Health Minister Nafsiah Mboi’s HIV prevention efforts have faced serious resistance from some influential Islamists in this Muslim-majority country. Her promotion of condoms has led to angry protests, and she also had to overcome loud objections to her advocating that the government adopt harm reduction strategies for people who inject drugs. In an interview with Science, Mboi explains how she won several battles over HIV prevention efforts, yet also frankly addresses the areas that still need far more attention from the government. In particular, the government has not squarely addressed the spread of HIV in men who have sex with men, a group that suffers from serious stigma and discrimination.
In several sub-Saharan African countries, HIV has spread widely via heterosexual sex, infecting 5% or more of adults. No Asian country has an epidemic that has made similar headway in heterosexuals, although the virus has spread widely in key affected populations like men who have sex with men, injecting drug users, and sex workers. Papua New Guinea, however, is distinct from other Asian countries in many ways, and 10 years ago, it appeared that HIV was set to explode there in the heterosexual population. This sub-Saharan–like epidemic never came to be, and the country now is struggling to realign its response. The central challenge today is conducting appropriate surveillance to accurately describe the epidemic the country does have, which is easier said than done given that the virus has spread in often remote, geographically distinct areas and in key affected populations that are difficult to reach for social reasons.
Large-scale studies have proven that medical circumcision, which removes the entire foreskin, reduces the risk of men becoming infected via heterosexual sex by about 60%. But researchers still debate the precise mechanisms that lead to this protection. Investigators are now studying traditional penile cutting in Papua New Guinea, which slits but doesn’t remove the foreskin, for possible clues. Some evidence suggests that traditional cutting may offer some degree of protection, and by conducting experiments with HIV and different types of foreskin in the lab, researchers hope to clarify the factors in foreskins that deter or assist the establishment of an infection.
In the mountainous, remote Eastern Highlands of Papua New Guinea, people gather in makeshift cinema houses to watch videos that feature people from their communities who became infected by HIV. The stars of the videos come to viewings, too, speaking with the audience about their experiences, as well as about measures they can take to protect themselves and the effective antiretroviral treatment available if they do become infected. Made by students at the University of Goroka, the videos are in the local pidgin and attract people who are not often reached by mass media campaigns that attempt to educate the public about HIV/AIDS.
Adeeba Kamarulzaman, a leading HIV/AIDS researcher who is the dean of the faculty of medicine at the University of Malaya, studied in Australia from the time she was in high school, and, when she returned home to Malaysia, successfully lobbied the government to import harm reduction strategies that had worked there. Although many Malaysians are afraid to confront their government, Kamarulzaman has repeatedly pushed for evidence-based reforms, regardless of the political sensitivities. As transmission has shifted primarily from drug users sharing equipment to sexual transmission, she is now advocating for prevention and treatment efforts that target some of the most highly stigmatized groups in the country, including men who have sex with men, transgenders, and sex workers.
Shortly after the AIDS epidemic surfaced in Australia, an aggressive effort began to prevent the spread of HIV in people who inject drugs. The harm reduction movement that evolved provided clean needles and syringes to users, as well as opiate substitutes like methadone that are not injected. A medically supervised injecting center also opened in Sydney—the first of its kind in the Southern Hemisphere—where people receive clean needles and syringes and legally use their drugs. HIV never got a serious foothold in this extremely vulnerable population, and Australia’s harm reduction strategies eventually spread to nearby Indonesia and Malaysia, which initially had epidemics driven mainly by injecting drug use.
To date, Australia has only had an estimated 35,000 total HIV infections, which per capita is about four times less than the United States—and is a testament to the country’s early efforts to prevent spread in high-risk groups. But there’s one troubling exception to this success story: Prevalence of HIV continues to rise among men who have sex with men; it jumped 10% in 2012 and it has steadily increased since 1999. Given that roughly 70% of HIV-infected people in Australia receive treatment and that 90% of them have undetectable levels of virus in their blood, these increases in prevalence raise questions about treatment as prevention, which studies have shown can dramatically reduce the risk of transmission between heterosexuals. Does treatment have less of a preventive effect in men who are having sex with men? Is so, why?