RESUMEN

OBJECTIVE: Papua New Guinea (PNG) has among the highest estimated prevalences of genital Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV) of any country in the Asia-Pacific region. Diagnosis and treatment of these infections have relied on the WHO-endorsed syndromic management strategy that uses clinical presentation without laboratory confirmation to make treatment decisions. We evaluated the performance of this strategy in clinical settings in PNG. DESIGN: Women attending antenatal (ANC), well woman (WWC) and sexual health (SHC) clinics in four provinces were invited to participate, completed a face-to-face interview and clinical examination, and provided genital specimens for laboratory testing. We estimated the performance characteristics of syndromic diagnoses against combined laboratory diagnoses. RESULTS: 1764 women were enrolled (ANC=765; WWC=614; SHC=385). The prevalences of CT, NG and TV were highest among women attending ANC and SHC. Among antenatal women, syndromic diagnosis of sexually transmitted infection had low sensitivity (9%-21%) and positive predictive value (PPV) (7%-37%), but high specificity (76%-89%) and moderate negative predictive value (NPV) (55%-86%) for the combined endpoint of laboratory-confirmed CT, NG or TV. Among women attending WWC and SHC, 'vaginal discharge syndrome' had moderate to high sensitivity (72%-78%) and NPV (62%-94%), but low specificity (26%-33%) and PPV (8%-38%). 'Lower abdominal pain syndrome' had low sensitivity (26%-41%) and PPV (8%-23%) but moderate specificity (66%-68%) and high NPV (74%-93%) among women attending WWC, and moderate-high sensitivity (67%-79%) and NPV (62%-86%) but low specificity (26%-28%) and PPV (14%-33%) among SHC attendees. CONCLUSION: The performance of syndromic management for the detection and treatment of genital chlamydia, gonorrhoea and trichomonas was poor among women in different clinical settings in PNG. New diagnostic strategies are needed to control these infections and to prevent their adverse health outcomes in PNG and other high-burden countries.

Asunto(s)

Infecciones por Chlamydia/diagnóstico , Chlamydia trachomatis/crecimiento & desarrollo , Técnicas y Procedimientos Diagnósticos/normas , Gonorrea/diagnóstico , Neisseria gonorrhoeae/crecimiento & desarrollo , Tricomoniasis/diagnóstico , Trichomonas vaginalis/crecimiento & desarrollo , Dolor Abdominal/diagnóstico , Dolor Abdominal/etiología , Adulto , Instituciones de Atención Ambulatoria , Infecciones por Chlamydia/complicaciones , Infecciones por Chlamydia/microbiología , Infecciones por Chlamydia/terapia , Técnicas de Laboratorio Clínico , Servicios de Diagnóstico , Femenino , Genitales Femeninos/microbiología , Genitales Femeninos/parasitología , Gonorrea/complicaciones , Gonorrea/microbiología , Gonorrea/terapia , Humanos , Embarazo , Complicaciones Infecciosas del Embarazo/diagnóstico , Complicaciones Infecciosas del Embarazo/terapia , Atención Prenatal , Salud Sexual , Enfermedades de Transmisión Sexual/diagnóstico , Enfermedades de Transmisión Sexual/microbiología , Enfermedades de Transmisión Sexual/parasitología , Enfermedades de Transmisión Sexual/terapia , Tricomoniasis/complicaciones , Tricomoniasis/parasitología , Tricomoniasis/terapia , Salud de la Mujer , Adulto Joven

RESUMEN

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. CONCLUSION: 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.

