Pacific Multi-Country Mapping and Behavioural Study:
HIV and STI Risk Vulnerability among Key Populations
Vulnerable populations in the Pacific are currently not receiving adequate HIV services. This was a key finding of a study conducted by University of New South Wales the and ASHM in 2016 in nine Pacific Island countries in Kiribati, Tuvalu, Vanuatu, The Kingdom of Tonga, Samoa, Cook Islands, Palau, Federated States of Micronesia and The Republic of Marshall Islands.
The study, titled Pacific Multi-Country Mapping and Behavioural Study: HIV and STI Risk Vulnerability among Key Populations, through surveys and in-depth interviews assessed and examined the behaviour risk factors and social and structural determinants of HIV risk that drive the epidemic among vulnerable groups, such as men who have sex with men (MSM), transgender people, female sex workers and seafarers. This study was commissioned by UNDP Pacific and the Pacific Regional Multi-Country Coordinating Mechanism and funded by The Global Fund to Fight AIDS, TB and Malaria.
The HIV epidemic in the Pacific region is characterized as low prevalence. However, despite the low overall rates of infection, the region is vulnerable to an increasing HIV epidemic. This is due to several factors, including inadequate data on key populations, limited awareness and understanding amongst policy makers of the epidemic’s potential long-term impact, unsupportive policy and legal environments, inadequate health systems, presence of stigma and discrimination against certain vulnerable groups, and low levels of community capacity and engagement in the policy making and programme implementation.
In addition to collecting data on behaviour, the study also conducted population size estimates in each of the nine countries, filling a gap needed for effective public health programme design and planning.
Access to HIV testing and treatment, care and support services were found to be poor, as was condom outreach, across all key population groups and countries.
HIV Program Adviser of ASHM's International Program, Michelle O'Connor spent six weeks in Tonga and Tuvalu working with local organisations to collect the data and found it an interesting, insightful and rewarding experience in leading the assessment of organisations working in HIV in each country.
"The studies found that many people are not receiving adequate sexual health and HIV services, support and information," reported Ms O'Connor. "For example between 0% to 59% of MSM and transgender reported accessing HIV services within the last 12 months. One of the key challenges faced in the small island countries is the stigma and lack of acceptance of MSM, Transgender and FSW."
"Levels of acceptance varied across the countries for example in Tonga and Samoa there appeared to be a greater level of acceptance which is likely to be due in part to the establishment of a transgender organisation and also in part due to the tradition of Leiti and Fa'fafine in each country." [These terms being closely attributed to 'transgender female' in the Tongan and Samoan language respectively].
However, the study reports that stigma was found as a barrier to accessing sexual health services as one participant from Tonga states, "They don't want serve you because you are the leiti'."
A further challenge of service delivery is the remoteness of islands and expense of travel. Many of the countries have outer islands which can only be reached by boat and petrol is expensive. As such outreach services such as condom distribution and HIV and STI testing and treatment is highly limited.
As one participant from the study in Palau states, "They are not really focusing on [outreach]. They do outreach about twice a year and I'm not happy about that".
Female sex workers were generally found to have a moderate level of HIV knowledge and access to sexual health services ranged from 0% to 79%. Only a minority knew where to access HIV testing. Female sex workers tends to be 'informal' in Pacific countries rather than in establishments, which can hinder outreach service access to them. However, some initiative such as outreach in Kiribati has been successful and requires further funding support to continue.
Stigma was also identified as a barrier to female sex workers accessing HIV testing, as one of the study's participant from Tonga speaks of her fear of getting tested, "I'm scared of seeing people. They think I go and... do this," referring to her fear that if she went to get an HIV test that people may find out and assume she is a sex worker, which is highly stigmatised.
The published findings in Pacific Multi-Country Mapping and Behavioural Study: HIV and STI Risk Vulnerability among Key Populations indicate an urgent need for reforms in Pacific island countries to adequately address HIV and sexually transmitted infections (STIs) among vulnerable populations. Important findings could be used to guide policy, services and programs for vulnerable populations in Pacific Island countries, including recommendations to introduce or scale up peer education, condom distribution and outreach programs for MSM, transgender and female sex workers.
“For the first time, many of these countries now have key pieces of evidence on which to base HIV prevention programmes for those groups most vulnerable to HIV,” said Professor Heather Worth, the lead researcher of the study from the School of Public Health and Community Medicine at the University of New South Wales.
Furthermore, greater attention is needed to deliver services and programs that fit within a sexual and reproductive rights framework so that services are accessible and non-discriminatory. Moreover, the organisations which support vulnerable populations require greater investment to continue to do so and expand upon their work.
“This research identifies key social and legal barriers that are hindering HIV prevention efforts that must be addressed, and lays out clear recommendations for policy makers and health programmers,” said Maisoon Elbukhari Ibrahim, Programme Manager, UNDP Pacific Office in Fiji. “Bringing the HIV epidemic to a halt is crucial to ensure that the social, health and economic development gains amassed in Pacific island countries continue to improve, and not be endangered.”
However, perhaps the key take home message is that differences exist between each country, therefore a one size fits all approach would not work and as such each requires a response tailored to their situation.
Download the Reports
A summary of the key findings and the individual country reports can be viewed below: