Partner testing, linkage to care, and HIV-free survival in a program to prevent parent-to-child transmission of HIV in the Highlands of Papua New Guinea.

BACKGROUND: To eliminate new pediatric HIV infections, interventions that facilitate adherence, including those that minimize stigma, enhance social support, and mitigate the influence of poverty, will likely be required in addition to combination antiretroviral therapy (ART). We examined the relationship between partner testing and infant outcome in a prevention of parent-to-child transmission of HIV program, which included a family-centered case management approach and a supportive environment for partner disclosure and testing. DESIGN: We analyzed routinely collected data for women and infants who enrolled in the parent-to-child transmission of HIV program at Goroka Family Clinic, Eastern Highlands Provincial Hospital, Papua New Guinea, from 2007 through 2011. RESULTS: Two hundred and sixty five women were included for analysis. Of these, 226 (85%) had a partner, 127 (56%) of whom had a documented HIV test. Of the 102 HIV-infected partners, 81 (79%) had been linked to care. In adjusted analyses, we found a significantly higher risk of infant death, infant HIV infection, or loss to follow-up among mother-infant pairs in which the mother reported having no partner or a partner who was not tested or had an unknown testing status. In a second multivariable analysis, infants born to women with more time on ART or who enrolled in the program in later years experienced greater HIV-free survival. CONCLUSIONS: In a program with a patient-oriented and family-centered approach to prevent vertical HIV transmission, the majority of women's partners had a documented HIV test and, if positive, linkage to care. Having a tested partner was associated with program retention and HIV-free survival for infants. Programs aiming to facilitate diagnosis disclosure, partner testing, and linkage to care may contribute importantly to the elimination of pediatric HIV.

Retention among ART patients in the Highlands of Papua New Guinea: evaluating the PAPUA model.

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.

Development of a clinical algorithm to prioritise HIV testing of hospitalised paediatric patients in a low resource moderate prevalence setting.

OBJECTIVE: To develop a clinical algorithm to identify paediatric patients who should be offered HIV testing in a setting of moderate HIV prevalence and limited resources. METHODS: In a prospective cross-sectional study at Port Moresby General Hospital, Papua New Guinea, carers of inpatients were offered HIV testing and counselling for their children. Recruited children were tested for HIV antibodies and DNA. Standardised clinical information was collected. Multivariate regression analysis was used to ascertain independent predictors of HIV infection and these were used to develop a predictive algorithm. RESULTS: From September 2007 to October 2008, 487 children were enrolled. Overall, 55 (11%) with a median age of 7 months were found to be HIV-infected. In multivariate analysis, independent predictors of HIV infection were: persistent fever (OR = 2.05 (95% CI 1.11 to 4.68)), lymphadenopathy (OR = 2.29 (1.12 to 4.68)), oral candidiasis (OR = 3.94 (2.17 to 7.14)) and being underweight for age (OR = 2.03 (1.03 to 3.99)). The presence of any one of these conditions had a sensitivity of 96% in detecting a child with HIV infection. Using an algorithm based on the presence of at least one of these conditions would result in around 40% of hospitalised children being offered testing. CONCLUSIONS: This clinical algorithm may be a useful screening tool for HIV infection in hospitalised children in situations where it is not feasible to offer universal HIV testing, providing guidance for HIV testing practices for increased identification and management of HIV-infected children in Papua New Guinea.

Papua New Guinea: real progress towards MDG 4 and real challenges.

With a mortality rate in the under-5 s of 93 per 1000 live births reported in the 1996 Demographic and Health Survey (DHS), Papua New Guinea (PNG) was at the time one of only four countries with stalled progress in child survival, and seemed destined to fail its national Millennium Development Goal (MDG) 4 target. However, accurate estimates have shown reductions in under-5 and infant mortality rates of 19% and 17% respectively, over 10 years from 1996 to 2006. In that period PNG adopted an integrated and coordinated approach to child health that includes all the essential interventions outlined in the Lancet's child survival series, under a framework consistent with the Western Pacific Regional Child Survival Strategy, associated with significant improvements in leadership and coordination of child health services by paediatricians at the provincial and national level. The reduction in child mortality since the mid-1990s is strong encouragement that such an approach can translate to real improvements. This paper outlines the recent advances in child health in PNG, identifying successful areas, and the challenges that lie ahead. There has been increased immunization coverage, introduction of vitamin A supplementation, bed-nets to prevent malaria, interventions to reduce mortality from acute respiratory infection, and improvements in the education of girls. These and improved leadership and coordination help to explain the recent significant gains in child survival.

Attitudes to HIV testing among carers of children admitted to Port Moresby General Hospital, Papua New Guinea.

AIM: To assess the acceptability of voluntary counselling and testing among the carers of children admitted to hospital in Papua New Guinea. METHODS: Forty semistructured interviews were carried out between February and April 2007. RESULTS: All the carers interviewed were women, mostly from Port Moresby. Virtually all of them attended primary school. About half of them attended secondary school but none completed it. Half of them knew an adult or child with HIV. Three quarters of the women interviewed would consent to having a child in their care tested for HIV, and over half of those who had never been tested would agree to be tested themselves. Correct answers to more than half the HIV knowledge questions posed were significantly related to agreement to an HIV test. CONCLUSIONS: This study supports the need for further evaluation of knowledge about HIV/AIDS and opportunities for health promotion in this group of women, particularly in view of the implication for voluntary counselling and testing and prevention of mother-to-child HIV transmission programmes in Papua New Guinea.

Burkitt lymphoma in Papua New Guinea--40 years on.

BACKGROUND: Burkitt lymphoma is common in tropical Africa and Papua New Guinea, where it has been reported to account for 16% of all childhood malignancies. AIM: This study aimed to compare the geographical distribution of recent cases and their anatomical site of presentation with findings from previous studies, and to determine survival using the current treatment protocol. METHODS: The study included all cases of Burkitt and Burkitt-like lymphoma in children up to 14 years of age diagnosed between January 1998 and December 2003. RESULTS: Thirty-six children were diagnosed with Burkitt lymphoma, accounting for 50% of all lymphomas and 13% of all childhood malignancies. The median age was 6 years (interquartile range 4-8 years) and the male:female ratio was 8:1. Facial structures were the most commonly affected sites, accounting for 21 (58%) cases, followed by spinal involvement in three. The majority (89%) of patients came from malaria-holo-endemic, coastal PNG and three were from the highland region. The national incidence was 1.7/100,000 but provincial rates varied, the highest of 13.4/100,000 being in Gulf province. Only two of the 16 patients who received chemotherapy were known to be in remission at 12 months. CONCLUSIONS: Burkitt tumour remains a common childhood malignancy in PNG. There is a need to improve diagnosis and reporting so that treatment can be started early. The most appropriate treatment regimen for use in PNG and other resource-poor countries remains to be determined.