Turning the tide

150 Pages·2009·1.52 MB·English

Report of the Commission on AIDS in the Pacific
Turning the Tide:
An OPEN Strategy for a response to AIDS in the Pacific
TURNING THE TIDE
An OPEN strategy for a response
to AIDS in the Pacifc
Report of the Commission on
AIDS in the Pacifc
Presented to
Mr Ban Ki-moon,
UN Secretary General,
on 2 December 2009
in New York
c o m m i s s i o n o n a i d s i n t h e pa c i f i c
first printed in 2009
this publication may be freely reproduced or distributed with appropriate
acknowledgement
This Report contains the collective views of the Commission on AIDS in the Pacifc and
does not necessarily represent the decisions or stated policies of the organizations that
have provided support to the commission.
free copies of this publication can be obtained from Unaids Regional support team
Asia and the Pacifc
9th floor, a Block,
United nations Building
Rajadamnern nok avenue
pranakorn, Bangkok 10200 thailand
tel: [phone]
fax: [phone]
Usp Library cataloguing-in-publication data
Turning the tide: an open strategy for a response to AIDS in the Pacifc: report of the
Commission on AIDS in the Pacifc – Suva, Fiji : UNAIDS Pacifc Region, 2009.
isBn 978-982-529-001-8
Ra643.86.o3t87 2009 362.19697
Design and layout by Art & Soul Limited, Suva, Fiji
Printed in Thailand at Eastern Printing Public Company Limited, Bangkok
Published by UNAIDS Pacifc Region, Fiji
Cover photos credits: Fiji Arts Council; Lynette Lee; UNICEF Pacifc/J. Hing; UNAIDS
Pacifc/ A. Makutu.
To protect the privacy of people who are HIV positive or otherwise affected by HIV
and AIDS we do not publish their photographs, except in cases where their identity
is protected or where the person involved, or in the case of children their parents/
guardians, have specifcally authorized publication of the photograph.
t U R n i n g t h e t i d e i
Contents
List of Figures, Tables and Boxes iii
Preface v
Acknowledgments vii
Abbreviations viii
Pacifc Map x
Executive Summary 1
introduction 1
The dynamics of HIV in the Pacifc 1
Risks, vulnerability and impacts 2
stigma and discrimination 3
The Pacifc response 3
empowering partnerships 4
the way forward — an open strategy 5
Recommendations 6
Leadership 6
Legislation and the enabling environment 6
Civil society 6
Strategic planning and implementation 6
Strategic information, surveillance and monitoring 9
Resourcing and aid effectiveness 10
1. The Pacifc: a unique and diverse region 11
1.1 introduction 11
1.2 the initial response to hiV 12
1.3 The Commission on AIDS in the Pacifc 13
2. The dynamics of HIV epidemics in the Pacifc 15
Key fndings 15
2.1 introduction 16
2.2 Reporting and surveillance systems 16
Second generation surveillance 17
2.3 the spread of hiV through the region 18
2.4 molecular epidemiology 22
2.5 Characteristics of people diagnosed with HIV in the Pacifc 22
Male to female ratio 22
Age 23
Children 24
Ethnic groups 25
2.6 modes of transmission 25
Co-infections 28
2.7 Projecting the Pacifc epidemic 29
3. Risks, vulnerability and impacts 32
Key fndings 32
3.1 introduction 33
3.2 stigma and discrimination 33
3.3 gender inequality and gender-based violence 35
3.4 commercial and transactional sex 37
3.5 male-to-male sex 39
3.6 alcohol and drug use 41
3.7 Young people 42
3.8 people on the move 43
3.9 traditional cultural practices 45
3.10 impacts 46
Papua New Guinea’s health system 46
Formal employment 48
3.11 Vulnerability of families 50
i i c o m m i s s i o n o n a i d s i n t h e pa c i f i c
Contents - continued
4 . T h e P a c i f c r e s p o n s e 5 3
K e y f n d i n g s 5 3
4 . 1 i n t r o d u c t i o n 5 4
P a c i f c R e s p o n s e s 5 4
4 . 2 L e a d e r s h i p a n d a c c o u n t a b i l i t y 5 4
