Dr Satish Chand
Sex sells, except when it comes to sexually transmitted infections (STIs). Worse still, if it is the subject of HIV -- where stigmatisation and misinformation run rampant.

The Lautoka clinic, for this reason, has a back door off the main street, to encourage people to come in for assistance. Most people, due to the stigma attached to STIs, keep their distance from talking about HIV.

But HIV is here, amongst us, and more than likely to stay and proliferate. It will affect us all; the businesses, the economy, the government, and the community as a whole. Even if inconvenient, this is the truth.

Like it or not, HIV is Our Business, and Your Business too!

The first case of Human Immunodeficiency Virus (HIV) was recorded within the Pacific region in 1984.

The number of people living with the virus has since increased, albeit at very different rates across individual countries.

I will, in this short piece, draw your attention to what we already know about this disease, what we don’t, and what can be done to contain its spread.

What do we know about HIV/AIDS?

We know that untreated, HIV kills, and slowly. The virus attacks the immune system of the host, making the individual increasingly susceptible to other illnesses.

AIDS (Acquired Immune Deficiency Syndrome) eventuates when the immune system gets severely compromised. The body at this stage is unable to fight off other pathogens, thus death results from diseases, such as Tuberculosis (TB), that otherwise would not have been fatal.

HIV cannot be cured, but its progression can be slowed down and managed with a cocktail of drugs administered under a strict medical regime.

The virus was first detected within the gay community in the US around the early 1980s, but is believed to have its origins in Africa. It has spread rapidly since then.

Every Pacific Islands country, other than Cook Islands, Niue, and Tokelau, had recorded the presence of locally confirmed cases of HIV by the end of 2006 (data from UNAIDS).

Papua New Guinea, according to the most updated figures, had some 18,000 (cumulative) infections by 2006.

Some 4000 new infections were recorded for this year alone; and, at this rate, some 162,000 people in PNG will have the virus by 2016.

New Caledonia with 272 (figures as of December 2004), French Polynesia with 260 (figures for December 2005), Fiji 200 (figures for December 2005), and Guam with 175 (figures for December 2005) had figures in triple digits.

The second inconvenient truth is that these numbers could be completely wrong: wrong by as much as a 1000 percent! PNG, for example, could already have as many as 180,000 people living with HIV.

Under-reporting is due to several factors including: tests carried out on patients only when they report to clinics with symptoms; some having these tests done abroad for fear of being exposed at home; and even when tested positive, some of this data never gets reported at the national level.

Furthermore, deaths caused by AIDS often get reported as being due to the proximate cause; TB as an example.

Poor health services as a whole, with testing facilities mostly available in the major hospitals only, does not help with the above.

Of the few studies that have been undertaken on this subject, the evidence points to heterosexual contact as being the primary transmission channel.

Vertical transmission, that from mother to child, while in the womb, during birth, and while breast-feeding is also growing, albeit from a low base.

Seafearers and their ports of disembarkation, sometimes with a thriving prostitution industry, have also been linked to the spread of STIs and HIV.

Wives of seafearers are the new statistics on people infected with HIV. They and their partners constitute the majority of the people with HIV in some of the islands. Intravenous drug use is not common in the islands, thus transmission from exchange of contaminated needles is less of a problem.

The broader literature points to the presence of sexually transmitted infections (STIs) as being a significant risk factor in the spread of HIV.

Many Pacific islands already have very high rates of untreated STIs, and these are also reported to be rising rapidly in some of our urban centres.

Poor levels of education about the disease, poor usage and acceptance of condoms, promiscuity, poverty, prostitution and traditional and religious taboosŃall compound this risk.

What do we not know about HIV?

Lots! Focusing just on the Pacific, there remains much to be learnt about both the prevalence of HIV and the factors responsible for its spread. The region may contain some of the world’s only countries without confirmed cases of the virus.

This in itself is a puzzle. Why is it that the virus has failed to reach the shores of these nations? Is this indeed the case, or are there other issues which have skewed the figures?

Its apparent absence from the Cook Islands is particularly interesting as the nation has regular and significant contact with the outside world via its vibrant tourism industry.

