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Time Runs Out On South Pacific HIV/AIDS Crisis

Scoop Investigation: Time Runs Out On South Pacific HIV/AIDS Crisis

Reporter Marietta Gross and Scoop co-editor Selwyn Manning examine this most important issue and report that HIV/AIDS in the South Pacific is insidiously working its way into isolated communities with an infection rate that threatens cultural, economic, and community stability. Experts interviewed say HIV/AIDS, not global warming, is the number one problem threatening Tuvalu's survival.


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  • Index:
    Typical Profile of Transmission in the Pacific Region
    Dealing with Discrimination and Gender Discrimination
    Parallels to Africa
    Papua New Guinea A Warning To A Vulnerable South Pacific
    Auckland to Host the Pan Pacific Regional HIV/AIDS Conference 2005
    Social/Economical Effects On The Community
    The Challenge of Accurate Data Collection
    Pacific Church Leaders Slowly Turning Cheek To Listen
    Details Of Treatment and Biology of HIV-infection: Dr Rod Ellis-Pegler.

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    HIV infection in the South Pacific has reached a crisis point and in one case now threatens the extinction of an entire race of peoples. Scoop investigations have discovered that Tuvalu's population is in danger of extinction unless urgent action is taken immediately.

    The HIV infection crisis is about to be thrust into our midst. Experts have told Scoop Media that this issue can no longer be swept under the carpet, that the South Pacific as a region must confront the reality that HIV has embedded itself within cultures that consider the topic forbidden.

    A major conference is to take place in Auckland in October where medical clinicians, social leaders, Church leaders and politicians will be immersed in the facts detailing the rate of HIV infection among Pacific populations, what must be done to reduce the rate of infection, what can be done for those who are infected with HIV, and how the region as a whole can pull together to ensure the South Pacific does not follow in the wake of Africa and Papua New Guinea.

    The Pacific Islands Forum secretariat has also been working on the HIV issue – the issue will be advanced when Pacific leaders meet at this year's forum in Papua New Guinea.

    The Pacific is notorious for sweeping issues under the carpet, particularly issues that challenge the cultural fabric of the Pacific way of life.

    Homosexual practise, violence against women, and, the inability of women in some cultures to say no to sex are paramount concerns among a Pacific patriarchal code that prevents an open and honest debate on HIV/AIDS from occurring – a debate that is essential should the South Pacific have a chance at beating the HIV epidemic and not fall into a figurative abyss titled HIV/AIDS.

    Papua New Guinea has a similar HIV profile to Micronesia, Solomon Islands, Kiribati where there is a disproportionately high rate of escalation. But Fiji also faces a crisis, as does Samoa, the Cook Islands group also is witnessing an increase in the numbers of people with HIV infection. Tonga, well there is an absence of official information on the number of people infected with HIV, or suffering from AIDS.

    New Zealand's rate has 21 people per 100,000 infected with HIV. Tuvalu's rate is 88 per 100,000. New Zealand's rate suggests about 2400 to 2500 people are infected with HIV. Tuvalu has 88 people.

    The information, experts say, shows Tuvalu's population is at risk – not by global warming but by the silent insidious killer infections that inevitably result from HI-Virus.

    The United Nations' UNAIDS organisation has indicated to Scoop Media it is extremely worried about the rapid rise of HIV infection in the Pacific. And Pacific Islands AIDS Foundation (PIAF) spokesperson, Maire Bopp Dupont too believes Tuvalu faces a crisis of survival.

    Ms Bopp Dupont, herself HIV-positive, said Tuvalu has suffered due to its small population and "by the fact that HIV/AIDS has made its bed amongst seafarers".

    "HIV will surely threaten the nation with collapse, when (it infects the) workforce in other areas of activity, particularly when senior staff become infected.

    "For Tuvalu," Ms Bopp Dupont said "HIV/AIDS could be quicker to harm than the sea level rise. That is something to consider."


    Typical profile of transmission in the Pacific region

    Globally the numbers of women living with HIV/AIDS have already gained on those of men, in some places in Asia and in the Pacific women have even got ahead of men. The foremost form of transmission in the South Pacific region is unprotected sexual intercourse, whereat heterosexual partners represent the fastest growing and/or largest affected group in most places.

    The ABC policy (Abstaining from sexual activity, Be faithful and Condom use), which has helped Uganda to confine the epidemic, may be disputed due to a changed profile of transmission.

    UNAIDS graphUNAIDS' Stuart Watson said: "We don't know beyond anecdotal information at this point. The stats in PNG indicated that the highest number of new infections detected are amongst women who identify themselves as 'housewives'.

    "This suggests that like in Cambodia married women in the Pacific (or at least in PNG) are in a similar situation – low risk, high vulnerability for example they have few partners, often only one, so their exposure or risk level remains low, but they are highly vulnerable because of social situations that don't allow them to negotiate their sexual encounters with their partners or husbands (who are often engaging with multiple partners with considerably higher risk factors such as commercial sex workers) and women who as yet don't have an adequate system of protection that they can control."

    Stuart Watson said this means the emphasis many sexual health programmes put on abstinence and fidelity actually put women at risk.

    "They abstain from sex outside of marriage, remain faithful to one partner, but the partner isn't doing the same and thus making these women more vulnerable," Stuart Watson said.

    Take Uganda (as mentioned above): back in 1986 the Ugandan political leadership publicly supported HIV/AIDS awareness campaigns within their country.

    Dr. Trevor Cullen, of the Edith Cowan University said: "This proved a key factor in quickening a substantial community response towards fighting the disease. The same is not true of many Pacific countries that either through ignorance of the impending reality or fear of negative publicity were unable to galvanize public support.

    "It was left to outsiders, namely NGOs to do their best. Many have done undertaken admirable initiatives and projects. In recent years, however, PNG's National AIDS Council (NAC) and the PNG media have worked hard to convince all stakeholders about the dire consequences of continued inaction," Trevor Cullen said.

