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| Journal of the New Zealand Medical Association,
12-August-2005, Vol 118 No 1220
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Sexually transmitted diseases and HIV/AIDS in Vanuatu: a
cause for concern and action
Dominik Zenner, Steven Russell
The number of officially reported cases of HIV and AIDS in
the Pacific Island countries remains low compared to other parts of the
developing world (Table 1), but in some countries, notably Papua New Guinea,
reported cases are rising. Estimates also show that reported cases may only be
the tip of the iceberg, with 16,000 (7,800–28,000) infected people in
Papua New Guinea1,2—an overall prevalence rate of 0.6%.3
Much higher prevalence rates are estimated among high risk
groups (up to 17% in female sex workers).4 As far
back as 1996, the United Nations Development Programme (UNDP)5 warned of an
epidemic in the region, and these warnings have been repeated recently by United
Nations Programme on HIV and AIDS (UNAIDS).6
Vanuatu recorded its first HIV case in September 2002, and a
second has now been officially reported. It is likely that more people are
HIV-positive but remain invisible to the scanty reporting and surveillance
systems in the country. Infections may be concentrated among high-risk groups
such as sex workers, but a high prevalence of other sexually transmitted
infections (STIs) and the risk environment in Vanuatu discussed below mean that
HIV infections are likely to spread to the wider population if effective
preventive actions are not taken.
Table 1. Reported HIV and AIDS cases (end of 2003) in
Melanesian countries
Source:
South Pacific Commission7; *as of December 2001; n/a=not available.
This article aims to fill a gap in current knowledge as the
first situational report on STIs and HIV/AIDS in Vanuatu, using the limited data
available. STIs are the focus of attention because potential HIV cases remain
hidden and because STIs themselves increase susceptibility to HIV transmission.
High STI prevalence rates may also indicate behavioural patterns that contribute
to greater transmission risk, such as multiple partners, commercial sex, and low
condom-use rates.
The paper examines the evidence on STI prevalence rates,
monitoring, and surveillance system weaknesses and the factors contributing to
the high-risk environment in Vanuatu. The viewpoint expressed is that these
findings are a cause for grave concern to the public health and development
community in Vanuatu and the wider region, and concludes by reviewing capacity
response weaknesses and policy priorities.
MethodsQuantitative and qualitative data were collected in May
2003 for a small research project approved by the Vanuatu Ministry of Health
(MoH) and the National Statistics Office (NSO).
Data were derived from three sources.
(These
information sheets record case numbers for gonorrhoea, syphilis, and genital
ulcers (not chlamydiasis or trichomoniasis) and should be processed by the
Statistics Unit of the MoH into an Annual Epidemiological Report. Some
non-government organisation (NGO) facilities also report to the MoH but many
private-for-profit surgeries do not. Procedure dictates that any HIV cases
should be reported directly to the MoH.)
Respondents were selected because of their
involvement with policy and practice and to obtain a spectrum of perspectives
and opinions. A standardised question guideline was used and the interviews were
taped, transcribed, coded, and analysed. This method generated complementary
qualitative data on the risk environment, monitoring and surveillance capacity
and other policy matters. Anonymity was guaranteed as part of the ethical
procedures of the research.
ResultsSTI prevalence rates in VanuatuData on STI incidence and prevalence rates in Vanuatu is
severely limited. All key informants working in the field of reproductive health
believed that STI rates were rising (particularly in urban areas), a conclusion
based on the limited data available, anecdotal evidence, and their overall
perception that risk factors were increasing (see below).
The first body of evidence comes from two STI prevalence
surveys. The first was a World Health Organization (WHO)-funded survey of 545
pregnant women conducted by the MoH in Port Vila in 2000.9 In this relatively
low-risk sample, 27.5% of the women were positive for
Trichomonas vaginalis, 21.5% for
Chlamydia trachomatis, and 5.9% for
gonorrhoea (Table 2). Out of the 66 teenage women tested, 58.1% had at least one
infection and the study concludes that these findings are ‘of major
concern’ and that ‘the unexpectedly high burden of disease among a
traditionally low-risk population of antenatal women argues for policy and
community-level interventions....’
