Adapting National HIV Strategy to a Socially and Geographically Concentrated Epidemic: The Case of Papua New Guinea Dr. Moale Kariko PNG National AIDS Council Secretariat

Outline of presentation What adaptation means for PNG Evolution in understanding of PNG epidemic and in its response Current efforts and adaptation Broad Challenges Concluding Messages

What adaptation means for PNG Progressive understanding of epidemic. Interrogation of interventions in light of improved understanding of epidemics. Ongoing adjustment of interventions in light of new evidence. Capacity development of implementers to adapt to the changing epidemic.

PNG Epidemics in 2001 Sharply increasing annual HIV diagnoses Limited access to testing & treatment services Little information on prevalence in general population and those at highest risk of infection Declared as generalized by UNAIDS in 2004 Speculation of a SS-African type epidemic Interventions based on generalized epidemic

PNG Epidemics in 2013 Wide access to HIV testing & treatment Good data on HIV prevalence in ANC women Some information on behaviour and prevalence in those at highest risk of infection Evidence Estimated prevalence in years is 0.65% Estimated 31,945 people living with HIV Over 3000 diagnoses annually Overall burden Concentrated in key populations Prevalence is highest in 9 (90% of all reported cases) of the 22 provinces Type of epidemic Female Sex workers Men who have sex with men Transgender individuals Key populations

PNG Response, Guided by MTP and NSP Strategies based on generalized epidemics Similar suit of interventions for all population groups and all provinces Prevention synonymous with awareness Little emphasis on STI No explicit focus on MARPS- only 1% of total national response funding benefited MARPS.

Turning Point NHS : –Identifies top 10 interventions for resourcing –Gives some attention to MARPS –Identifies and prioritises high burden provinces Mid Term Review of NHS May/June 2013: –Recommended a re-think of prevention approach –Prioritise MARPS –Different packages for high & low burden provinces –Adopt CoPCT model of service delivery –Recommends a review of architecture NASA I & II: highlighted limited spend on MARPS

Current Efforts and Adaptations (1) Improving evidence –Synthesis of program data and size Estimation for MARPS- underway; –Preparation for IBBS for MARPS and limited coverage of general population in selected high burden provinces. –Reviewing reporting templates to include MARPS specific indicators –Improving program reporting

Current Efforts and adaptations (2) Programming Shifts –Rethinking prevention and adopting CoPCT model to strengthen link between clinical and non clinical interventions –Differentiated response- different package for different provinces and population sub-groups –Mapping of hotspots where MARPS converge –Comprehensive condom programming policy –Greater engagement with MARPS –Enhanced advocacy & rights based approach.

Current Efforts and adaptations 3) Resource Realignment –Increase in resource allocation for MARPS activities (1% in 2009/10 to 9% in 2011/12) –Increase in number of implementing organization working on MARPS programs –More funding for activities in 9 high prevalence provinces

Current Efforts and adaptations 4) Review of HIV architecture –Integration of National AIDS Council with the National Department of Health- underway –Greater decentralization of management and coordination functions to provinces –Capacity development for implementing partners.

Broad Challenges Inadequate evidence remains a concern Legal barriers- same sex relationship and sex work are illegal in PNG Transition from dual to single architecture Funding uncertainty- 76% of the response is external Tension between advocating for the rights of MARPS and widely held view that PNG is a Christian country Capacity for evidenced based programming and implementation.

Concluding Messages Understanding of PNG epidemic has changed with improvement in evidence Earlier prediction that it would follow the Sub-Saharan African trend was inaccurate Current evidence point towards a concentration in key populations and in 9 of the country’s 22 provinces.

Concluding Messages The response has evolved with the evolution in understanding of the epidemic Current efforts are aimed at improving evidence, creating the enabling environment and realigning resources to ensure more focus on MARPS. Our greatest challenges lie in achieving legal and institutional reforms; improving implementation capacity and sustainability.

Thank you Acknowledgement: NACS, NDoH, Donor Partners, Stakeholders UNDP – Country Office