Asunto(s)

Circuncisión Masculina , Prepucio/cirugía , Infecciones por VIH/prevención & control , Herpes Genital/prevención & control , Sífilis/prevención & control , Adolescente , Adulto , Circuncisión Masculina/métodos , Estudios Transversales , Humanos , Masculino , Persona de Mediana Edad , Papúa Nueva Guinea , Prevalencia , Conducta de Reducción del Riesgo , Conducta Sexual , Adulto Joven

RESUMEN

INTRODUCTION: Papua New Guinea is a Pacific Island nation of 7.3 million people with an estimated HIV prevalence of 0.8%. ART initiation and monitoring are guided by clinical staging and CD4 cell counts, when available. Little is known about levels of transmitted HIV drug resistance in recently infected individuals in Papua New Guinea. METHODS: Surveillance of transmitted HIV drug resistance in a total of 123 individuals recently infected with HIV and aged less than 30 years was implemented in Port Moresby (n = 62) and Mount Hagen (n = 61) during the period May 2013-April 2014. HIV drug resistance testing was performed using dried blood spots. Transmitted HIV drug resistance was defined by the presence of one or more drug resistance mutations as defined by the World Health Organization surveillance drug resistance mutations list. RESULTS: The prevalence of non-nucleoside reverse transcriptase inhibitor transmitted HIV drug resistance was 16.1% (95% CI 8.8%-27.4%) and 8.2% (95% CI 3.2%-18.2%) in Port Moresby and Mount Hagen, respectively. The prevalence of nucleoside reverse transcriptase inhibitor transmitted HIV drug resistance was 3.2% (95% CI 0.2%-11.7%) and 3.3% (95% CI 0.2%-11.8%) in Port Moresby and Mount Hagen, respectively. No protease inhibitor transmitted HIV drug resistance was observed. CONCLUSIONS: The level of non-nucleoside reverse transcriptase inhibitor drug resistance in antiretroviral drug naïve individuals recently infected with HIV in Port Moresby is amongst the highest reported globally. This alarming level of transmitted HIV drug resistance in a young sexually active population threatens to limit the on-going effective use of NNRTIs as a component of first-line ART in Papua New Guinea. To support the choice of nationally recommended first-line antiretroviral therapy, representative surveillance of HIV drug resistance among antiretroviral therapy initiators in Papua New Guinea should be urgently implemented.

Asunto(s)

Fármacos Anti-VIH/farmacología , Farmacorresistencia Viral , Infecciones por VIH/epidemiología , Infecciones por VIH/transmisión , VIH/efectos de los fármacos , Adolescente , Adulto , Fármacos Anti-VIH/uso terapéutico , Femenino , VIH/clasificación , VIH/genética , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/virología , Humanos , Masculino , Pruebas de Sensibilidad Microbiana , Mutación , Papúa Nueva Guinea/epidemiología , Filogenia , Vigilancia de la Población , ARN Viral , Adulto Joven

RESUMEN

Adherence to antiretroviral therapy (ART) is paramount for virological suppression and positive treatment outcomes. ART has been rapidly scaled up in Papua New Guinea (PNG) in recent years, however clinical monitoring of HIV+ individuals on ART is limited. A cross-sectional study was conducted at two major sexual health clinics in high HIV prevalence provinces in the Highlands Region of PNG to assess ART adherence, factors affecting adherence and the relationship between ART adherence and virological outcomes. Ninety-five HIV+ individuals were recruited and administered a questionnaire to gather demographic and ART adherence information whilst clinical data and pill counts were extracted from patient charts and blood was collected for viral load testing. Bivariate analysis was performed to identify independent predictors of ART adherence. Fourteen percent (n = 12) of participants showed evidence of virological failure. Although the majority of participants self-reported excellent ART adherence in the last seven days (78.9%, 75/91), pill count measurements indicated only 40% (34/84) with >95% adherence in the last month. Taking other medications while on ART (p = 0.01) and taking ART for ≥1 year (p = 0.037) were positively associated with adherence by self-report and pill count, respectively. Participants who had never heard of drug resistance were more likely to show virological failure (p = 0.033). Misconception on routes of HIV transmission still persists in the studied population. These findings indicate that non-adherence to ART is high in this region of PNG and continued education and strategies to improve adherence are required to ensure the efficacy of ART and prevent HIV drug resistance.

