randomized prospective clinical cohort study.

Research Sites: Three well woman clinics in Madang, Milne Bay and Western Highlands Provinces.

Study Duration: 3 years.

Subject Duration: Women will be recruited at their first screening visit and followed for 1 year.

Aim: To measure the effectiveness, health system implementation requirements, cost-effectiveness and acceptability of point-of-care Xpert HPV testing for the early detection and treatment of cervical pre-cancer in high-burden, low resource settings.

Primary Objective: Evaluate the performance of Xpert HPV Test for the early detection and treatment of cervical precancer lesions when conducted at point-of-care in routine clinical settings using self-collected vaginal specimens.

Secondary Objectives:

1. Evaluate the cost-effectiveness of point-of-care Xpert HPV testing for the early detection and treatment of cervical pre-cancer lesions;
2. Evaluate the health system implementation requirements of point-of-care Xpert HPV testing for the early detection and treatment of cervical pre-cancer lesions;
3. Evaluate the acceptability of point-of-care Xpert HPV testing for the early detection and treatment of cervical pre-cancer lesions;
4. Evaluate the laboratory performance of self-collected vaginal specimens compared with clinician-collected cervical specimens for the detection of cervical cancer biomarkers.