Source:
WHO9
The second survey, conducted by the Vanuatu Family Health
Association (VFHA) in cooperation with the WHO and MoH in West Ambae Island,
found lower prevalence rates (5.2% and 1.5% for
Trichomonas and
Chlamydia respectively) in a random
sample of clinic attendees.10 The lower infection rates in these more remote
rural areas are not surprising, but the results of the urban and rural studies
are difficult to compare because of the different sampling and also age
composition of the two surveys.
In the urban study, the median age was 25 years and in the
rural study 35 years; and given that 60% of Ambae’s population is below 24
years, the rural sample of older women does not reflect the ‘normal’
population nor the most sexually active group.
The second body of evidence comes from the authors’
analysis of routine MoH case returns from facilities. Weaknesses in public
sector STI monitoring and surveillance systems and data quality should be
highlighted. Facility reporting rates were found to vary considerably between
provinces; for example, ranging from an 18% questionnaire return rate in Penama
Province in 2002 to 72% in Sanma Province in the same year, and seemed to depend
on provincial and facility capacities such as staffing levels, training and
motivation to complete returns. Penama had the lowest average return rate from
1995 to 2002 (62% of questionnaires) and its understaffed hospital lacking an
STD treatment room and appropriate laboratory facilities underlines
this.8 The 2002
country-wide return rate (48%) was markedly lower than previous years
(64–83%), probably as a result of a change to the information sheet that
led to some confusion. The public sector’s weak capacity to manage the
case reporting system is illustrated by the fact that since 1988 the MoH has not
processed monthly returns into an Annual Epidemiological Report.8
Acknowledging the weaknesses of Vanuatu’s STI
reporting system and the crude results generated, STI case numbers have been
estimated by taking the cases recorded by MoH facilities and adjusting for the
respective under-reporting rates of each province in each year:
Estimated cases = reported cases
× reporting rates-1
The total case numbers of all three recorded STI entities
between 1995–2002 (gonorrhoea, genital ulceration, and syphilis) are
presented in Figure 1 and corresponding adult prevalence rates for each STI in
Table 3.
Figure 1. Countrywide STI estimates (gonorrhoea,
genital ulceration, and syphilis) in Vanuatu
 Table 3. Prevalence rates for gonorrhoea, genital
ulceration and syphilis (total cases as a percentage of the adult population
aged 15–59 years for 1995–2002*)
Source:
MoH11,12 and NSO13; *Prevalence was calculated for the adult population using
1999 National Census data and incorporates inter-census population growth rates
derived from the NSO demographic analysis report.
Gonorrhoea cases were far more numerous than syphilis and
genital ulcer cases nationally; for example, in 2000 there were 1358 gonorrhoea
cases compared to only 166 syphilis and genital ulcer cases. A steep rise in
male gonorrhoea cases and a decline in female cases between 2001 and 2002 may
have been exaggerated by changes to the MoH reporting form.
Reported case levels and prevalence rates of about
1.2–2% for the three STIs appear to have been fairly consistent over time,
but two important gaps in the MoH data justify the inference that STI prevalence
is likely to be much higher. First, MoH data exclude trichomonasis and
chlamydiasis due to lack of adequate testing methods (i.e. polymerase chain
reaction), and these STIs are far more prevalent according to WHO survey data
(Table 2). Second, it is likely that poor surveillance systems, low awareness of
STIs, and poor patient access to services mean a gross under-reporting of
cases.
Patient under-reporting is illustrated when looking at Shefa
Province which saw a dramatic rise in reported syphilis and genital ulceration
cases (notably by females) after a new reproductive health clinic (Kam Pussum
Hed Clinic) was opened by the Wan Smolbag NGO in 1999 and submitted its first
case reports to government in 2000 (Figure 2).
Shefa Province’s steep rise in reported cases after
its clinic’s establishment indicates that it was addressing unmet needs;
improving service delivery in other provinces could lead to a similar rise in
reported STI cases through improved access. The accessibility of care provided
to women at Kam Pussum Hed Clinic and its discreetness on the outskirts of Port
Vila were important factors explaining the rise in utilisation.
