HIV in the Philippines
Window of Opportunity
or Predictable Failures?
by Godofredo U. Stuart Jr., MD

In the landscape of HIV seroprevalence, the past few years have shown an alarming spike, and 2015 reports have shown no signs of abating.

In 2003 a report was published on the ASEP (Aids Surveillance and Education Project) experience in the Philippines. It was a rather comprehensive report, encompassing all aspects of HIV and AIDS prevention and education. It blazoned how a decade ago, the Philippines seemed to be on the verge of a crisis, with no sentinel surveillance, many lacking the basic education for prevention, high risk behaviors were believed to be widespread, including commercial sex and needle sharing among IVDU, and warned how the window of opportunity to prevent the spread of HIV was "closing fast." It was a self-congulatory report, lauding the success of HIV prevention and education efforts, patting itself on its shoulder, boasting that ten years later HIV incidence remained low.

So, what happened? Today, 12 years later, we are back to 23 years ago. We can cut and paste that 1992 paragraph of gloom and doom to present day fears and concerns on the burgeoning HIV epidemic. Who fell asleep at the helm? We can finger point at the old and familiar: the failure of education, political inertia, a church that continues to dictate its antiquated sex credo as it holds holy sway on the language of sex education and prohibition on condom use. Or, we can admit to the having been blind sided by the flourishing milieux of high risk behaviors in call centers, burgeoning sex trades venues and red light districts, and a class-coming out sexual revolution in the gay community, infected OFWs returning home—all contributing to a seroprevalence spike.

Despite that spike, the Philippines with its estimated population of 100 million, is a low-HIV-prevalence country with one of the lowest incidences of infection, with less than 0.1 percent of the adult population estimated to be HIV-positive. The seroprevalence concern is in the threatening concentrates of risk populations—MSM, those in the sex trade, and a small niche of IVDU. As of December 2014, the Department of Health (DOH) AIDS Registry in the Philippines reported 22,527 people living with HIV/AIDS. Adding urgency to these numbers, the UN reports that the country has one of the fastest growing number of HIV cases in the world, with one study reporting a jump in the number of new HIV cases from 1 new case every three days in 2000 to one new case every hour and 15 minutes, or 17 new cases in a day. March 2015 reported 667 new HIV cases or 21 new cases a day. The WHO augurs that if the prevalence rate exceeds 5%, in a matter of two years time, the HIV in the six areas of concern (prevalence rates among MSM: Quezon City 6.6%, Manila 6.7%, Caloocan 5.3%, Cebu 7.7%, Davao 5.0%, and Cagayan de Oro 4.7%) will be uncontrollable. And 2020 forecasts based on current trends are foreboding: an increase of infected heterosexuals by 200%; bisexuals, 1,300%; and homosexuals, 1,500%.

The Gay and Bisexual Community
A report recently published that about 85% of HIV cases in the Philippines were identified in gays (men having sex with men). Men having sex with men (MSM) is the predominant mode of transmission in the Philippines.

It comes as no surprise. In the Philippine sexual revolution of the past two decades, change has been most visible in the homosexual community—the ubiquitous presence of gays in the commerce of radio and television, with a masa acceptance that helped open the closet doors for many, with increased public visibility especially among the BCD and creating the seeming increase in the number of gays.

An estimate has been made that a minimum 10% of the population is gay. This number pales to the common street guesstimate that 4-5 of 10 Filipinos are gay or bisexual. The numbers are too high or too low, depending on where you live or who is polled. The ubiquitous presence of gays on radio and TV, likely contribute to the skewing of estimates.

According to a 2002 Young Adult Fertility and Sexuality Survey, 11% of sexually active Pinoys between the ages of 15 and 24 have had sex with someone of the same sex.

CNN is said to have listed the Philippines as one of Asia's top travel spot for gays, "full of gorgeous gay-friendly beaches and welcoming gay bars." The country has even been ranked as one of the most gay-friendly in the world, and the most gay-friendly in Asia.

Grapevine stories tells of bathhouse-type venues with a merry-go-round of dozens of different partners, one bragging of over 100 different contacts in one year. Hidden in the MSM (men having sex with men) numbers are an estimated 30-40% who are bisexuals, unaware of their serologic status, with the potential to infect their female partners: prostitutes, wives, and girlfriends.

FSW (Female Sex Workers)
The first wave of HIV infections was identified in FSW around the US military bases. The exodus of the American military helped stem the early rise of HIV cases. However, the red-light commerce is a booming enterprise. Despite the FSW seeming low contribution to the total HIV numbers, they continue to be a very vulnerable population, with anatomical risks and often compromised positions in condom negotiations.

The Trade Union Congress of the Philippines warned the number of OFWs testing positive for HIV may reach over 4,000 this year. One report on new cases estimate more than 30% to be among homosexual and bisexual OFWs. The OFWs now comprise some 14 percent of the 24,936 cases in the Philippine HIV and AIDS Registry as of April 2015.

Other High Risk Venues
There are other niches of risk populations: intravenous drug users in an unmanageable population of shabu addicts, sex tourism and child prostitution, call centers that have been flagged as red-hot zones, and of course, a small population who gets infected through heterosexual or bisexual transmission. These are separate risk populations that need separate programs of outreach, surveillance, and education.

In any efforts of HIV/AIDS prevention and treatment, education is forefront and paramount. Every pulpit of concern urgently clamors for more effective education. The past is littered with failed efforts on education. Although there have been a Health Department campaigns and media blitzes for HIV and AIDS awareness, misconceptions and ignorance on cause, prevention and risk practices are still widespread.