4 . 3 L e g a l f r a m e w o r k s 5 5
4 . 4 P a c i f c h e a l t h s y s t e m s 5 6
4 . 5 p l a n n i n g a n d c o o r d i n a t i o n 5 8
Planning 58
Coordination 59
National AIDS Council of Papua New Guinea 60
Aligning regional mechanisms with national priorities 60
Funding Levels, Needs and Aid Effectiveness 61
4.6 Funding for HIV in the Pacifc 61
Levels of aid 61
Funding sources 63
Funding fows 66
4.7 absorptive capacity 68
4.8 aid coordination and effectiveness 69
4.9 future funding needs 71
Implications of the global economic crisis 72
5. Empowering partnerships 74
Key fndings 74
5.1 introduction 75
5.2 civil society contributions to the hiV response 75
5.3 engagement with national policy- and decision-making 77
5.4 Regional and international civil society organizations 79
5.5 churches and faith-based organizations 80
5.6 greater involvement of people living with hiV and aids (gipa) 83
5.7 engaging employers and workers 84
5.8 media 85
5.9 other organizations 87
6. Navigating the future — an OPEN strategy 88
introduction 88
Recommendations 88
Leadership 88
Legislation and the enabling environment 89
Civil society 89
Strategic planning and implementation 89
Strategic information, surveillance and monitoring 91
Resourcing and aid effectiveness 92
Attachments
1. HIV testing sites in the Pacifc countries and territories, 2009 93
2. Surveillance and behavioural surveys in the Pacifc countries and territories 94
3. sti prevalence studies among women attending antenatal clinics 96
4. Pacifc Island Countries and Territory public health laws 97
5. focus of early national strategic plans 102
6. an overview of the current status of national strategic plans 104
7. Application of the Pacifc Aid Effectiveness Principles 105
8. allocation of hiV funds by country and sources of funding 107
9. map of solomon island hiV service delivery sites 108
10. map of Kiribati hiV service delivery sites 109
11. Terms of Reference for the Commission on AIDS in the Pacifc 110
12. List of commission members 113
References 118
t U R n i n g t h e t i d e i i i
L ist of Figures, Tables and Boxes
F i g u r e s

1 . P a c i f c c o u n t r i e s r a n k e d b y H um a n D e v e l o pm e n t I n d e x ( H D I ) , 1 9 9 7 & 2 01017
2 . A v e r a g e a n n u a l n u m b e r o f n e w n o t i f c a t i o n s a n d p r o p o r t i o n a l H I V c a s e - l o a d s i n P a p u a N e w G u i n e a
c o m p a r e d t o a l l o t h e r P a c i f c c o u n t r i e s , 1 9 8 5 – 2 0 0 6 2 1
3 . R a t i o o f m e n t o w o m e n i n f e c t e d w i t h h i V o v e r t i m e 2 3
4 a . M a l e H I V c a s e s b y a g e g r o u p i n e a c h s u b r e g i o n , 1 9 8 4 – 2 0 0 6 2 4
4 b . F e m a l e H I V c a s e s b y a g e g r o u p i n e a c h s u b r e g i o n , 1 9 8 4 – 2 0 0 6 2 4
5 a . H I V n o t i f c a t i o n s i n a l l P a c i f c c o u n t r i e s e x c l u d i n g P a p u a N e w G u i n e a 2 5
5 b . H I V n o t i f c a t i o n s i n a l l P a c i f c c o u n t r i e s , D e c em b e r 2 0 0 5 2 5
6 a - b . p r o p o r t i o n o f h i V c a s e s b y r e p o r t e d e x p o s u r e i n m i c r o n e s i a a n d g u a m2 6
7 p r o p o r t i o n o f c a s e s b y r e p o r t e d e x p o s u r e i n n e w c a l e d o n i a 2 7
8 a - b . p r o p o r t i o n o f h i V c a s e s b y r e p o r t e d e x p o s u r e i n p o l y n e s i a a n d f r e n c h2 7p o l y n e s i a
9 a - d . p r o p o r t i o n o f h i V c a s e s b y r e p o r t e d e x p o s u r e i n m e l a n e s i a ; m e l a n e s i a e x c l u d i n g p a p u a n e w
g u i n e a ; f i j i ; n e w c a l e d o n i a ; p a p u a n e w g u i n e a 2 8
1 0 . p r o p o r t i o n o f y o u n g m a l e - t o - m a l e s e x i n t h e l a s t 1 2 m o n t h s 4 0