    Religious leaders, he said, are bound by their own laws and codes: "Many, I think, would like to play a more public role but opt instead for a pastoral message of care and compassion, and so avoid the tricky issues of education and prevention. It's a great pity because they are well-placed to deliver much clearer and stronger messages. If contraceptives and condoms are the problem, then one would think that an emergency situation demands emergency measures."


    Dealing with Discrimination and Gender Discrimination

    In Papua New Guinea as in Africa and greater Asia there are still stories of people being stoned to death because they are HIV-positive, or being beaten or abandoned. PNG legislated in 2003 to highlight and outlaw this problem.

    Newly elected prime minister Sir Michael Somare was forced to address the rise of HIV legislatively. Under the guidance of the United Nations' UNAIDS PNG's legislation outlawed discrimination and stigmatisation of people with HIV/AIDS and people presumed to have HIV/AIDS.

    One of the driving factors behind the law was due to the criminality of violence, but a second factor was an acknowledgement of how intimidation and victimisation targeting homosexuals, or those thought to be carriers of HIV infection and also oppression of women was preventing those who subscribe to high-risk groups from coming forward for testing and treatment.

    Scoop Image: New Zealand AIDS Foundation executive director Rachael Le Mesuier.Rachael Le Mesurier, Executive director of the NZ AIDS Foundation, said abuses such as these occur most particularly in PNG: "There are more cases in the other islands we are beginning to suspect that this sort of behaviour is also happening. But it's hard to collect the information when we have very small numbers, as there are at the moment, but they are increasing," Ms Le Mesurier said.

    These are quite extreme examples which may not occur regularly, but, still, they make clear that action has to be taken so that HIV-positive people are able to lead their lives in dignity and as equitable part of society. Isolation of HIV-positive people is definitely neither a particularly useful nor a socially mature way of responding to the spread of the disease.

    A number of NGOs have already realised the need for action upon these issues, including the AIDS Task Force and the Fiji Network of Positive People in Fiji, the National AIDS Council and a positive peoples' group in PNG - also the Pacific Islands AIDS Foundation based in the Cook Islands headed by Maire Bopp Dupont.

    These organisations have been working on a range of different levels: On the one hand they recognise a need for a change of the legislation, also being supportive to policies put out by local authorities, but what might be even more important on the other hand is trying to normalise HIV by giving it a personal face. This is realised through HIV-positive people themselves who act as peer educators going into schools and together with the organisations working with local villages and communities.

    PIAF AIDS Ambassador Irene Malachi doing outreach in Vanuatu. Photos courtesy of the Pacific Islands AIDS Foundation.

    Maire Bopp Dupont explained: "The legal setting can help regulating discrimination by discourage people from doing it but also reassure non-positive or discourage positive that transmitting the virus voluntarily is a crime. The responsibilities are on both side and these need to be reinforced. PIAF has set up a legal and human rights task force to help improve legislations across countries, but also educate Positive people themselves. However, legal changes take time to happen.

    "Therefore, it is important that we keep educating people towards individual responsibility and safer and fairer behaviours. PIAF believes that the real change is to come from the people themselves. Therefore we assist and encourage greater exposure of Positive Lives towards the learning of all our people," Ms Bopp Dupont said.

    Stuart Watson, UNAIDS: "PNG does have legislation and several other countries are working on legislation that would criminalise such action. Of course any physical harm to another person is already covered under other legislation in all countries. The issue is adherence to legislation and criminal codes and changes in attitudes. Part of this is being done through advocacy work by HIV positive people themselves – trying to "normalise" HIV and put a personal face to the issue. That's probably more important than any legislation. In PNG a positive people's group (Igat Hope) has just been launched. Fiji has the Fiji Network of Positive People."

    Infection rates around the world are growing disproportionately faster amongst women than among male populations. The investigation of the reason therefore has started and once they are entirely defined any effort has to be undertaken to address these problems. On the one side women must be given the ability to negotiate the use of condoms, on the other side it's essential to discuss the economic situation of women in places like PNG, where they are forced into sex work, not by choice but since it's the only option for them to stay alive.

    So is gender discrimination as effective way to deal with HIV/AIDS?

    Maire Bopp DupontMaire Bopp Dupont: "Yes, because it highlights the reasons why women are becoming more and more infected and also indicates some answers for actions to be undertaken to save the reproductive partner of human being."

    Stuart Watson, UNAIDS: "Definitely – women as I said above are more vulnerable than men. Infection rates around the world amongst women are growing disproportionately faster than for male populations. We have to understand why this is so and find ways to address this."

    New Zealand based Reverend Mua Strickson Pua from the Pacific Islanders Presbyterian Church of Aotearoa said: "Our Church is still attempting to redress gender discrimination with cultural control processes. Hence we still have some Pacific communities that will not select women for eldership and ordination even though the Churches national policy is very clear: no Gender discrimination."

    Rev. Pua is an outspoken critic of restrictive conservatism among the churches but believes the message is slowly getting through to those who are the "gatekeepers" of open and meaningful discussion.


    Parallels to Africa

    Africa's AIDS orphans.The current situation of PNG awakes the fear that the Pacific region might be hit as seriously as Africa, where some countries have a prevalence of 33 to 39 per cent. Actually, PNG looks like Africa did five years ago.

    New Zealand AIDS Foundation's Rachael Le Mesurier said: "Ten years ago PNG looked a bit like Fiji looks like now. So we have got plenty of warning signs. What we have to do is speed up the process even for places like NZ, these twenty years was to raise discussion about sex and sexuality, how human beings behave sexually and get into that discussion, the issue of using condoms."

    Is this statement supported by other experts?

    Yes. Some experts (Trevor Cullen and Stuart Watson) were aware that the potential of such a tragic development was existent, at least in PNG. The rapid growth is fuelled by demographic and cultural factors including ignorance and denial, poor health facilities, no medicines or counselling, traditional taboos that prevented discussion of sexual matters and a great deal of fear and stigma attached to the disease. The infection rates are pushed also by high rates of sexually transmitted infections, young and sexually active population and high unwanted pregnancy rates.

