Women and HIV in a moderate prevalence setting: an integrative review

The following inclusion criteria were applied to the identified articles, book chapters and reports:

The nature of the literature was classified as: a) original research, b) reviews, c) program descriptions and d) commentary/discussion paper using an adapted research identification schema [43]. Original research was further classified as: (i) descriptive; (ii) measurement studies; (iii) operations/intervention research [43]. The Critical Appraisal Skills Programme (CASP) system of appraisal was adopted to appraise the rigour, key methods, credibility and relevance of the diverse literature being considered for inclusion [44].

The changing economic, social and cultural context of PNG is reported to influence the risk of HIV for women. Urbanisation and modernisation result in changed economic, social and cultural conditions, including changed sexual practices. Separation from traditional lands and forms of subsistence (such as gardens) means services in exchange for goods or money is required for survival. For women in urban and peri-urban environments in PNG where there are very limited employment opportunities, the selling or exchanging of sex for money or goods is often ‘survival sex’ [51]. Bruce et al. [53] argue that economic deprivation is likely to influence sexual behaviours which increase the risk of HIV infection. Clark and colleagues support this position, stating that the selling of sex results from a high and increasing population density along with a rapid increase in poverty [61]. Changing economic drivers in PNG are leading to increased mobility for men and women, bringing new social and cultural norms and mores and an associated increased risk of HIV transmission. Lepani states that in contemporary PNG, “where men and women move, money moves as well” [34]. The Highlands Highway was a particular focus of a study by Gare et al. [30] who found that while the highway serves as the major economic route, it may also be the main conduit for the transmission of STIs and HIV between provinces. Wardlow in her work on men’s extramarital sexuality in rural PNG, also highlighted the link between economic drivers and HIV saying: “HIV/AIDS prevention policies and programs should specify and target the socioeconomic structures that make the choice of extramarital sex so likely” [55]. Men and women who live in urban areas and then return to rural villages are also seen as responsible for bringing HIV, creating a social schism between those who travel away to work and those who stay in the village [62]. This dynamic was similarly described in the Yupno region of PNG, with Keck quoting a young man as saying, “the men come and go…and bring this disease (HIV) here into the village” [13].

Cultural factors such as traditional beliefs around sexuality and reproduction, bride price and the inability to discuss sexuality and HIV prevention openly are contributing to increased risk of HIV for women in PNG. Cultural understandings of sexuality and reproduction are discussed at length in a number of the articles reviewed [13, 34, 55, 56, 62‐64]. Cultural practices such as bride price can increase women’s risk of HIV by placing men in a position of power over sexual decision making. Bride price is an exchange of goods (increasingly, including cash) that is paid to the wife’s family by the husband’s family. Some men whose family pay a bride price expect their wives to practice fidelity but do not expect their wife to be their only sexual partner since they were the givers of bride price. Reporting research from the Highlands of PNG, Wardlow describes pasinda meri (literally passenger woman in Tok Pisin) as a woman who doesn’t belong to anyone or who has given up her social and cultural roles [55]. Usually this results in selling sex or exchanging goods for sex for survival [51]. Becoming a pasinda meri is often a consequence of a woman’s anger at their treatment within cultural systems of bride price and compensation. Being a pasinda meri results in a freedom to live outside of cultural norms and while an expression of a woman’s agency it often results in stigmatisation, repudiation and physical attacks by both men and women [51, 55, 64]. Kelly et al. report the gendered nature of talk about sex, with young men using explicit language about sex in public spaces, while young women discuss sex one-on-one in private indicating the different ways young women and men discuss sex in PNG [56].

Women in PNG experience gender-based inequality, including less access to economic, education, legal and employment opportunities than men [61]. It was reported that women were often unable to negotiate safe sexual practices with their regular partners (including condom use and fidelity). It is also difficult for women to leave high risk relationships [61]. This inequality impacts women’s exposure to HIV and thus the epidemiology of HIV in PNG [34, 65]. Physical violence was experienced by 58% of the female sample in one study [22]. Violence not only exposes people to HIV transmission, but can also be a consequence of living with the virus. Rape is a likely contributing factor to the spread of HIV in PNG, with instances of lainups (gang rape) common [34]. A study led by Gare reported that 21% of the 210 women interviewed had been the victim of a lainup[30]. In PNG, there is a statistically significant link between violence against women and HIV transmission, including sexual abuse in intimate partner relationships, making the improved status of women in PNG a priority area for HIV prevention action [22, 65].