Could it be that people prefer to be tested and treated in New Zealand in order to preserve their anonymity in the context of a small island state?

Some of the statistics are less than reliable. It is difficult to believe, for example, that Solomon Islands (and Vanuatu) have just six (two) cases of HIV when the figures are in the thousands in neighbouring PNG.

The case for PNG, alarming as it may be, is just as bizarre. The virus was confirmed in PNG in the mid-1980s, but its spread over the past two decades has been nowhere near what has been observed in Southern Africa where the prevalence rate amongst adults has reached 15 percent.

PNG, many argue, has very similar risks factors. Even if the spread of HIV is lagging that of Southern Africa, why this may be so is worthy of scrutiny.

Answers to the questions posed above may provide lessons on what could be done to halt the spread of HIV.

I next propose some policy interventions that may be trialled while answers are found to the puzzles posed above.

What can be done to contain the spread of HIV?

Knowing the facts on the epidemic has to be a priority if means are to be found to slow the spread of HIV.
Collecting the requisite information is both time and resource intensive. Thus, some simple interventions may have to be made while the facts are being collated.

An all out attack on STIs is long overdue. This will draw those with HIV and others at risk of being infected into clinics, thus providing the opportunity to help those in need. It will also provide the data to analyse the spread of the virus.

The availing of information on how HIV spreads in the population has proved to be effective elsewhere.

The ABC (Abstinence, Be faithful, and use Condoms) has both appeal and a proven track record for success.

Naturally, the whole community cannot be expected to take up the entire ‘ABC’ slogan. Adults and parents particularly, church patrons, and even teachers are uncomfortable discussing sexuality and STIs with those most at risk.

We can, however, have a well targeted campaign focusing on three key stakeholders: the schools, the church, and the sex industry. Schools and the departments of education can be the central pillar to rest the ‘A’ on; the Church could do the same for ‘B’; and the sex industry can be leaned upon to support ‘C’.

A highly knowledgeable commentator on HIV quipped that: “Sex -- it is often a do-it and laugh about it but don’t mature -- talk about it attitude all around!”

On the first, it is timeŃserious consideration was given to making sex educationŃcall it reproductive health if that sounds betterŃcompulsory in schools. Quality and timely information has to be the first line of defence.

Classes in reproductive health could be incorporated as part of personal development for school children.
Training teachers to accomplish this task has to take priority.

On the second, our churches and their counterparts have preached faithfulness for generations. Why not engage them for a campaign, not just their blessings, for the ‘B’ in the ABC-slogan? Pacific Churches, via their Nadi Declaration of 2004, have committed themselves to supporting the ABCD message.

The ‘C’ has been a tough one, but tougher still has been an acceptance of the proliferation of a sex industry in nearly every urban centre of ours.

A thriving sex industry in Majuro, Port Moresby, Suva, etc, is no secret to anyone except the bureaucrats.

Why not recognise the presence of this industry and use it to arm the workers with the protective ‘C’?

Preaching on its own is unlikely to be enough, however. Better job opportunities for our youth and improved access to education and health services are likely to induce greater care against contracting STIs, and HIV.

Prostitution, for example, would be less of a problem if more employment opportunities were available.

Penultimate word of caution -- mis-targeting of the ‘ABC’s with the different stakeholders can create problems.

You would, for example, be setting up for failure by tasking the sex industry to spread the gospel on ‘A’ (that of abstinence).

Similarly, promoting ‘C’ (use condoms) in churches will be less than satisfactory. Surprisingly, some pastors do spread this message, realising that we all are fallible.

Finally, millions of dollars, much of it donor funded, have already been poured into containing the spread of HIV within some of our islands.

The Pacific, as a whole, follows the world trend of a huge increase in funding to combat the spread of HIV and AIDS, and for the care of those living with the virus.

Funding for the region from the Global Fund has at least quadrupled over the recent past. Has this helped in combating the spread of HIV in the region?

There is little evidence to argue one way or another.

There is consensus amongst the commentators that money, or the lack thereof, is not the issue. What then is?