    Dr. Trevor Cullen said, "Having lived in Malawi in southern Africa from 1981 – 1991, I saw how the disease suddenly appeared in 1984 and within 6 years, nearly 10 per cent of the population were infected with the HIV virus. The disease spread like a bush fire... Similar factors for its spread exist in PNG."

    The first HIV-case was detected in CNMI (Saipan) in 1984 and since then the epidemic has made its way to every country and territory in the Pacific except for Nuie and Tokalau, which haven't reported any cases yet. A disturbing classification figure was recently revealed by Fiji: its rate is increasing by roughly 22 per cent per annum.

    Stuart Watson said: "On top of this, the small states of the Pacific are more vulnerable – could a country of only 10,000 people with most of the HIV cases related to the main income earning sector sustain a 1%, or 5% or 10% infection rate?"

    Uganda, when compared to other African nations, demonstrated with its ABC education policy that a significant difference can be achieved in reducing HIV infection rates when politicians and community leaders get behind a pro-active strategy.

    Its success with the ABC policy is a reminder to all nations to learn from the experiences of others. But the South Pacific can also learn from Africa's mistakes.

    The South Pacific's decision makers (political, tribal and church leaders) need to commit to a plan urgently if the Pacific region wants to avoid a situation marked by death and agony, similar to Africa where economies and cultures have been destroyed.


    Maire Bopp Dupont and Nelson Mandella. Image courtesy of PIAF

    Papua New Guinea A Warning To A Vulnerable South Pacific

    Where war, conflict, civil unrest thrives, the rates of HIV infection climb. This has been the experience of Africa's nations where the HIV/AIDS epidemic now has caused community collapse and has threatened the death of whole generations.

    Military conflicts encourage the spread of HIV by sexual abuse of the "enemy". Moreover people have to worry about their basic survival, escaping violence, bullets, so that there is no room left for other concerns. Research globally points out that uniformed armed personnel are five to seven times more likely to contract sexually transmitted infection than their civilian counterparts.

    Papua New Guinea and Bougainville has faced war, conflict and ongoing civil unrest for the past 16 years, where estimates place the number of deaths resulting from the conflict at 15,000. It too has experienced the highest rate of infection to be found in the South Pacific where deaths from HIV infection continue to stack up year after year – long after the soldiers put down their arms or left its shores.

    The PNG/Bougainville conflict was the longest seen in the South Pacific. It began as a dispute over land and alleged environmental damage between islanders and multi-national copper mining companies. It soon became an independence war involving government forces, armed militias, mercenaries.

    In 1994 former PNG Prime Minister Sir Julius Chan signed an agreement with several Bougainville secessionist leaders that allowed a transitional administration in Bougainville. Bougainville Revolutionary Army leaders did not sign and continued to fight for independence. The following year a Bougainville Transitional Government was sworn in under leadership of Theodore Miriong. Miriong's leadership was short-lived with him being assassinated at his home in south-west Bougainville in 1996.

    In 1997, Chan hired foreign mercenaries from Sandline International to support government troops in Bougainville. The move established arms trading lines, brought in foreigners from abroad among them arguably soldiers carrying the HIV infection – it is theorized that this too contributed to a vulnerability to the epidemic already entrenched in PNG. A PNG Army mutiny followed as did civil unrest. Chan was forced to resign. Human rights organisations reported widespread abuses on both sides, including rape, torture and executions.

    UNAIDS, which has an office in PNG and Fiji, reported in 2003 that Papua New Guinea had the highest reported rate of HIV infection in Oceania with up to 28,000 people estimated to be HIV positive and with an estimated HIV prevalence of almost one percent of all pregnant women attending antenatal clinics in Port Moresby. The country's epidemic appeared largely heterosexually driven. Only 15 percent of sex workers reported regular condom use and HIV prevalence among PNG's sex workers had reached 17 percent by 2003.

    Edith Cowan University's Dr Trevor Cullen said: "Both UNAIDS and WHO strongly suggest that current figures for HIV /AIDS in PNG do not reflect that the actual reality and so give a false sense of security. One central problem is data collection. A meeting in Port Moresby of medical experts (November 2004) revealed how only seven of the 20 provinces in PNG had some sort of surveillance. People think the epidemic is still out at sea. But it came ashore years ago."

    Sexually transmitted disease rates are key indicators of how open a society is for HIV infection to take a hold – and other South Pacific island nations are vulnerable. Again UNAIDS reported in 2003 that: in Vanuatu 28 percent of pregnant women had Chlamydia and 22 percent had Trichomonas infection. Samoa had 31 percent of pregnant women with Chlamydia and 21 percent had Trichomonas infection.

    War was not the only crisis to afflict PNG - Later in 1997, PNG declared a state of disaster after a drought killed over 1000 people and a further 1.2 million risked starvation. In July 1998 Tsunamis hit north-west coast obliterating villages and killing 3000 people.

    August 2002, Sir Michael Somare was elected as PNG's prime minister for a third time. In August 2004 Australia deployed police to help fight rampant crime including elevated crime rates for sexual crime. By December 2004, Australia warned PNG was on course for social and economic collapse. In May 2005 Australia withdrew its police officers after the PNG Supreme Court ruled the deployment as unconstitutional. On May 27 2005, Bougainville islanders went to the polls to elect their first autonomous government.

    By December 2000, the then PNG prime minister Sir Mekere Morauta described HIV/AIDS as a "silent catastrophe". And in 2003 his replacement Sir Michael Somare was forced to address the rise of HIV legislatively. Under the guidance of the United Nations' UNAIDS PNG's legislation outlawed discrimination and stigmatisation of people with HIV/AIDS and people presumed to have HIV/AIDS. It provided a regime of voluntary informed consent for HIV-testing, with pre-test counselling and post-test support; ensured confidentiality of medical records and HIV/AIDS information, and made provision for contact tracing; criminalised the deliberate or intentional transmission of HIV, and provided a means of warning and discouraging people who knowingly continue reckless behaviour that would or could endanger others.

    But violence against those known to have HIV infection continues, adding to a problem where people are loathed to be tested. Commentators like Maire Bopp Dupont suggests only education, explanation and hands-on advocacy at community level can change attitudes, and she suggests this will take time.