Asunto(s)

Terapia Antirretroviral Altamente Activa , Infecciones por VIH/tratamiento farmacológico , VIH/efectos de los fármacos , Cumplimiento de la Medicación/estadística & datos numéricos , Adulto , Altitud , Recuento de Linfocito CD4 , Estudios Transversales , Epidemias/prevención & control , Femenino , Geografía , VIH/fisiología , Infecciones por VIH/epidemiología , Infecciones por VIH/virología , Conocimientos, Actitudes y Práctica en Salud , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud/métodos , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Papúa Nueva Guinea/epidemiología , Factores Socioeconómicos , Encuestas y Cuestionarios , Carga Viral/efectos de los fármacos

RESUMEN

UNLABELLED: Background Infection with herpes simplex virus type 2 (HSV-2) is common worldwide and an important risk factor for HIV infection. Aetiological diagnosis of HSV-2 is typically determined with the use of commercially available type-specific enzyme-linked immunosorbent assays (ELISAs). This study aimed to determine the prevalence of HSV-2 among people attending sexual health clinics in the Highlands of Papua New Guinea. The study also aimed to compare the performance of two type-specific ELISA assays, the Kalon and HerpeSelect glycoprotein G2 assays, in this context. METHODS: Participants were recruited as part of a longitudinal sexual health study. Participants attended four appointments over a 12-month period and had blood taken for HSV-2 serology at each time point. Both the Kalon and HerpeSelect assays were performed as per manufacturer's instructions. RESULTS: A total of 132 participants were tested for HSV-2 using the Kalon and HerpeSelect ELISAs. HSV-2 prevalence was 52% (95% CI, 43-60) and 61% (95% CI, 52-69) with Kalon and HerpeSelect assays respectively. There was high concordance (87%, ?=0.75, P<0.001, n=115) between the two assays at the manufacturer recommended index value cut-offs. For participants with discordant results at baseline, (n=16), three sero-conversions were observed over the 12-month period when sequential sera was tested. CONCLUSIONS: A high HSV-2 prevalence was observed in this clinic-based population. Our longitudinal data indicate the higher prevalence of HSV-2 detected with the HerpeSelect ELISA was likely due to false positives rather than a higher sensitivity in the early stages of infection.

RESUMEN

OBJECTIVES: The optimal benefits of antiretroviral therapy (ART) can be compromised by the emergence of HIV drug resistance (HIVDR) resulting in treatment failure. ART was introduced in Papua New Guinea (PNG) in 2004, yet biological data on HIVDR are lacking. The aim of the study was to investigate levels of HIVDR in ART-naive and -experienced patients in PNG. METHODS: We recruited, interviewed and collected blood from 108 ART-naive and 102 ART-experienced patients from two Highlands provinces of PNG. Dried blood spots were tested for HIVDR from all patients with detectable plasma viral load of ≥200 copies/mL using established in-house assays. RESULTS: The PCR amplification success was 90.6% (n = 96) and 66.7% (n = 12) using dried blood spots from ART-naive and -experienced patients, respectively. Transmitted drug resistance was detected in 2.1% (n = 2) of samples from ART-naive patients; acquired drug resistance was detected in 50% (n = 6) of samples from ART-experienced individuals. CONCLUSIONS: Our data showed that transmitted drug resistance in PNG is low and acquired drug resistance is higher with 12.7% of the ART-experienced patients failing treatment. As ART access is rapidly expanding in PNG, monitoring of drug resistance is paramount for early detection of treatment failure.