1 1 . p r o p o r t i o n o f y o u t h i n U s t e r r i t o r i e s r e p o r t e d l y i n j e c t i n g d r u g s 4 2
1 2 . p o r t m o r e s b y g e n e r a l h o s p i t a l i n t e r n a l m e d i c i n e c o m m o n c a u s e s o f a d4 m6 i s s i o n s
1 3 . P a c i f c H I V a l l o c a t i o n ( i n c l u d i n g P a p u a N e w G u i n e a ) f r o m a l l o f f c i a l s o u6r c2e s , 2 0 0 1 – 2 0 1 2 ( U S $ m i l l i o n s )
1 4 . A n n u a l H I V f u n d i n g p e r c a p i t a , 2 0 0 4 – 2 0 0 7 6 2
1 5 . S o u r c e a g e n c i e s t o t h e P a c i f c ( e x c l u d i n g P a p u a N e w G u i n e a ) b y p e r c e n6t4a g e c o n t r i b u t i o n
1 6 . c o u n t r i e s c o v e r e d b y r e g i o n a l p r o j e c t s a n d o r g a n i z a t i o n s 6 4
1 7 . D o n o r f n a n c i n g o f t h e H I V r e s p o n s e i n P a p u a N e w G u i n e a b y s o u r c e b y6 y5e a r ( A $ )
1 8 . g o v e r n m e n t o f p a p u a n e w g u i n e a f u n d i n g f o r h i V r e s p o n s e 6 5
1 9 . S p e n d i n g o n H I V a c t i v i t i e s i n t h e P a c i f c b y f o c u s a r e a , 2 0 0 5 – 2 0 0 8 ( U S $6)6
2 0 . a l l o c a t i o n o f f u n d i n g i n p a p u a n e w g u i n e a 6 7
Ta b l e s

1 . Ye a r t h a t H I V w a s f r s t d e t e c t e d 1 8
2 . C um u l a t i v e r e p o r t e d H I V, A I D S a n d A I D S d e a t h s a l l P a c i f c c o u n t r i e s , t o D2e0c em b e r 2 0 0 8
3 . i m p l i e d a n n u a l c o m p o u n d g r o w t h r a t e s f o r t h e d e c a d e t o 2 0 0 7 2 1
4 . T B – H I V c o - i n f e c t i o n i n a d u l t s i n P o r t M o r e s b y G e n e r a l H o s p i t a l , 2 0 0 6 – 2 02098
5 . p a t i e n t s w i t h h i V - r e l a t e d i l l n e s s e s i n p o r t m o r e s b y g e n e r a l h o s p i t a l 4 7
6 . n e w h i V - p o s i t i v e r e g i s t r a t i o n , m t h a g e n h o s p i t a l 4 8
7 . n a s f U n d : e m p l o y m e n t c a t e g o r i e s o f c l a i m a n t s f o r h i V a n d a i d s - r e l a t e d4 9i l l n e s s e s a n d d e a t h s
8 . N am b a w a n S u p e r a n n u a t i o n S c h em e : D e a t h c l a i m s f r o m A I D S a n d A I D S - r e4l a9t e d c a u s e s , 2 0 0 3 – 2 0 0 8
9 . P e r c a p i t a O D A , To t a l e x t e r n a l e x p e n d i t u r e o n h e a l t h a n d H I V a s p e r c e n t a6g3e ( U S $ – 2 0 0 5 )
B o x e s

1 . s a m a n t h a ’s s t o r y 3 0
2 . s i o n e ’s s t o r y 3 5
3 . g e n d e r i n e q u a l i t y i n p a p u a n e w g u i n e a 3 7
4 . Yo u n g g a y p r o s t i t u t e s i n f i j i 3 8
5 . Yo u t h s e x i n s o l o m o n i s l a n d s a n d V a n u a t u 4 3
6 . P a c i f c m o b i l i t y 4 4
7 . g e u a ’s s t o r y 5 2
8 . f l o r e n c e ’s s t o r y 7 7
9 . t h e p a p u a n e w g u i n e a c o u n t r y c o o r d i n a t i n g m e c h a n i s m ( c c m ) a n d c i v i 7l 8s o c i e t y
1 0 . T h e P a c i f c I s l a n d s J u r i s d i c t i o n s A I D S A c t i o n G r o u p ( P I J A A G ) 7 9
1 1 . P a c i f c I s l a n d s A I D S F o u n d a t i o n ( P I A F ) 8 0
1 2 . a m o d e l f o r c o m m u n i t y - b a s e d c a r e f o r c h i l d r e n 8 1
1 3 . c o l l a b o r a t i o n f o r h e a l t h i n p a p u a n e w g u i n e a 8 5
1 4 . t h e s a m o a a i d s f o u n d a t i o n 8 7
i V c o m m i s s i o n o n a i d s i n t h e pa c i f i c
t U R n i n g t h e t i d e V
Preface
The Pacifc region covers an immense geographical area and for the most part comprises
countries with very small, dispersed and highly mobile populations. Within the Pacifc
region are some of the world’s smallest, most isolated and least developed countries.
