Effects of periodic presumptive treatment on three bacterial sexually transmissible infections and HIV among female sex workers in Port Moresby, Papua New Guinea.

BACKGROUND: Sexually transmissible infections (STI) are common in female sex workers (FSW). AIM: To determine if 3-monthly periodic presumptive treatments (PPT) would reduce the prevalence of STI in FSW. METHODS: In a cohort study conducted between November 2003 and September 2004, FSW were enrolled, counselled and interviewed. Informed consent was obtained. Testing by using polymerase chain reaction (PCR) for Chlamydia trachomatis (Ct), Neisseria gonorrhoeae (Ng) and Trichomonas vaginalis (Tv), and serology for HIV were performed at baseline and final follow-up visits. Each FSW received 3-monthly oral amoxicillin, probenecid, a combination of amoxicillin and clavulanic acid, and azithromycin. Tinidazole was administered once. RESULTS: The cohort consisted of 129 FSW at baseline and 71 at final follow-up visit. Of these 71 FSW, there was a significant decline in the proportion with positive PCR results for Ct from 38% to 16% (P=0.001), Ng from 56% to 23% (P=<0.001) and Tv from 62% to 30% (P=<0.001) between baseline and the final follow-up visit. HIV prevalence increased from 15% to 21% (P=0.125). CONCLUSIONS: PPT was statistically effective in reducing STI but rates rebounded rapidly. Several new HIV infections occurred. If PPT is to be very effective in FSW where the prevalence of STI is so high, then 100% condom use with clients and regular sexual partners (RSP), and high rates of notification of RSP would be required if low incidence and prevalence of STI were to be achievable.

HIV knowledge, risk perception, and safer sex practices among female sex workers in Port Moresby, Papua New Guinea.

Sex workers are considered a high-risk group for sexually transmitted infections, including human immunodeficiency virus (HIV), and are often targeted by prevention interventions with safer sex messages. The purpose of this study was to explore the extent to which knowledge of HIV and perception of risk influence safer sex practices among female sex workers (FSWs) in Port Moresby, Papua New Guinea. FSWs (n = 174) were recruited from 19 sites to participate in the study. Qualitative data were collected using semistructured interviews with FSWs (n = 142) through focus group discussions and (n = 32) individual interviews. In addition, quantitative data were collected from all FSWs using a short structured, demographic questionnaire. Data were analyzed using recurring themes and calculations of confidence intervals. Despite some common misperceptions, overall, most FSWs were basically aware of the risks of HIV and informed about transmission and prevention modalities but used condoms inconsistently. Most reported using condoms 'sometimes', almost one-sixth 'never' used condoms, only a fraction used condoms 'always' with clients, and none used condoms 'always' with regular sexual partners (RSPs). Among these FSWs, being knowledgeable about the risks, transmission, and prevention of HIV did not translate into safe sex. The findings suggest that certain contextual barriers to safer sex practices exist. These barriers could heighten HIV vulnerability and possibly may be responsible for infection in FSWs. Specific interventions that focus on improving condom self-efficacy in FSWs and simultaneously target clients and RSPs with safer sex messages are recommended.

A cross-sectional study of reported symptoms for sexually transmissible infections among female sex workers in Papua New Guinea.

BACKGROUND: Sexually transmissible infections (STIs) are common in female sex workers (FSWs), most of which are asymptomatic and therefore under-reported. Our aim was to determine the sensitivity and specificity of reported symptoms obtained via questionnaire augmented with leukocyte esterase (LE) urine dipstick test for the detection of Chlamydia trachomatis (Ct), Neisseria gonorrhea (Ng) and Trichomonas vaginalis (Tv) detected using polymerase chain reaction (PCR). METHODS: In November 2003, a cohort of FSWs was screened for STIs and completed a questionnaire. RESULTS: We enrolled 129 FSWs (90% participation rate) of whom 48 (37%), 30 (23%) and 53 (41%) were diagnosed with Ng, Ct and Tv, respectively, by PCR. Of those diagnosed with any of these infections, 78% reported anogenital symptoms and of those without infections, 28% reported symptoms. Anogenital symptoms were present in over 50% FSWs. Genital odour (present in 26%), lower abdominal pain (present in 29%), dysuria (present in 19%) had a sensitivity around (50%), specificity (>80%) and all were significantly associated with positive PCR results for individual organisms; however, the sensitivity of these symptoms to detect the presence of any positive PCR result was low (<50%). When LE urine dipstick test result of >1 was combined with the presence of three reported symptoms the sensitivity was 86%, specificity of 73% and a positive predictive value of 72%; a better predictor of infections. CONCLUSIONS: Our finding suggest an approach that incorporates LE urine dipstick test >1 and multiple symptoms may be a feasible option for screening infections among FSWs in resource constraint settings.