Figure 2. Genital ulceration and syphilis estimates in
Shefa Province based on reporting rates there each year
 The risk environment for STIs and HIV/AIDS in VanuatuHigh STI prevalence and several socioeconomic factors
interact to make a range of people susceptible
to infection, thus creating a risk environment for the rapid spread of
STIs and HIV/AIDS:
Demographic
structure—Young people are particularly vulnerable to HIV infection
(globally half of new cases are among 15–24 year olds).14 In Vanuatu, 59%
of the population are under 24 years and 18% aged between 15 and 24 years old13
thus making a large section of the population vulnerable now (and in the near
future) at a time of rapid socioeconomic change through urbanisation, migration
and transition to cash economy among others.15
Poverty and
inequality—Until recently, Vanuatu has experienced comparatively
low economic growth rates which have caused rising unemployment and
impoverishment.16 Unequal gender relations add to these risk
factors. Women’s greater physiological and
societal susceptibility to STI and HIV transmission is internationally
recognised,17-19 and key informants gave abundant examples to illustrate
women’s limited bargaining power over when and how they have sex (rooted
in cultural and social norms that expect women to be timid and to obey their
husbands), as well as fears of abuse and violence.
Political and social
institutions—Vanuatu’s rural society (and to a lesser extent
its urban society) is hierarchical and patriarchal (male dominated)—with
leading roles ascribed to the male chief, the pastor, and village elders. Key
informant interviews confirmed that public talk about sex and reproductive
issues is generally taboo and perceived by community leaders as a threat to the
sociocultural integrity of the community—thus imposing serious barriers to
reaching rural areas and women with sexual health awareness campaigns.
Condom distribution is sometimes equated with the
encouragement of casual sex or promiscuity. Even in Port Vila, a large
randomised Knowledge, Attitudes, and Practice (KAP) survey
(n=1053)—conducted by the NGO Vanuatu Young People’s Project
(VYPP)—found considerable resistance to condom use, and women were accused
of promiscuity if they suggested condoms.15 MoH staff themselves are embedded in
this sociocultural context which one government informant argued contributes to
a degree of ‘ambivalence about the distribution of condoms.’
Economic activity and risky
livelihoods—The South Pacific Commission (SPC) warns that high
levels of migration and lifestyle changes associated with new economic activity
and rapid urbanisation are risk factors for the spread of STIs and HIV.20 An
estimated 19% of the Ni-Vanuatu (indigenous) population do not live on their
home islands but migrate to urban centres for work.21 The tourist industry is
also large, accounting for 40% of GDP and employing 4000 people.22 For example,
in 2000, 57,500 tourists and 50,000 cruise ship passengers visited Vanuatu
(compared to Vanuatu’s 186,678 inhabitants).
Although more sex education is recommended by UNGASS, 19 the
Government admits that only limited sex education is available in tourist hotels
and workplaces.23 Key informants also argued that the rapid transition to a cash
economy and urbanisation were driving increases in risk factors such as the
commercial sex industry and alcohol consumption.
Service infrastructure and
biomedical knowledge—According to key informants, a widespread lack
of knowledge about prevention or treatment of STIs is a key risk-factor. The
UNDP adult literacy rate is only 34%24 and 56% of the population receive only
primary education up to class 6 (age 12) with no learning about reproductive
health matters. Awareness campaigns achieve low coverage outside the main urban
centres due to limited geographical access, people’s limited access to
television and radio media, and the social taboos around sex noted above.
Key informants at the MoH saw lack of awareness and lack of
access to curative services as mutually reinforcing, because if people are not
interacting with services then they are not receiving information and advice.
Information delivery by rural health workers may be further restricted by taboos
if they come from the communities where they work.
DiscussionThe high STI prevalence rates found by a WHO antenatal
survey in 2000, and the first officially reported case of HIV 2 years later, are
a cause for concern for the public health community in Vanuatu. Although routine
MoH STI-case reporting shows no clear pattern of increase, complacency would
seem misplaced given reporting system gaps and the likelihood of
under-reporting, notably in rural areas. Poverty, gender inequality, and poor
health service and awareness coverage interact to make a range of people
susceptible to infection.
Policy lessons for Vanuatu come from countries that have
successfully tackled the epidemic and reduced incidence, either at an early and
concentrated stage of the epidemic (e.g. Thailand) or after the disease had
spread to the general population (e.g. Uganda).
