Innovative partnerships to combat the spread of HIV infection in Papua New Guinea are tackling a lack of provincial capacity as well as risky behaviors and gender inequality.

Western Highlands, Papua New Guinea —Missionary nun Rose Bernard runs the Shalom Center, an HIV testing and counseling center in Banz, a market town in the Western Highlands of Papua New Guinea (PNG).

“I started this center after seeing HIV/AIDS positive women calaboosed to the home, looking after the family, the garden, and the pigs. While their partners go out with their buddies, the women had no one to talk to.” According to Bernard, many women resist confiding in their husbands, fearing abuse. “They can stay at the center where we tell them not to be afraid. We tell them HIV/AIDS is a sickness like any other and can be treated. We give them hope that they can still lead normal lives.”

Faith-based centers, like Bernard’s, are part of coalition of stakeholders that are tackling the spread of HIV and AIDS in PNG, under the government’s HIV/AIDS Prevention and Control in Rural Development Enclaves Project, financed by a $15 million grant from ADB.

A Public–Private Partnership Approach to Prevention

PNG’s commodities-based economy continues to grow amid a global downturn, but its performance belies structural weaknesses that include a shortage of capacity in the public sector, especially outside Port Moresby.

ADB’s HIV/AIDS Prevention and Control grant brought together the government, big business, church groups, and NGOs to respond to the particular cultural contexts of PNG. Businesses drive the project; provincial health authorities develop their capacity to deliver prevention and treatment services; and church groups and NGOs work with communities at a grassroots level and address people’s real motivations and constraints.

The project focuses on preventing the spread of HIV and AIDS in PNG’s economic heartland, the Highlands region, where 40% of the population lives and which is the source for most mineral, petroleum, and agricultural exports. Companies here have a strong incentive to be proactive in the project: they need to protect their labor forces, which include large numbers of mobile men with disposable income, a high-risk group for HIV infection.

A major part of the project has been to improve the rural health clinics that provide HIV testing, counseling, and treatment—and other primary health care services.

In Western Highlands, for example, the enclave operator is W.R. Carpenter, a tea and coffee plantation company. Since the project got under way in 2007, W.R. Carpenter has renovated and refurbished 22 health clinics or aid posts (as of 31 August 2010). The company also provides training for the staff in these facilities and organizes awareness workshops for its workers and the wider community. In other enclaves, where extraction companies operate in lessdispersed areas, 51 health facilities (as of 31 August 2010) have been renovated.

The clinics offer HIV counseling, testing, and treatment—and more besides. In the village of Aviamp, for instance, a health center refurbished in 2008 at a cost of 60,000 kina (K) ($22,000), serves a population of over 15,000. “We see between 60 and 100 patients a day,” said one health extension worker. “Malaria is the most common disease, followed by pneumonia, diarrhea, wounds and injuries, and AIDS. We treat most cases with basic drugs and refer severe cases to the hospitals in Kudjip or Mount Hagen.”

Making Men Better Partners

In addition to building clinics and improving access to health care, the government, through this project, is also trying to change sexual practices that spread the virus, the bailiwick of NGOs and church groups. There are a number of marital practices in PNG that experts believe may contribute to inequality between the sexes. For example, it is still common, especially in the Highlands, for a man to pay for a bride, and many men, even the educated, also take several wives. Health experts believe that inequality between the sexes, perhaps fueled by these practices, contributes substantially to the culture of multiple and concurrent sexual relationships that fuel the spread of HIV and other sexually transmitted infections (STIs).

With government funding from the ADB grant, Population Services International (PSI), an international NGO, is advising men on healthy sexual behaviors, including developing more considerate relationships with their partners.

“The sexual health workshops represent a cutting edge approach to HIV and other STIs. We don’t just talk about the dangers of HIV and how to use condoms. It’s like marriage counseling,” said Cynde Robinson, country representative for PSI. “We look at people as sexual beings and, by helping men better understand their needs and those of their partners, we make it easier for them to change their behavior.”

The PSI behavior change program is supported by AusAID and NZAID, as well as the government and ADB. The bilateral agencies have each contributed $3.5 million in grants.

So far, the project has conducted over 40 workshops for 1,000 men, including workforce enclave and community leaders, on topics ranging from threats to fertility, from STIs to good communication between partners. More recently, PSI started workshops for women, a proposal suggested by some of the male participants. “We started our first women’s training at Ramu, which was enthusiastically received,” Robinson said.

Convincing the Church

For the project to be successful, it needed support from religious leaders, some of whom, because of their faith, were not initially on board. “Pastors are among the most rewarding groups I have worked with. We remind them of the urgency of their own desires. We cite the Bible, ‘Love is as powerful as death,’” said Kel Browne, ADBaffiliated health services specialist, who has led courses on sexual health. “We also point out that today’s youth has to delay marriage because they cannot afford the rising bride price, and we ask what youth are going to do with their God-given sexuality for 10 or 15 years.”

Already, the workshops have claimed some successes. The chairman of the Porgera Council of Churches began one workshop by saying he did not believe pastors should be promoting the use of condoms.

However, at the end of the workshop, he said, “I wish to retract what I said before. We churches are responsible to our people and so we should provide options. Condom use can be of benefit to our young people.”

“I do not promote condoms for birth control,” said Bernard, “but the Church recognizes the right of an individual to self-protection from life-threatening danger. As a counselor, I have to teach every method of protection, and it’s the people who make the decisions.”

Measures of Success

Some believe the workshops are already changing behavior. “We have follow-up sessions after the workshops and people tell us that, whereas they were careless in their sexual behavior before, they are more careful now,” said Betty Kaime, who runs the AIDS program for W.R. Carpenter. “People say they are using condoms and are reducing their number of sexual partners.”

Since late 2009, the government significantly improved distribution of its free condoms. As a result of the greater availability of condoms as well as more voluntary testing and counseling services, the number of HIV-positive cases in the W.R. Carpenter districts rose by only 5 to 22 in 2009. “We think HIV is being contained,” said Kaime.

Encouragingly, demand for the behavior change workshops is strong. “We can’t keep up with requests,” said Browne, who said the course is now available on DVD for wider distribution.

As an indication that it is on the right track, ADB will continue to support the National Department of Health in implementing the new National Health Plan (2010–2020). “The support will focus more on widening the scope to include primary health services, especially in rural areas where health needs are greatest,” said Sakiko Tanaka, an ADB social development specialist.