    It is accepted, stigma is a common barrier to preventing the spread of HIV.

    Experts say Papua New Guinea resembles Africa's HIV-affected nations of five years ago.


    Auckland to host the Pan Pacific Regional HIV/AIDS Conference 2005


  • 1. Get the political leaders of the Pacific countries to attend
  • 2. Show the human face of HIV
  • 3. Examine the role of the media
  • 4. Expose the lack of drugs for slowing the onset of AIDS.
  • Scoop Image: Pacific Island leaders at the Pacific Islands Forum 2004, Apia, Samoa.
    Pacific Islands leaders are being urged to attend the Pan Pacific Regional HIV/AIDS Conference in Auckland.

    From October 25 to 28 2005 the Pan Pacific Regional HIV/AIDS Conference is going to take place in Auckland, which is about to raise the issues of leadership, engaging communities, improving care and building knowledge. Also topics like mobility, culture, gender and vulnerability will be discussed within the frameworks and parameters of the Pacific. In total the Auckland conference means a remarkable occasion for the South Pacific region, as the Pacific usually gets buried within the traditional Asia Pacific gathering.

    The aim of the conference is to bring any concerned persons together, particularly People Living with HIV/AIDS, leaders,caregivers and so on. One of the interview partners stated the importance of getting the political leaders of the Pacific countries to attend the conference, as sending uninformed delegates lacking in interest and influence would help no one.

    Stuart Watson, UNAIDS: "We hope all the issues you've raised above related to mobility, culture, gender, vulnerability, etc will be raised but within the frameworks and parameters of the Pacific. There has only ever been one other opportunity to bring together the Pacific as opposed to Asia Pacific (where the Pacific usually gets buried) – so this is extremely important to help improve our knowledge of the situation in the region and how we respond to it."

    Once again the conference should show the human face of HIV, to which everyone is potentially vulnerable. There is no imaginary fence that protects people from this disease, which affects real people in our communities.

    Moreover the participants should concentrate on the lack of drugs for slowing the onset of AIDS. Inhabitants of New Zealand, Australia, Tahiti or New Caledonia can easily obtain the necessary medication. But a majority of HIV-patients in PNG and other Pacific countries have no access to the vitally important medicines.

    Trevor Cullen: "There are, however, no such drugs for the majority of those living with HIV in PNG and other Pacific countries. So, it's a double whammy - no medicines and no other support."

    Fiji for example has reported 142 HIV-cases by the end of 2003, but has received funding of ARV (anti-retroviral)-drugs for only 40 people.

    Media have played a controversial role in giving the epidemic its image. They are said to have adopted a reactive rather than proactive approach. Experts demand a change of their attitude towards realizing their responsibility and involving educational and preventative messages.

    After the conference a two-days-workshop is going to take place also in Auckland, which will bring 30 to 40 Pacific tribal leaders together. This meeting is funded by UNAIDS and will be specifically looking at the progress of the strategic action points agreed in March 2004.


    Social/Economical Effects On The Community

    The high prevalence of HIV/AIDS in small islands communities of the Pacific threatens to be widespread and devastating. It poses an economic, social and security threat against the future of each country, communities, and people.

    A charismatic advocate for HIV/AIDS awareness from the Cook Islands is Maire Bopp Dupont who herself is HIV-positive.

    Ms Bopp Dupont told Scoop Media that beyond the shock and trauma of discovering one is infected with the virus, and beyond realisation of how prevalent HIV-infection is among the peaceful islands and atolls of the Pacific is understanding the loss of income it generates for whole families: "Which is often followed by a loss of opportunities for the person with the virus, the partner and the children who have less chances to have an education.

    "If the person diagnosed with HIV is the main or sole income earner of the family, this loss has a fatal impact on the survival of the household," Ms Bopp Dupont said.

    Tuvalu is the typical example of such scenario and this is even more accentuated by the fact that HIV/AIDS has made its bed amongst seafarers, at the heart of the biggest economic activity of the country. HIV will surely threaten the nation with collapse, when (it infects the) workforce in other areas of activities, particularly when senior staff become infected.

    "For Tuvalu," Ms Bopp Dupont said "HIV/AIDS could be quicker to harm than the sea level rise. That is something to consider."

    The result of the disease in the Pacific means it will take out work forces, take out parents, mothers and fathers, it means that there will be a whole generation that is being lost, it takes the guts out of the economy, takes the guts out of the culture.

    Stuart Watson of UNAIDS said: "We are also certain that the issue of men having sex with men is well under reported and understood because of cultural and religious factors."

    A common criticism highlighted by every expert contacted for this investigation is that leaders of the Pacific, for cultural reasons, have had their "heads in the sand for too long" – that, it is hoped, is about to change.


    The Challenge of Accurate Data collection

    Ministries of Health are the first source for cumulative number of reported cases. They are collected through their testing and monitoring structures at national level through hospitals and clinics. As this Scoop Media investigation has discovered, the accuracy of reported numbers must be considered the tip of the HIV iceberg. The United Nations suggests that in the South Pacific each reported case represents three or four "unknown cases". In Papua New Guinea this ratio increases to 10.

    "Actual numbers are most likely to be higher than that we know of today. The under-estimation of HIV/AIDS cases is very much a result of the low testing and monitoring capacity. Some could argue that this hides a deliberate act from governments to "keep it under the carpet" or an ignorance on the issue itself," Maire Bopp Dupont said.

    The United Nations' UNAIDS wing recently began to collate behavioural and biological data sampling populations in seven Pacific Island countries. But analysed data from these studies will not be available for some months yet. Its representative Stuart Watson told Scoop Media: "We hope the data derived from this Second Generation Surveillance will provide us with better information on which to base interventions, education and advocacy programmes."

    This revelation of under-reporting of HIV infection rates offers insight into how insidious this disease is.

    Scoop Image: Dr Rod
Ellis-Pegler.Infectious diseases physician Dr Rod Ellis-Pegler heads New Zealand's largest HIV-infection clinic at Auckland District Health Board. He told Scoop Media that in New Zealand most people found to be HIV-Positive are discovered relatively early and as a result of voluntary testing. But this is not the case for people who have arrived in New Zealand from abroad.