These lessons include the early strengthening and
implementation of STI/HIV surveillance systems; high-level political leadership
and commitment to HIV/AIDS prevention; treatment and surveillance strategies; a
multi-sectoral response across ministries; response partnerships with a range of
civil society actors; and strict promotion of condom use in the commercial sex
industry.25,26
The need for such responses in Vanuatu is pressing, and the
Government recently published its response with the
Vanuatu Policy and Strategic Plan for HIV/AIDS
and Sexually Transmitted Infections 2003–2007.23 The core aims and
policies of the Strategic Plan are to
improve monitoring and surveillance systems; to increase awareness about STIs
and HIV/AIDS (particularly among high-risk groups); to promote condom-use; and
to reduce the incidence of STIs through better prevention and treatment
measures.
Despite the Strategic
Plan’s good intentions and ambitious aims, government capacity and
political commitment will be the key to success. Government capacity is clearly
limited in terms of budget constraints, shortages of skilled and motivated
staff;22 and weak information systems. The MoH recognises the importance of
improving its crude and erratic STI and HIV surveillance systems in order to
identify needs and to monitor incidence and evaluate planned
interventions—and some of these investments could be covered through the
recurrent budget.27
More ambitious HIV surveillance systems (noted in the
Strategic Plan), or surveys to evaluate
awareness and prevention programmes that conform to international standards, are
likely to require external funding and human resource support from the
international community.
Targeting awareness campaigns and services at high-risk
groups is also fraught with difficulties because such groups are hard to
identify or reluctant to be found. According to key informants, sex workers are
particularly difficult to reach due to societal attitudes. NGOs working with
this group emphasised the need for great caution and discretion to avoid
negative community reactions to their work. Indeed, reaching other vulnerable
groups such as women in rural communities will be difficult due to the
aforementioned political and social institutions and taboos around public talk
about sex, gender inequalities, and access difficulties.
Even if a range of vulnerable groups can be reached, greater
awareness will not necessarily empower them to change risky behaviours (if
poverty and gender inequalities persist), and changing underlying social
relations that play a role in STI transmission is never
easy. These challenges, however, should
neither deter action nor prevent successes, as the examples of Thailand and
Uganda have demonstrated, and peer education among young people, particularly
girls, may be the most appropriate and feasible point to begin interventions.
Such engagements might also build capacity and facilitate more ambitious
initiatives with vulnerable groups in the future.
MoH-capacity weaknesses mean that Government should explore
the possibility of partnership with the NGO sector to deliver services. Indeed,
several NGOs in Vanuatu have already demonstrated they can deliver reproductive
health campaigns and services, and partnerships with NGOs and community-based
organisations will strengthen capacity for reaching vulnerable groups.
NGO programmes were identified during the situational
analysis, and included: two reproductive health clinics in Port Vila (including
Kam Pussum Hed) and one in Luganville; a community theatre group that promotes
awareness about sexual health matters and tours the islands six times every
year; several peer-to-peer education initiatives with youth in urban areas; and
radio shows. The MoH Strategic Plan
acknowledges the significant contribution that NGOs can make to the fight
against HIV/AIDS, and partnerships are most likely to be successful if
relationships of trust, equal collaboration, and mutual support can be
developed.
Government-capacity weaknesses also point to the need for
international support to implement the
Strategic Plan. At a recent UNAIDS
workshop in Fiji, the scaling up of HIV awareness and prevention programmes for
young people in the region was emphasised as an urgent priority to prevent an
HIV/AIDS epidemic in the Pacific—and both the Global Fund to Fight AIDS,
TB, and Malaria (GFATM) and the Australian Agency for International Development
(AUSAID) have committed funds to strengthen a regional AIDS strategy and
capacity to deliver services.6
Another priority in Vanuatu is to develop monitoring and
surveillance systems; and a response by a re-invigorated National AIDS
Council23—to coordinate government actors within the MoH and National
Statistics Office, NGOs, and international agencies (such as WHO or
GFATM)—would be an important contribution to the fight against HIV/AIDS.
HIV is new to Vanuatu, and although many organisations seem
determined to fight its spread, strong political leadership will be needed to
overcome rivalries and push for such a coordinated response.28
Author information:
Dominik Zenner, GP Registrar, Cologne, Germany; Steven Russell, Lecturer in
Health Policy and Social Development, School of Development Studies, University
of East Anglia, Norwich, UK
Correspondence: Dr
Steven Russell, School of Development Studies, University of East Anglia,
Norwich NR4 7TJ, UK. Fax: +44 (0)1603 451999; email: S.Russell@uea.ac.uk
References:
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