Artemisinin-naphthoquine combination (ARCO) therapy for uncomplicated falciparum malaria in adults of Papua New Guinea: a preliminary report on safety and efficacy.

BACKGROUND: The use of anti-malarial drug combinations with artemisinin or with one of its derivatives is now widely recommended to overcome drug resistance in falciparum as well as vivax malaria. The fixed oral dose artemisinin-naphthoquine combination (ANQ, ARCO) is a newer artemisinin-based combination (ACT) therapy undergoing clinical assessment. A study was undertaken to assess the safety, efficacy and tolerability of ANQ combination in areas of multi-drug resistance to generate preliminary baseline data in adult population of Papua New Guinea. METHODS: The clinical assessment was an open-labeled, two-arm, randomized study comparing ANQ combination as a single dose regimen and three days regimen (10 mg/kg/day) of chloroquine plus single dose sulphadoxine-pyrimethamine (CQ+SP) for the treatment of uncomplicated falciparum malaria with 28 days follow-up in an adult population. The primary outcome measures for efficacy were day 1, 2, 3 7, 14 and 28-day cure rates. Secondary outcomes included parasite clearance time, fever clearance time, and gametocyte carriage. The main outcome measures for safety were incidences of post-treatment clinical and laboratory adverse events. RESULTS: Between June 2005 and July 2006, 130 patients with confirmed uncomplicated P. falciparum were randomly assigned to receive ANQ and CQ+SP, only 100 patients (51 in ANQ group and 49 in CQ+SP group) were evaluated for clinical and parasitological outcomes. All the patients treated with ANQ and CQ+SP showed adequate clinical and parasitological response with 28 days follow-up. The cure rate for ANQ on day 1, 2, 3, 7, 14, and 28 was 47%, 86%, 92%, 94%, 94% and 94%, respectively. Recrudescence account for 6%; all were cleared on day 21. For CQ+SP treated group the cure rates were 24%, 67%, 82%, 82%, 84% and 88%, respectively. Recrudescence accounted for 10%; all were cleared on day 28 except for one patient. Both regimens were well tolerated with no serious adverse events. The proportion of gametocyte carriers was higher in CQ+SP treated group than ANQ treatment (41% versus 12%; p < 0.05). CONCLUSION: While these data are not themselves sufficient, it strongly suggests that the ANQ combination as a single dose administration is safe and effective for the treatment of uncomplicated P. falciparum malaria in the adult population of Papua New Guinea and deserves further clinical evaluation.

The first year of a formal emergency medicine training programme in Papua New Guinea.

OBJECTIVE: To describe a programme catalyzing the development of emergency medicine in Papua New Guinea (PNG). METHODS: Five emergency physicians rotated through a new position of Senior Lecturer in Emergency Medicine in the University of PNG during 2003. The position was established as a consequence of emergency physician input supported by AusAID in 2002. RESULTS: Fifth (final)-year medical students and medical officers in the Emergency Department at Port Moresby General Hospital undertook formal and bedside problem based learning. The first trainees for a Master of Medicine in Emergency Medicine programme were inducted and supported. Emergency department management was provided with specialist input. Research projects were initiated, dealing with snakebite, chloroquine toxicity and HIV/AIDS. The first year of an emergency nursing curriculum was supported. CONCLUSIONS: There is now considerable enthusiasm for the development of emergency medicine as the hospital generalists' specialty. Emergency nursing training has also made a start. Limitations on resources will require flexibility to sustain the project. Further support by emergency physicians will be needed.