development progress over the past 30 years, particularly in economic growth and
poverty reduction, has been uneven across the region; it would be fair to say that it has
been slow and even negative in some countries.
the reasons for this are many and complex. geographical isolation, wide dispersal,
poor internal transport infrastructure and small populations preclude many Pacifc island
countries from benefting from economies of scale in commerce and in the provision of
public services. the narrow economic bases of most of the countries limit their means
to create employment and improve living standards. this has resulted in escalating
urbanization and poverty, extremely limited job opportunities particularly for youth, and
erosion of human capital.
The Pacifc island region has also experienced pockets of instability. Social and political
unrest, civil conficts and natural disasters have all contributed to the development
burden. the region’s vulnerability is compounded by the impact of climate change and
globalization. in the context of these and other challenges, the hiV epidemic, which
has had enormous health, social and economic consequences throughout the world,
is posing an additional threat. Failure to slow the epidemic in the Pacifc would have
direct and signifcant impacts, nationally and regionally, on social, health and economic
development gains.
a number of factors have hindered the region’s response to the epidemic: limited
awareness and understanding of the potential long-term impact of the epidemic,
unsupportive policy and legislative environments, weak health care delivery systems and
low levels of community engagement and capacity to respond spring immediately to
mind. as in other parts of the world, the low levels of support and commitment among
communities and policy makers can possibly be attributed to a preoccupation with the
many and competing health and development issues facing the region.
This is the context in which the former Executive Director of the Joint United Nations
programme on hiV/aids (Unaids) dr peter piot proposed an objective and independent
analysis of the status and impacts of the epidemics in the region, in order to assess and
provide policy options to countries and territories and their development partners. this
work, has received the full support of michel sidibe, the current executive director of
Unaids.
This task was entrusted to an Independent Commission on AIDS in the Pacifc, established
in october 2007 with a mandate to study and consider the real and potential impacts of
HIV on the Pacifc region, and to recommend strategies for accelerated and strengthened
responses to hiV.
given the short time frame, the commission agreed to make use of already available data
and information and to commission operational research around identifed critical gaps in
the region’s knowledge base.
V i c o m m i s s i o n o n a i d s i n t h e pa c i f i c
t h e c o m m i t m e n t a n d z e a l wciot hm mwihsisciho n m e m b e r s h a v e t a k e n o n t h i s t a s k
r e f e c t s t h e i r p a s s i o n f o r t h e i m p o r t a n c e o f t h i s w o r k a n d i t s s i g n i f c a n c e i n a c h i e v i n g
a n i n c l u s i v e a n d c a r i n g s o c i e t y t h a t i s a l i v i n g e x p r e s s i o n o f t h e c h e r i s h e d v a l u e s o f t h e
P a c i f c w a y o f l i f e .
W i t h g r e a t s o r r o w , m e m bce rosm omf i st sh ieo n l e a r n t t h a t i n t h e c o u r s e o f h i s t e n u r e ,
t h e C h a i r p e r s o n , D r L a n g i K a v a l i k u o f To n g a , a h i g h l y r e s p e c t e d a n d e x p e r i e n c e d P a c i f c
l e a d e r , h a d p a s s e dt haewc aoym. m i s s i o n m e m b e r s , t h es eUcnrae itda rsi a t a n d i t s
c o u n t r y o f f c e s i n P a p u a N e w G u i n e a a n d F i j i o f f e r t h e i r r e s p e c t a n d c o n d o l e n c e s t o D r
K a v a l i k u ’s f a m i l y a n d t h e p e o p l e o f ttohneg aK,i nagnddo md e od fi c a t e t h i s r e p o r t t o h i s
m e m o r y.
