The World Health Organization (WHO) and the Joint United Nations Program on HIV and AIDS (UNAIDS) has recommended that male circumcision (MC) be considered as an essential component of comprehensive HIV prevention programs in high prevalence settings. This followed three large-scale phase III clinical trials in Africa which showed that MC has a protective efficacy of around 60% in preventing HIV acquisition in men during vaginal intercourse; although there has been debate about the ability to generalise these findings to other populations and contexts. Papua New Guinea (PNG) has the highest HIV prevalence in the Asia-Pacific region, estimated to be around 0.9%. Interest in introducing an adult MC program as part of HIV prevention strategies in PNG has been mounting. Mathematical modelling has confirmed that MC could have a moderate impact in reducing the incidence and prevalence of HIV. With significant geographical and cultural diversity, and difficulties delivering even simple health programs, PNG provides a context of extreme system complexity. Health workers (HWs) are central to the successful delivery of such a health program but the influences of HW culture and practice on new health programs has rarely been examined. This thesis aims is to explore the nature of HW relationships with the system and the people they serve through examining the application of a future adult MC program as part of a comprehensive HIV prevention strategy in PNG.
Approach and Findings
This thesis adopts a complex adaptive system approach to explore HW relationships and dynamic interactions with the potential implementation of a MC program for HIV prevention. The research was completed from 2009 – 2011 using qualitative methods, including focus group discussions, in-depth interviews, participatory workshops, and reflective field notes, triangulated with an extensive literature review. The thesis consists of ten chapters divided into four themes. Each theme introduces an element of the complex socio-cultural and system relationships that are likely to be implicated in the development of a MC program for HIV prevention in PNG.
Theme one reviews the positioning of MC for HIV prevention in the global context, and through a comprehensive literature review examines lessons that may be applied to PNG (Chapter 2). The review shows that implementation of programs in Africa have been complicated by challenges in health system readiness, diverse socio-cultural environments and concerns about risk compensation.
Theme two explores some of the potential issues of integrating a MC program into the socio-cultural context of PNG. Using a Modified Delphi approach with sexual HWs in PNG, a classification of penile cutting in PNG shows the extensive diversity of meaning for ‘male circumcision,’ with implications for HIV prevention (Chapter 4). A multi-method qualitative study completed with community members confirms divergent expectations of a MC program and the need to develop locally adapted programs (Chapter 5).
Theme three explores the strengths and weakness of the health system and the impact this may have on HW relationships with the health system and the communities they service. Using an analysis of a comparable program, the national no-scalpel vasectomy program, the vulnerability of the health system to implement a MC program in PNG is highlighted (Chapter 6). Clinical audits of a sample of PNG health facilities that may be called on to implement a MC program reveal HWs already participating in authorised and unauthorised penile cutting practices, despite the limited capacity of health facilities (Chapter 7).
Theme four explores the behaviour of PNG HWs. Through in-depth interviews with frontline HWs about their motivations to be involved in sexual and reproductive health services in PNG, it is shown that strong links to the community often outweigh organisational ties (Chapter 8). The final study investigates HW participation in emergent unauthorised penile cutting practices showing that reasons range from attempts to meet community and socio-cultural responsibilities to improving social status (Chapter 9).
This thesis has confirmed that PNG HW culture and practice has an impact on the introduction of new interventions, subverting, adapting and translating them with unintended consequences. The findings show that penile cutting practices are performed in PNG for a diverse range of reasons, in potential tension with the HIV prevention agenda. Structural weakness in the health system renders it currently unable to deliver such a program and along with HIV estimates being lower than previously feared, a wide-scale roll out of a national MC program cannot be recommended. However, despite the lack of a formal national MC program, HWs are already involved in a self-organized system of penile cutting practices that are not for HIV prevention; not policy driven; currently unrecognised by the National Department of Health; but integrated intimately into society and culture. Overall, the results suggest that successful health system strengthening activities will be extremely difficult to implement and roll out in these circumstances without acknowledgement of these complex issues and subsequent intervention.