Analysis of Sepik populations of Papua New Guinea suggests an increase of CYP2C19 null allele frequencies during the colonization of Melanesia.

The cytochrome P450 (CYP) isozyme CYP2C19 metabolizes clinically important drugs, including the anti-malarial proguanil currently used for multi-drug resistant Plasmodium falciparum malaria. CYP2C19 activity varies among geographical regions due to high frequencies of two null alleles (CYP2C19*2/*3) in Asian and especially Pacific populations. Previously, we reported an unprecedentedly high frequency of CYP2C19 poor metabolizers (PM) within populations of Vanuatu, which suggested even higher PM frequencies in Papua New Guinea. We examined CYP2C19 allele frequencies of three malarious populations from inland East Sepik Province, Papua New Guinea to evaluate this prediction and the use of proguanil in malaria treatment programs. These Papua New Guinean populations have PM frequencies intermediate between island South-east Asia and Vanuatu, most likely resulting from genetic drift during the settlement of the Pacific. This study highlights the medical consequences of population origins and the need for a better understanding of the genetic diversity of our global species.

The aetiology of severe anaemia among antenatal patients of the Port Moresby General Hospital.

Between October 1998 and September 2000, 111 consecutive pregnant patients admitted to the Port Moresby General Hospital antenatal ward with a haemoglobin level of 6 g/dl or less were studied. The main causes of the severe anaemia were as follows: iron deficiency on its own or in combination with another factor 66%--iron deficiency on its own 43% and combined folate and iron deficiency 23%--and folate deficiency 18%. Malaria was a contributory factor in 13 patients (12%). A combination of blood film, bone marrow study, serum assays of ferritin, folate and vitamin B12, and mean corpuscular volume (MCV) was used to determine the cause of the anaemia. Ferritin levels on their own poorly correlated with the presence of iron in the bone marrow. A low MCV correlated well with iron deficiency anaemia while a high MCV was associated with folic acid deficiency. It would seem therefore that while a bone marrow study is mandatory to reach a definitive diagnosis of severe anaemia, MCV, in conjunction with the red cell morphology on blood film, would be a good marker for iron and folic acid deficiency anaemia, especially as we do not have serum assays readily available for folate, ferritin and vitamin B12 in Papua New Guinea.

The tropical triangle: a health education alliance for the Southwest Pacific.

INTRODUCTION: Few collaborations between universities in developed countries and medical schools in developing countries have been described in detail in the medical literature. We describe a collaboration between three medical schools, one in a developed country and two in developing countries based on shared challenges and missions. THE ALLIANCE: James Cook University School of Medicine (JCU), Fiji School of Medicine (FSM) and University of Papua New Guinea School of Medicine (UPNG) are all located within the tropical regions of the Southwest Pacific. All schools serve vast geographical areas where much of the population lives in rural and remote communities with limited access to medical care. JCU's first class started in 2000 as the only complete medical school in Tropical Australia and was founded with a mission to meet the health care needs of rural, remote and underserved populations in the region. FSM educates medical students from most English-speaking developing Pacific Island Nations. UPNG serves a predominantly rural developing nation where infectious diseases and other diseases of rural developing nations predominate. Based on their common challenges and goals, the three schools established an informal collaborative relationship called "the Tropical Triangle" in the late 1990s. OBJECTIVES, ACTIVITIES AND CHALLENGES: These very different institutions are committed to an effective partnership based on mutual understanding and knowledge of each other's day-to-day challenges. Faculty development seminars on medical education have already been carried out in Fiji by JCU staff. JCU has also offered several PhD scholarships to FSM staff, three of which are in the process of being taken up. JCU has offered to make available its online teaching resources to FSM and UPNG. Student exchanges are planned, and FSM and UPNG have exchanged examiners on several occasions for the MBBS and postgraduate programs. The possibilities for collaborative research on regional problems are being explored. CONCLUSION: The Tropical Triangle Alliance is a special and perhaps unique alliance based on equality and shared challenges. The benefits from this alliance flow both ways. The alliance may serve as a model for other collaborations between health education institutions in developed and developing countries.