    "We very often see people who had been tested for reasons of chance or if they happen to be in an at risk group, which, normally in this country, are men who have sex with men," Dr Ellis-Pegler said.

    "For people who are not born in this country, predominantly people that come in under refugee schemes or asylum seekers, very often present to us further down the track of HIV infection. Some of them are grievously ill."

    He said this is because HIV infection is "a chronic, creepy, low-grade infection with an agent which basically attacks cells central to your immune system's integrity.

    "I often tell my students if I had been Hitler and wanted to invent a nasty germ and to decide where it might attack in a sense to maximize misery, this (HIV infection) wouldn't have been a bad selection. It goes right to the core in the immune system and just gnaws away for years and years," Dr Ellis-Pegler said.

    He said on average, eight to ten years after the moment of infection a patient's CD4 count (a biological test that indicates the strength of an individual's immune system) reaches about 200 cells per cubic millimetre: "Which is the time when we statistically know that things are going to start go wrong."

    Therefore, when one considers the official HIV infection rates collated in the South Pacific, one can appreciate that the figures while representing findings discovered in 2003, actually more accurately reflect the numbers of those infected by the disease perhaps eight years earlier.


    Pacific Church Leaders Slowly Turning Cheek To Listen

    Rev Mua Strickson PuaScoop approached the Reverend Mua Strickson-Pua who is an Aotearoa-born Samoan also with Chinese ancestry. Rev. Pua is from the Pacific Islanders Presbyterian Church of Aotearoa.

    He said Pacific Churches and Pacific leaders have a long way to go before true dialogue on HIV infection can take place: "As an ordained Minister who works in the Pacific Nations communities I am disappointed with the Churches' lack of vision and theology when addressing HIV/Aids," Rev. Pua said.

    "The Pacific Islands' Church is the corner stone of our conservative Pacific communities. Thus for some Churches and Faith communities they do see their role as being gate keepers. Yet the Pacific Church is being challenged to get involved and interact with its Pasifikan Gay and Lesbian communities. This can only happen with good will and a commitment to each other. At this stage it is early days and there is a long way to go."

    Conservatism, and a strict cultural observance aligned to fundamental Christian values weaves through the fabric of every day Pacific life. Pacific Churches and leaders wield much power within communities and homes of Pacific Islands families: Rev. Pua said therefore "it is vitally important to engage with these educative processes of social change for social justice to come into being."

    And as New Zealand AIDS Foundation's Rachael Le Mesurier pointed out: discrimination is certainly an issue in New Zealand and it is a far bigger issue in the Pacific.

    But there is a reluctance from those outside of the Pacific Islands community to comment and discuss the cultural order that sweeps discussion of HIV under the tapa-cloth covers and far from the light of day.

    New Zealand physician, Dr Rod Ellis-Pegler said: "I don't pretend to have any (deep knowledge) of Samoa, PNG… it's not my field. I don't have any special wisdom or knowledge in that field and I am concerned not to patronise people there."

    World Health Organisation.It is a mark of respect and a point of genuine concern that should New Zealand or Australia wave a figurative finger at Pacific leaders and say: "Come on, get your head out of the sand and do something before it is too late" then it may have the opposite effect.

    But as Rachael Le Mesurier, said: "We (New Zealand) are of the Pacific, and our Prime Minister (Helen Clark) makes it quite clear that she thinks that we are part of the Pacific. And I think many people are looking at this part of the world, they look at us, they see us as an island of the Pacific.

    "With that approach, the Aids Foundation, we need to be seen as part of the family and that means that we need to look after our neighbours. We need to make sure that as a region we are well protected against HIV and preventing it from taking a hold.

    "We share the community, we (New Zealand) have one of the largest Pacific populations outside those Pacific countries here in New Zealand, we are a Pacific country. So rather than saying what we should be doing for the people over there it's more a matter of anything we do for the local region will benefit and we are one in the same," Rachael Le Mesurier said.

    Rev. Pua said Pacific churches are still dominated by introspective self-survival: "Our Pacific Churches have yet to grasp the importance of being involved with proactive education.

    "HIV and AIDS is still considered controversial, (the view is) dominated by reactionary theology of fear and punishment. Hence, until the Church begins its own self education within its institutions and communities, it is not ready to engage in a meaningful and proactive action with other communities.

    "In the beginning stages it will be action by individual groups within the Church who will instigate this momentum for change," Rev. Pua said.

    Scoop Image: Samoan elders at the Pacific Islands Forum 2004, Apia, Samoa.
    Rev. Mua Strickson Pua said the Pacific's elders, religious, and community leaders need to place discussion about HIV/AIDS on the agenda.

    "We in the Pacific Churches need to have materials' that understands the social context, spiritual dimensions, and cultural processes for the change mechanism to take place.

    "From our Pacific Churches perspective, some educative-medical-materials engages (affronts) faith and cultural ethnic communities in a confrontational manner. It also comes across as ethnocentric, secular, and white middle class. Thus it is limited by its Mono-cultural practices of failing to acknowledge that heterogeneous communities exist," Rev. Pua said.

    But he insisted that in the current environment it is critical that we do no give up: "Rather we have arrived at a point and time in our journey that once again requires us to restock and carry on. Theologically there is some solid social change and social justice work going on but quietly. The time is right to bring this once again to the attention of our Churches and communities," Rev. Pua said.

    So how far has the Church come in the last five years?

    "I would say we have even further to go," Rev. Pua said.

    "For Pacific Churches in harsh economic times its members tend to practice a right wing political manner. We are still in denial mode. Like an ostrich with its head in the sand maybe the issue will go away. All those issues in this section of the questionnaire are being addressed but it needs a radical revamp and commitment to justice and aroha."

    He said there are those inside the church that are determined to advocate change: "Alliances and allies require an understanding and commitment to work across the board. Thus the Pacific Churches activists, on social issues, social justice, and on a theological plain, need to work in conjunction with those other educators and social change activist outside the Church. Creating from a local level process of change but also making those connections on a multilevel come multitask praxis e.g. regional, national, and internationally.

    "Thus a much more appropriate cultural spiritual political process can be enacted upon for these diverse institutions and communities. We must be engaging in broad communication networks and communities beyond our comfort zones. It's about greater risk taking but more importantly engaging these institutions and communities. Building relationships and earning their trust whilst we all work towards true justice for all."

    The Pasifikan Church and Faith communities are influential in the Pacific. They are equally as powerful among the Pacific Islands communities in New Zealand, particularly Auckland and Manukau.

    Church leaders do have the "mana" to discuss from their pulpit issues that will be discussed in the homes and amongst the communities. Their social status in conservative society assures them that issues they raise will be attended to or noted.

    "Our Presbyterian Church stance currently is liberal but the practices and reality is right wing. At present our right wing conservatives are in power hence the reflections of their theological and political agendas.

    "We on the left wing (Rev. Pua is a Green Party candidate for this year's General Election) of the political theological spectrum are actively engaged in the change processes, but thus there is a long way to go," Rev. Pua said.

    Amongst any Pacific Churches, he said, there is a dominant right wing theology of discrimination and oppression against Gays, Lesbians, and HIV AIDS. Gender discrimination and sexual violence have yet to be addressed.

    "Our Pacific leaders have not yet worked through these issues other then the right wing political and theological dogma. The seeds of true Aroha and Justice are out there happening but it needs to be on a larger scale."

    New Zealand AIDS Foundation's Rachael Le Mesurier, told Scoop Media: "HIV/AIDS always finds the fracture point in our society and what HIV/AIDS is doing in the Pacific, as it has done and still does here, is it challenges the very prejudices and options in our gender, in violence, and discrimination. These sorts of issues are really parallel to HIV/AIDS."


    An Interview With: Infectious diseases physician Dr Rod Ellis-Pegler
    Head of New Zealand's largest HIV-infection clinic at Auckland District Health Board.

    Dr Rod Ellis-Pegler said testing is essential to ascertain the true rate of infection among communities.

    Homosexual men who have multiple partners should have an annual check for an HIV infection.

    "Most of patients who are indigenous New Zealanders come to us because of testing that's been done because of general risk or some specific episode of at-riskness."

    Therefore in New Zealand most people diagnosed as being HIV positive are identified relatively early.

    The New Zealand experience suggests however immigrants who present with HIV infection, particularly those who originate from developing nations, including refugees and asylum seekers, often present "further down the track of HIV infection".

    They, Dr Ellis-Pegler said are "more likely to statistically to be symptomatic, some of them are grievously ill."

    "HIV infection is a chronic, creepy, low-grade infection with an agent which basically attacks cells central to your immune system's integrity…

    "It goes right to the core in the immune system and just gnaws away for years and years. And we measure that immune system integrity by measuring the concentration of CD4 or T4 cells in the blood. We stumbled on it essentially, the virus lives all over the body in a lot of cells, we measure these cells, the CD4 cells or T4 cells – they are lymphocytes and while found in all parts of the body, are also in the blood stream, and it turns out that it's possible to sample them and we count their concentrations.

    "And with the passage of time with HIV infection we can watch them as a measure of immune system depletion. It turns out to be a very good prognostic indicator of when HIV infection is about to severely affect the patient," Dr Ellis-Pegler said.

    "In terms of CD4 counts over 500 cells is normal. Over the passage of years, slowly this number of cells falls, sometimes it goes fast, sometimes it's slower. But on average 8-10 years after your moment of infection your CD4 count reaches about 200 cells per cubic millimetre - which is the time when we statistically know that things are going to start go wrong."

    "The aim of modern medicine is to pick people up before their cell count has got to a point where they are crook and make decisions about the right timing of medicines so we can stave off that falling CD4 count.

    "And as people take these drugs, and we get on top of their virus, and we suppress the amount of virus, and we get the viral load down as low as we can get it, then the immune system will start incredibly to reconstitute itself," Dr Ellis-Pegler said.

    "Our entire attack on this infection, is as it is for virtually every infection, some agent that targets the infecting agent. And that is what these drugs work on, in the nuclei of infected cells."


    Treatment for HIV infection rests upon three families of drugs.

    Dr Rod Ellis-Pegler explains: "You can compare them with antibiotics we use to cure bacterial infections… but we have many families or ordinary antibiotics.

    Scoop Image: Dr Rod Ellis-Pegler.
    Dr Rod Ellis-Pegler - head of New Zealand's largest HIV infection clinic at Auckland District Health Board.

    In treating HIV infection there are only three families of drugs, and as is typical when treating an infection, there tends to be some degree of cross resistance within the family.

    When treating ordinary infection there are a large number of drug families to choose from – meaning cross resistance is much less of a problem.

    With HIV infection, there are not enough different families to enable us to avoid cross resistance.

    Dr Ellis-Pegler said: "Having said that, people are putting a lot of money into discovering different families of drugs that might work against the virus, but that is not easy and they are being discovered painfully slowly at the moment."

    He said the treatment of HIV infection has evolved over the last 15 years since the drug AZT arrived: "And basically we use three drugs in every person who is infected."

    "It was established very quickly in trials that one drug was better than none - so people were better with one rather with nothing. We then we discovered two was better than one and then we discovered that three was better than two," Dr Ellis-Pegler said.

    Research showed that four drugs produced more side effects than three: "So the world uses three drugs, and basically we use one from every single family. And the intellectual reason for that is one family will protect somewhat against development of resistance in the other family.

    Scoop Image: CombiVirAZT, and a second drug called 3TC are combined in one capsule named CombiVir – the two drugs are within the same family so the pharmaceutical company combines the two drugs together in one pill.

    CombiVir is taken with Efavirenz which is from a totally different family.

    "If costs are not an issue then that's what we use," Dr Ellis-Pegler said. This cost equates to NZD$8000 to NZD$10,000, per patient, per year.

    An alternative to Efavirenz is Nevirapine which is from a totally different family.