Asunto(s)

Fármacos Anti-VIH/uso terapéutico , Farmacorresistencia Viral , Infecciones por VIH/tratamiento farmacológico , VIH-1/efectos de los fármacos , Inhibidores de la Transcriptasa Inversa/uso terapéutico , Adolescente , Adulto , Alquinos , Terapia Antirretroviral Altamente Activa , Benzoxazinas/uso terapéutico , Ciclopropanos , Pruebas con Sangre Seca , Femenino , Seropositividad para VIH , Humanos , Lamivudine/uso terapéutico , Masculino , Persona de Mediana Edad , Nevirapina/uso terapéutico , Papúa Nueva Guinea , Estavudina/uso terapéutico , Insuficiencia del Tratamiento , Carga Viral , Adulto Joven , Zidovudina/uso terapéutico

RESUMEN

UNLABELLED: Background Papua New Guinea (PNG) has one of the highest prevalences of HIV and sexually transmissible infections (STIs) in the Asia-Pacific region, and one of the highest burdens of maternal syphilis and cervical cancer globally. Despite this disease burden, only limited clinical research in sexual and reproductive health has been conducted in PNG. METHODS: A longitudinal clinical cohort study was conducted at two sexual health clinics. Participants completed a behavioural interview, clinical assessment and genital examination at baseline, and at 12, 24 and 50 weeks, including specimen collection for STI diagnostics. RESULTS: In total, 154 people attended a screening visit. Reattendance at 12, 24 and 50-weeks was 87%, 78% and 80% respectively. At baseline, HIV prevalence was 3.3%; chlamydia (Chlamydia trachomatis), 29.2%; gonorrhoea (Neisseria gonorrhoeae), 22.1%; Trichomonas vaginalis 15.6%; herpes simplex type-2 (HSV-2), 46.1%; active syphilis, 11.7%. Multiple infections were common particularly among women. The incidence of chlamydia was 27 per 100 person-years (PY); gonorrhoea, 15 out of 100 PY; T. vaginalis, 29 out of 100 PY; HSV-2, 12 out of 100 PY; syphilis, 8 out of 100 PY. No incident HIV cases were recorded. At baseline, 39% of men in Mt Hagen and 65% in Port Moresby had a penile foreskin cut, with a dorsal slit being the most common. Two men underwent penile cutting during the follow-up period. CONCLUSIONS: The prevalence and incidence of STIs, HIV and penile cutting were high among sexual health clinic attendees. High retention figures suggest that this population may be suitable for future interventions research and clinical trials.

RESUMEN

BACKGROUND: Despite more than 10,000 patients on antiretroviral therapy (ART), there remains a dearth of operational research in Papua New Guinea related to HIV service delivery. This study examined the effectiveness of a locally developed model of HIV service delivery called PAPUA (Patient and Provider Unified Approach) in the Highlands of Papua New Guinea. The model emphasizes coordinated patient and provider support along with decentralized services to rural districts in the Highlands. METHODS: We conducted a chart review among HIV-infected adults on ART at clinics in Eastern Highlands Province, where the PAPUA model was implemented in addition to the standard of care, and in Western Highlands Province, where the standard of care was implemented. We calculated yearly retention rates and used multivariable Cox proportional hazards regression analyses to compare retention rates across the provinces. RESULTS: Data for 2457 patients from the 2 provinces were analyzed. Among patients receiving ART under the PAPUA model in Eastern Highlands, the 12-, 24-, 36-, and 48-month retention proportions were 0.79, 0.73, 0.68, and 0.63, respectively. When we compared retention probabilities across the 2 provinces, patients receiving care under the PAPUA model had a 15% lower rate of attrition from care during the first 4 years of ART (hazard ratio, 0.85; 95% confidence interval: 0.74 to 0.99; P = 0.03), after adjusting for age, gender, and year of enrollment. CONCLUSIONS: The PAPUA model seems to be a promising intervention although it is inextricably linked to the limitations posed by a resource-constrained health system.

Asunto(s)

Antirretrovirales/uso terapéutico , Terapia Antirretroviral Altamente Activa , Infecciones por VIH/tratamiento farmacológico , Cumplimiento de la Medicación/estadística & datos numéricos , Adulto , Femenino , Humanos , Masculino , Papúa Nueva Guinea