Integrated Regional Information Networks - December 24, 2008

"You have to talk to him, you have to go and meet him," she told Joshua Jochapai, the nursing and counselling officer at the centre, which provides HIV testing and antiretroviral therapy (ART). He responded, slightly exasperatedly, that he was trying.

The Western Highlands are a jumble of broad valleys, steep mountains and fierce rivers - part of a rugged geology that runs across the centre of the Melanesian island. It is the most heavily populated part of the country, with a growing economy based on gold, copper and agricultural produce cultivated on the highly fertile land.

PNG's most important road, the Highlands Highway, which begins in the eastern coastal town of Lae, has encouraged trade, migration and a mixing of cultures along its route to the mines in the west. Some time in the recent past, HIV was added to this amalgam, and the area now has the highest prevalence in the country outside the capital, Port Moresby.

Dr Kaima runs the Tinanga Clinic at Mount Hagen general hospital. Three days a week, she treats sexually transmitted infections (STIs) - a much earlier, and still deeply-rooted epidemic in PNG - while two days are set aside for HIV counselling and treatment. Out of 2,000 registered patients at the clinic, 900 are on ART.

Stigma waning?

When HIV first began to emerge in the late 1980s, families often hid away those believed to be infected, there were even reports of killings. The first real study into attitudes towards people living with the virus conducted in 2005 found a mixed response in the Western Highlands.

"While people in some communities said they would help and look after the person with AIDS, often through the help of God, others said they would isolate themselves from the person, never share food or drink with him/her and would not wash in the same running water," the study noted.

Dr Kaima believes the stigma is waning. "A lot of people have seen the trauma of their relatives dying and are starting to come forward, they are realising the importance of getting tested early before they die. With ART, they can see how the quality of life improves."

She is certain more people would test for HIV and enroll on ART if the facilities at the primary health care level were less basic. Instead, people are forced to travel to the urban health centres, which many cannot afford.

HIV prevalence nationally is estimated at just over 2 percent out of a population of 6 million, and is projected to climb to more than 5 percent by 2012, with over two-thirds of the cases in rural areas.

In 2006, the Tinanga Clinic tested 1,300 people of which 150 were found to be HIV positive; in 2007, 1,600 tested and 200 were positive. "HIV is overtaking STIs," said Kaima.

Men not coming forward

Agnes Mek runs the Rebiamul Centre. She has 300 patients on ART, the overwhelming majority women. Although polygamy is common in PNG, so are extra-marital affairs; women test in higher numbers because they know how HIV is transmitted, and they are worried about their husbands' cheating, she said.

"Our women don't have much say as to how things are done. Once you get married you submit to your husband, and that extends to the bedroom," she told IRIN/PlusNews, adding that this was especially true in the Highlands with its warrior traditions and well-guarded male privilege.

Mek has difficulty getting men to test for HIV, or even to go onto treatment along with their wives. It is not so much their fear of discrimination, she believes, but the shame associated with being responsible for bringing the virus into the home; or perhaps just as importantly, the proof it provides their peers of "loose" moral behaviour.

It is possible that the man with four HIV-positive wives, whose irresponsibility so incensed Dr Kaima, could be on treatment; it is not uncommon for men to seek ART outside their communities - one reason why Port Moresby has such a disproportionately high HIV prevalence rate. Mek suggested that he could also be in deep denial, and accusing his wives of being responsible for his infection.

Communities under strain

PNG society is under extreme pressure. Accelerated cultural change - the first European contact with the Highlands was not until the 1930s - is taking place against the backdrop of an economy that cannot create enough jobs, or keep its children in school.

The traditional egalitarian imperative, that the community takes care of its own and wealth must be redistributed to those in need, is beginning to unravel.

The Rebiamul Centre is looking after 150 children who have lost their parents to HIV, sending 40 of them to school. "With life becoming more stressful, extended family members cannot take on an extra mouth to feed," Mek explained.

And for adults on ART who are now living when they thought they would die, there is the problem of readjustment. "As they recover, their needs become harder to meet; they need jobs and those are hard to find."

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