There is a range of findings about women’s knowledge about HIV represented in the literature, with women who sell sex, young women and mothers the focus of studies that include this topic. The majority of women who sell sex or exchange sex for goods know HIV transmission occurs through sexual intercourse [50, 58, 66, 67], although some young people lack adequate knowledge of HIV, including not knowing HIV is an STI that can occur within marriage or a stable relationship [13, 56]. HIV is associated with sex and referred to as sik blong koap (which translates as ‘sexually transmitted infection’) [56]. On the whole, HIV is not believed to be associated with sexual relationships with regular partners or within marriage, with many believing condoms are not needed in relationships where trust is established [34, 53, 56, 62]. Often, HIV is understood to come from outside the area in which one lives, by people who don’t belong to the area or from those who belong to the area but who have travelled outside and brought HIV back [13, 62, 68]. In PNG, sickness is commonly understood as a result of wrongdoing, embedding the virus within complex social, cultural and spiritual understandings [13, 34, 63, 69]. Links are made in the Southern Highlands between apparent witchcraft and HIV. Hayley reports AIDS produces the kind of dying that “lend[s itself] to witchcraft accusations”, which can result in torture of accused women and, on occasions, early death [69]. Knowledge of HIV may influence choices about HIV testing [57], but rarely changes sexual behaviour, as many women in PNG are in unequal power relations and have limited power to negotiate safe sex. This lack of agency is common amongst married women [54]. As Kelly and her colleagues remind us, a woman’s risk is far more dependent upon her ability to make and act upon decisions than knowing about HIV and its transmission [56].

The dominance of Christianity influences the way women experience HIV in PNG. Combined with the effects of colonisation, Christianity preserves beliefs about unequal gender roles and expected sexual behaviours of women [34]. One informant told Dundon, “In the beginning God created man and woman so that plan is in order, it’s in place” [62]. Christian churches have greatly influenced understandings of HIV and AIDS, as SikAIDS, as it is known in Tok Pisin, is linked with immoral behaviour, promiscuous sex and prostitution [13]. SikAIDS is described variously by Christians as a punishment from God, divine retribution, or a call to relinquish sinful sexual practices [13]. Most importantly, condom use is not accepted by some Christian churches as condoms are seen as a mechanism to elude God’s punishment for immoral sexual practices [55]. This rationale extends to male circumcision for HIV prevention. Some women explained that male circumcision is incongruent with Christian principles because it enables promiscuous behaviour and spoils the body (the temple) created by God [70].

A dichotomy is present in the literature about women living with HIV in PNG, with women divided into passive victims (the ‘mothers’) and promiscuous vectors (women who sell sex) [34]. Lepani theorises that women are either represented as victims of HIV or responsible for the spread of HIV. To reduce their risk of being a victim of sexual violence and thus of being infected with HIV, women are expected to stay inside, safe, sedentary and secluded with the inference being that if this code of behaviour is not observed, “rape is the consequence of women being out of place” [34]. Regrettably, research findings fail to support the idea that staying at home ensures safety from sexual assault with Lewis et al. reporting that 44.5% women in a study had experienced sexual abuse perpetrated by their intimate partner [22].

Women seen as responsible for the spread of HIV in the literature are mostly women who sell sex based in the Highlands and PNG’s capital, Port Moresby [30, 50, 53, 61]. Women who sell sex are known as pamuk meri or pasin pamuk (prostitute) or tukina meri (literally a woman who sells sex for 2 Kina, the currency of PNG) [54]. Women who sell sex are often not able to insist upon condom use (including with their intimate partners) and are frequently punished for selling sex by rape, including by gang rape [30, 53]. There is also evidence that women who leave their husbands due to rape and violence are also deemed HIV vectors and thus responsible for spreading HIV [54, 55]. In Western Province, senior women considered to possess special spiritual powers can identify and enact retribution upon women who are deemed a HIV vector (including divorced women and women who sell sex). This retribution can take the form of social, cultural or spiritual isolation and, on occasions, physical punishment. [30, 50, 53, 62]. Women living with HIV are also often accused of being a pasin pamuk or pamuk meri[55]. This attitude is often reflected in the way health services are provided (or not) to women, with expressions of stigma reported [64].

A variety of ideas about HIV prevention are explored in the literature reviewed. These include: encouraging young people to adhere to kastom and church requirements [13, 34]; patrolling the community and figuratively “building a wall” around an area [62, 63]; and, increasing HIV education opportunities and access to condoms [30, 50, 53]. Seeley and Butcher discuss an example of increased economic and social agency of women and how this may reduce risk of HIV acquisition, because of women’s enhanced bargaining position within the household. These findings demonstrate the importance of expanding a structural and gendered understanding of HIV in PNG as a method of developing strategies for HIV prevention [65].

The majority of original research in this review is descriptive research about women and HIV in PNG, with no operations or intervention research. Operations research (also known as operational research) is defined as research which aims to “develop solutions to current operational problems of specific health programmes or specific service delivery components of the health systems” [71], while implementation research aims to “develop strategies for available or new health interventions in order to improve access to, and the use of, these interventions by the populations in need” [71]. There is debate in the literature about the similarities and differences between operations research and evaluation. The intent of both is to systematically collect and analyse program or project data. However, operations research differs from evaluation in that the purpose of operations research is to influence practice and policy [72], whereas the primary focus of an evaluation is to provide information which will (i) improve a product or process (formative evaluation) or (ii) report upon the effectiveness or impact of the project or program (summative evaluation) to generate knowledge about good practices [73].