    "There are always debates about whether this medicine is as good as the other, and the side effects are different, but Nevirapine is somewhat cheaper."

    Dr Ellis-Pegler said the differences are minimal: "They have to do with how quickly we manage to lower the viral concentrations in the blood stream. Nevirapine isn't so good when there are huge amounts of viruses in the blood stream.

    "Nevirapine is cheaper and is part of a combination often quite widely recommended for countries that are less developed. There are companies producing these which can do so dramatically more cheaply than we do in the West."

    India began producing generic versions of drugs designed to treat HIV infection. However, while the west's pharmaceutical companies "backed off" challenging India's right to manufacture the drugs on ethical grounds, India in April signalled it would cease manufacturing copies of AZT, 3TC and Nevirapine.

    "I find India's decision a bit surprising," Dr Ellis-Pegler said.

    So what are the side effects from these drugs?

    "The truth is CombiVir is a pretty easy pill to take. Side-effects include a little bit of anaemia from the AZT component, but not a big deal and something we notice when we measure it rather than the patient experiences it. 3TC has so few side effects we sometimes wonder if it is a drug! So CombiVir is a pretty simple pill to take, maybe sometimes a bit of a headache with it early on.

    "Efavirenz has central nervous system side effects, and the most common thing is very vivid dreams, quite a bizarre side effect. That generally lasts only for a few nights.

    "We often tell people to start Efavirenz on Friday night. The other thing this can do is give you a rash, a nasty rash, it's a hypersensitivity rash," Dr Ellis-Pegler said.

    The alternative Nevirapine which is of the same family can cause more of a rash than Efavirenz: "These are quite nasty rashes, and the thing we do when first starting off, is to give one pill per day for a fortnight and then go to twice a day, that seems to reduce the risk of rash."

    Nevirapine affects the liver in about 20 percent of patients – women suffer this side effect more than men.

    So are physicians able to prevent the virus from advancing indefinitely?

    "No not indefinitely," Dr Ellis-Pegler said. "There is a tiny group of patients that are called long term non-progressors, who for reasons that are not entirely clear over the long term do not (see the virus) progress. Their cell count seems to hang in some abnormal position, like 300, but nothing seems to happen. And an aspect of this is understood in that some of them have a strain of the virus that has a genetic defect that seems to make it weaker.

    "There are some people that go on for a long time. But in general, there is a depressing fall in CD4 count.

    "There are about a quarter of our patients whom we are following here that we are not treating, we are just following. And we just check the CD4 count maybe every three months, six months, nine months, or one year depending on their rate of CD4 fall."

    Do these patients require medicine?

    "No medication at all. The only preventative measures making sure they don't transmit it to other people.

    "The prognosis for that group is the prognosis for the whole of HIV infection, we know from accumulated information that balancing risks with balancing cost… and cost is a huge component of it. When a patient's CD4 count dips below 300, at that point I am starting to say 'well mate I think this is all getting closer but looking at your rate of fall up until know and it seems to be pretty consistent over the last four years, I suspect in the next year you will have to begin treatment'."

    "Other patients come in grievously sick, they have already got complications, they may have got some sort of particular pneumonia associated with HIV-infection. We know before we have done a CD4 count on those people it will be 20 or 15.

    "We know perfectly well that those patients are already in trouble. And of course, as you might expect you do not need to be Einstein to expect that patients that come in with low CD4 counts in general do less well than patients who have been followed and where we have made appropriate decisions at the appropriate time. There are people who have a CD4 count of 20 and come in crook… (in these cases) we may only ever get their CD4 counts back to 200-250."

    And what is the difference between HIV infection and AIDS?

    "AIDS is a historical diagnosis. AIDS of course was the first thing that was defined in America in 1983. Doctors simply started noticing in New York in particular men with these curious tumours. Dermatologists first noticed it. And these were incredibly rare tumours seen in old men and in particular men from a Jewish background. And another dermatologist would say 'I saw two last week and they were both gay men.' That is how awareness (of the disease) evolved."

    Doctors named the disease Acquired Immuno Deficiency Syndrome.

    "AIDS is an historical label. To be honest we know that nations count it because it is imminently countable - the number of people you have with AIDS. But the truth is AIDS is a moment ten years after the infecting event occurred. From a public health perspective it is of little relevance. It is certainly relevant to people who have got it - don't get me wrong - but from a public health sense you cannot focus on people with AIDS, you need to focus on the problem eight to 10 years earlier," Dr Ellis-Pegler said.

    "Americans claim to have identified HIV, but the French actually recognised the virus first. And again they sat in a room like they always do when they find new germs and ask what should we call it? And they called it the Human Immunodeficiency Virus.

    "And so AIDS is just right down toward the unhappy end. For the clinical problems that are virtually invariable after varying periods of time for people who have been infected with HIV. It is an absolute consequence of HIV. People in our unit do not think of AIDS to be honest. We talk about HIV infection all the time. We are required by Ministry of Health government statute to report AIDS. We do not report HIV infection or notify it to use the technical term.

    "HIV numbers are actually much better because they are collected spontaneously and anonymously by the three laboratories in New Zealand that do HIV testing. And while HIV infection is not notifiable, in the sense that I as a doctor must send the health department a piece of paper notifying it, the HIV infection is well collected in numbers because it is done totally anonymously as all tests are coded and are filed through to Dunedin."

    So is the incidence of HIV among heterosexual women rising here in NZ?

    "Yes it is. There's no question of it, if you take the question of homosexual men - the epidemic has been dominated in this country by men who have sex with men. But as the years have gone by the heterosexual curve has steadily crept up and of course that is in both men and women who are heterosexual. With men, you cannot be absolutely certain that they are telling you the truth that they are heterosexual or homosexual in nature and that is everyone's privilege but with women (with HIV) you know they have acquired that from heterosexual sex assuming they are not an intravenous drug user or something.

    "Yes the incidence of HIV is increasing amongst the heterosexual community in this country and it is increasing of course among heterosexual women. That is predominantly an imported epidemic. It is among either people who have lived in countries with high heterosexual transmission, like Zimbabwe, South Africa, South East Asia, and so on, and the rate among heterosexual men has started to increase too."