t h e c o m m i s s i o n m e m b e r s u s e t h i s o p p o r t u n i t y t o t h a n k U n a i d s f o r t h e i n i t i a t i v e
a n d i n t e r e s t i n t h i s w o r k a n d f o r t h e f n a n c i a l a n d t e c h n i c a l s u p p o r t p r o v i d e d t o t h e
c o m m i s s i o n .
t h ec o m m i s s i o n m e m b e r s a l s o t h a n k t h e g o v e r n m e n t s , c i v i l s o c i e t y o r g a n i z a t i o n s a n d
p e o p l e o f t h e P a c i f c w h o c o n t r i b u t e d t o i t s w o r k .
T h e f n d i n g s a n d r e c omm e n d a t i o n s c o n t a i n e d i n t h e r e p o r t a r e i n t e n d e d f o r p o l i c y -
m a k e r s , p r o g r a m m e i m p l e m e n t e r s , d e v e l o p m e n t p a r t n e r s , c o m m u n i t i e s , p e o p l e l i v i n g
w i t h h i V a n d a l l t h o s e c o n c e r n e d a b o u t t h e i m p a c t o f a nadi d rse sipn o n s e s t o h i V a n d
t h e P a c i f c .
I n D r K a v a l i k u ’s m em o r y, w e , t h e m em b e r s o f t h e C omm i s s i o n o n A I D S i n t h e P a c i f c ,
p r e s e n t t h i s r e p o r t t o a l l t h i n k i n g a n d c o n c e r n e d p e o p l e o f t h e P a c i f c r e g i o n .
h o n o u r a b l e meilseaf otn i ( h t ) R e t z l a fmf sm mp a i r e B o p p d u p o n t
d r s a t i s h c h a n d m r W a r r e n L i n d b e r g
d r . R o b m o o d i e h o n o u r a b l e d a m e c a r o l K i d u , c B e , m p
m s h i t e l a i p o l u m e K i e l e J V R P r a s a d a R a o
t U R n i n g t h e t i d e V i i
Acknowledgements
Acknowledgements
Janine Constantine, Report Writer
margaret chung, Report drafter
art and soul Limited, designer
Peer Reviewers
Kamma Blair, holly Buchanan-aruwafu, Bill Bowtell, marian claeson, Rob condon, salli
davidson, maura elaripe, peter ghys, Robert greener, philip hill, michael Kidd, Urarang
Kitur, Rachael Le mesurier, Ken moala, Roslyn morauta, mark mcgillivray, tracey mcintosh,
Jeff O’Malley, Tim Sladden, Claire Slatter, Daniel Tarantola, Bill Whittaker, David Wilson
Other Contributors
dickson aopi, sailosi Batiratu, detlef Blumel, Leon Buskers, ann clark, daoni esorom,
gerald haberkorn, shane hussein, sr tarcissia hunhoff, samisoni Kakaivalu, elizabeth
Kuburam, margaret mairi, Lili makutu, Rod mitchell, Richard sinamoi
AusAID, NZAID, Secretariat of the Pacifc Community, Samoa AIDS Foundation, UNDP
Pacifc Centre
Researchers
University of new south Wales, UnsW global; Burnet institute; La trobe University,
Australian Research Centre in Sex, Health and Society; University of the South Pacifc;
Rei frank; Lawrence hammar; evelyn Lavu; Renagi taukarai
Research Team and Secretariat
Lakkana Ariyasinsuwong, Taoufk Bakkali, Mereoni Bale, Tony Bates, Rachel James,
tevita Kaufuti, Losana Korovulavula, amelia makutu, Lice movono, maria nepel, tracey
newbury, avelina Rokoduru, christine stypula, mohamed turay, pauline titus-nathan,
Tim Rwabuhemba, Stuart Watson, Jone Vakalalabure, Steven Vete.
Country Partners
the commission thanks all of the people and organizations who gave their time to
meet with us during our visits to fiji, papua new guinea, solomon islands, samoa and
New Caledonia. We regret that time constraints prevented us from visiting all Pacifc
countries.