Limited literature about the impact or outcomes of strategies implemented by government departments or non-government organisations addressing HIV at a programmatic level is published in the peer-reviewed literature. Health services can be unhelpful or dysfunctional [64]. There are few positive accounts of successful HIV prevention activity in the peer-reviewed literature, with Seeley and Butcher’s article being an exception [65]. The exclusion of non-peer reviewed government and non-government organisations reports accounts for some of the gaps identified in this review. While descriptive research is required to develop a deep understanding and an evidence base for action, research about woman and HIV in PNG needs to progress to action-oriented operations and intervention research in order to provide policy makers with evidence for decision making. The Global Fund to Fight AIDS, Tuberculosis and Malaria recommend a minimum of 5-10% of HIV program funds be used on monitoring and evaluation activities, including operations research [74], indicating there is an opportunity for operations, implementation and/or health system research with and for women in PNG about HIV to shift from description to action.

In addition to the lack of operations or intervention research, there are still a number of gaps in the descriptive research available. Current prevalence estimates are mostly based on HIV identified in antenatal clinics in PNG. We need to know more about PNG women outside the context of antenatal clinics or selling sex [1]. Unequal power between men and women reduces the bargaining abilities of women, including in long-term sexual relationships [53]. In PNG, some women describe feeling offended when men ask to use condoms when having sex with them in the context of marriage or long-term relationships [75]. Additionally, women requesting a condom to be worn in the context of such relationships fear they will be perceived as a tukina meri[75]. More research is required to understand these relational dynamics and their impact upon HIV risk in PNG. There is limited research about women and HIV risk in the matrilineal societies in PNG, with the exception of Lepani’s work in the Trobriand Islands [34, 76]. Do women in matrilineal societies experience the drivers of HIV differently to those in the Highlands for example? Does land ownership by women contribute to a reduced HIV risk? How is this being impacted by modernity and development? The economic inequity that is described in the literature would be better understood with operations or intervention research being conducted to address social, cultural and/or economic issues to enhance HIV prevention in PNG.

In the light of this review about women, it is clear the role of masculinity as perceived and enacted in PNG is important for HIV prevention in PNG. A renewed focus is required “on masculinities and policy and program frameworks that integrate the issues of male sexual privilege and gender violence” [34]. Male privilege, expressed by violent manifestations of male power needs to be challenged. Richard Eves’ research about masculinity in PNG, which is manifested by men perpetrating violence, is an example of the growing understanding of the social, cultural and spiritual drivers of violence [3]. Research about masculinity in PNG needs to be expanded while remaining contextualised. Some answers may lie in work being done in Vanuatu by Sister Lennon and colleagues, who assist men to consider women as mothers and sisters to connect them with the ‘feelings’ of a rape victim [2].

Limited literature in this review focused on the experience of women living with HIV and AIDS or the experience of women caring for a HIV positive person/people. Stigma against people living with HIV was reported [67]. Women bear the burden of caring for people living with HIV around the globe, with PNG no exception. There are program activities being conducted and reported upon in PNG in forums such as the PNG Medical Symposium (2012; 2013). However, there is opportunity for further operations research to be conducted with people living with HIV in PNG [27].

Literature included in this review provides knowledge about the context of women’s lives in PNG, the gender issues they face, their understanding of HIV and the way women are perceived in relation to HIV. The range of findings about women’s knowledge of HIV reflects the way in which these research findings were generated: from internationally sanctioned knowledge, attitude and practices questions to sociocultural focused, geographically bound ethnographic methods. The current focus on strengthening the capacity of researchers from PNG to undertake HIV research will further enhance the nature and amount of HIV research in PNG [27].

Peer-reviewed literature provides evidence of explicit research methods, results and recommendations which are less able to be influenced by organisational and government agendas [77]. However, the peer review process and the claim of quality has its’ critics, particularly with the advent of a plethora of open access journals and availability of reports and other information online [78]. Peer-reviewed literature about women and HIV in PNG is a useful source of evidence. However, much valuable, nuanced and important evidence for decision making is available in the grey literature. This is demonstrated by the non-peer reviewed systematic literature review of HIV literature in PNG by King and Lupia, which contributed an important synthesis of literature about HIV in PNG [41]. Key recommendations from this review have been instructive for the HIV response in PNG. Recommendations included: increasing the involvement of churches in the HIV response, being guided by culture, working with groups living with or at higher risk of HIV and providing women with more options. In addition to information and behaviour change, more focussed support was recommended for the public sector and researchers [41].