    So what advice has Dr Ellis-Pegler for Pacific Islands physicians and leaders with respect to HIV infection?

    "You have to be honest about it.

    "Here (in New Zealand) we regard ourselves as western and reasonably open about it. But not everyone wants everybody to know they are HIV infected. It is just the way of the world. Here, we keep their notes secure. When we dictate letters on our system here we do it with a restricted template so people cannot get in or hack their way into it. We have inserted barriers so to ensure people's information remains private.

    "You ask me about the Pacific, and I feel uncomfortable because it is easy to pontificate from here when you look at ourselves, neither are we New Zealanders totally open about it."

    But would Dr Ellis-Pegler advise the Pacific nations to: 1 - face up to the problem 2 - initiate education and awareness campaigns 3 - put in pace proactive measures to minimise where possible unnecessary increase in the disease 4 - explore effective and cost-affordable treatment for those with HIV infection?


    "You are absolutely correct and you know these things and can state them more precisely than I can, and are doing so there.

    "It does have to come out in the open in the educational sense. And young people who bear the brunt of this infection have to be given the opportunity to know the information.

    "Openness is also about the homosexual sex issue but there is also the "empowering women" issue in some societies.

    "And again, I am sitting in my office here pontificating about this, I do not claim to be especially knowledgeable about it but there are similar challenges in all societies including the Pacific where women do not have the power to simply say no to sex."

    What breakthroughs are being discovered?

    "We desperately need a vaccine. Without a vaccine millions and millions more people will die.

    "Yes much research has gone into vaccine development and vaccine development is difficult.

    "This virus produces more organisms per day in an infected individual than any other infection that we have ever known about. Because of the nature of the virus it has a high mutation rate so we do not talk about HIV species we talk about HIV quasi-species in trying to invent a word that copes with this mutability and changeability such as we have never experienced before.

    "For example your viral population at the end of the day is inter-genetically, structurally, just a tad different from what it was at the beginning of the day.

    "That is an enormous ask of your immune system to adapt to that sort of thing going on - it is a huge challenge considering the very fact to me with my sort of biological knowledge, the very fact that it takes eight to ten years to wear out the immune system given that sort of onslaught - it just beggars belief to me.

    "I would never have guessed if someone had put this up to me as a thesis and said 'go on have a crack at how long it takes to blast hell out of the immune system with a virus that is producing this many billion particles a day in change.' I would have said 'oh I don't know a couple of months or something.'

    "I find it biologically implausible the reality of it - it is an extraordinary resistance. It is a huge tick to the evolutionary mechanisms which have provided us with our immune system that it can hang on for a long time in the face of this sort of microbial onslaught. I find it amazing.

    "But I don't find it amazing that they have not found a vaccine… God knows how many years we have ahead of us away from developing a vaccine for HIV infection.

    "But without it, the only solutions are: modifying human sexual behaviour. And that is not the easiest territory to modify and we now have 25 years of the depressing evidence of that.

    "Of all that is known, look at Zimbabwe, look at China, look at India, the epidemic is just beginning there, and the rate of HIV infection in these countries is soaring. Papua New Guinea particularly is bad. It is possible to get terribly terribly depressed about it. And yes millions more people are going to die."


    -- Ref.

    UNAIDS Fact-Sheet - OCEANIA

    An estimated 35 000 people in Oceania are living with HIV. In 2004, although less than 700 people are believed to have died of AIDS, about 5000 are thought to have become newly infected with HIV. In 2004 there were 7100 women living with HIV in the region.

    The annual number of new HIV diagnoses in Australia has gradually increased from 650 in 1998 to about 800 in 2002. A growing share of those diagnoses was in people who had become infected in the previous year—which suggests that the increase in new diagnoses could be linked to a revival of unsafe sex.

    As is the case in New Zealand, HIV transmission in Australia continues to be mainly through sex between men, which accounted for more than 85% of new HIV diagnoses from 1997 to 2002. Injecting drug use was responsible for about 4% and heterosexual intercourse for 8.5% of newly acquired infections in that period.

    The per capita rates of HIV diagnoses among indigenous people in Australia since 1993 have been similar to those in non-indigenous people. But higher proportions of diagnoses have been among women and have been associated with injecting drug use.

    At least half the estimated 14 000 people living with HIV in Australia are receiving antiretroviral therapy, reflecting both the age of the Australian epidemic and extensive treatment access.

    Papua New Guinea, which shares an island with one of Indonesia's worstaffected provinces, Papua, has the highest prevalence of HIV infection in Oceania. Roughly 16 000 people of the adult population of about 2.5 million were living with HIV at the end of 2003.

    In Papua New Guinea, more than twice as many young women (aged 15–24 years) as men have been diagnosed with HIV. In 2003, for the first time, more HIV infections were detected in women than in men.

    HIV-infection levels appear to be low in other parts of Oceania, but the data are extremely limited. On remote islands, seafarers and their partners appear to be most at risk and high rates of sexually transmitted infections are being detected.

    Once HIV makes its way into the tiny populations of island nations in Oceania, diffuse epidemics are likely to follow. Prevention strategies that reduce and treat sexually transmitted infections and that quickly bolster AIDS knowledge among the general population are urgently needed.


    PNG: Teachers Dying Of HIV/AIDS Could Force The Closure Of Some Schools

    In Papua New Guinea, education officials are warning many schools could be forced to close due to the ever-increasing number of teachers dying from HIV-AIDS related illnesses. The warning was made recently by the chairman of PNG's main insurance fund when he visited the country's Western Highlands Province to deliver cheques to the families of seven teachers who had died from the disease. Papua New Guinea currently has the highest number of HIV-AIDS cases in the Pacific region.

    *Presenter/Interviewer:* Caroline Tiriman

    *Speakers:* David Gordon Mcleod, British High Commissioner to PNG ; Martin Kenehe, chairman, PNG National Teachers Insurance Limited.

  • - PNG: Teachers dying of HIV/AIDS.
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