I have written opinions on the failure of the education: The Comic Failure of Language in Sex Education and the Predictable Failure of HIV Education in the Philippines. Education will continue to fail if it continues to kowtow to the dictates of a church who insists on a language of sex education expunged of vernacular sex words which it has decided are vulgar or bastos, with no place in the setting of decent conversation and education. Many do not recognize the colonial roots and church's influence on language cleansing in sex education and the prudishness in conversation when it pertains to sex—many convinced of its vulgarity. Others who see it as it is can only shrug and say: The Church won't allow it. . . Hindi papayag ang simbahan. . . Napakalakas nang simbahan.

The religious constraints placed on education has been comic. In an earlier sterilized effort of the Philippine National AIDS Council on HIV education (HIV and AIDS 101 and Republic Act 8504 Basics), there was not a single mention of the word "condom" in its ABCDE of AIDS prevention.

Thankfully, that might be a thing of the past. Activism against the establishment has won small battles. Education efforts have turned a new leaf. Clinics have sprouted with secular teaching modules. The condom has finally become part of the language of HIV education and prevention, replete with demo models of penises.

Even with the exclusion of the church, the great task for educators will be the translation of education and information into a comprehensible regional vernacular; Taglish or regional dialects, and when needed, infused with ample doses of Swardspeak.

Sex and HIV/AIDS education is a continuum and should be sensitive and appropriate to the varied audiences being addressed. For the young, sex education should be a departure from the stale and sterile birds-and-bees type of teaching. For the general public, education should focus on prevention and risk behaviors, unexpurgated and stripped of "hiya" or "bastos", with emphasis on safe sex practices, condom use, anal sex, and the importance of knowing one's HIV status, that HIV infected patients might feel well for many years, until their immune system declines significantly enough to cause symptoms or opportunistic infections. For the masa, the CDE, it should be in a language that they understand, without the preponderance of English words that causes "nosebleeds." For MSM and bisexuals, education should be brutally frank, delivered in their vernacular, Taglish, or swardspeak, focusing on their sexual risk practices and anal sex; and for bisexuals, the added risks for their female partners (girl friends, wives, or prostitutes). For FSW education, efforts should focus on their higher risks, safe sex practices focusing on both vaginal and anal sex, condom and lubricant use, For those who test negative, they should be aware that there is a window of a month, from contact to seroconversion. For those who tests positive, the importance of safe sex practices, to learn of the disease process, its usual decade long course, symptomatology, treatment options and how treatment extends lives and decreases the risk of transmitting infection to their partners. For those already infected and on treatment, education should focus on treatment compliance, prognosis, monitoring for opportunistic infections.

The setting for sex and HIV education matters, not just in language and messengers, but also in abilities and sensitivities. Many physicians are uncomfortable dealing with HIV patients, lacking in knowledge and the time to keep current in information, the sensitivity to want to address certain patient populations, and the ability to advise on the taboo subjects of risky sexual practices related to HIV infection. Likewise, patients easily sense this inability and discomfort and reflexly distance themselves and withdraw into silence and denials. In a country where 85% of HIV infections are in MSM, clinics staffed by dedicated and well-trained gays and lesbians can provide much needed atmosphere of trust, sensitivity, and nonjudgmental compassion.

Condoms play a crucial and central role in the prevention of HIV and other sexually transmitted diseases. Male and female condoms effectively reduce the transmission of HIV, besides reducing other sexually transmitted diseases. In HIV epidemic settings, condom use has been found to significantly reduce rates of HIV, with an estimate that condom use might have prevented about 50 million new HIV cases since the HIV epidemic. Education should include its storage and proper use, how to minimize condom failures, the use of double condoms and water based lubricants especially for anal sex.

Despite the 2010 Catholic Church historic shift on its ban on condoms—that condom use can be morally justified, that it is acceptable to use a prophylactic when the sole intention is "to reduce the risk of infection" from AIDS, a first step to a more humane sexuality—the local church hierarchy continues to refuse to grant its blessing to condom use in the setting of HIV prevention.

But with condoms the bigger problem is not the church, but rather, the cultural aversion to it, and to some degree, the stigma associated with its use. Education and easier availability can help in the effort to make the condom commonplace. "Better alive, with condom use; rather than sick or dead, without."

Although its practice is frequently assumed to be confined to the gay male population, anal intercourse appears to be more popular than possibly expected among heterosexual couples under 45, according to a Center for Disease Control and Prevention (CDC) report.

The report, titled "Sexual Behavior, Sexual Attraction and Sexual Identity in the United States," which reportedly polled thousands of people between the ages of 15 and 44 from 2006 through 2008, found that 44 percent of straight men and 36 percent of straight women admitted to having had anal sex at least once in their lives. In another poll, 40% of women 20-24 years of age had experienced receptive anal intercourse.

Condom use during heterosexual anal intercourse is lower than condom used during anal sex among MSM. This is compounded by the belief that while 96 percent of teen girls believe they can get HIV from vaginal intercourse, 20% did not think they can get it through anal intercourse.

Having a smaller anus and rectum, women are also at greater risks for anal fissures, and at greater risks for anal trauma than MSM.

Despite the increasing popularity of male-female anal intercourse, probably pornography-boosted, anal sex continues to be a tabooed subject in the physician's Q&A of usual concerns, or at best, invariably skimmed over. When it comes to female anal sexuality: "Doctors don't ask, patients don't tell, and educators gloss over." And for women in anal receptive intercourse, this spells risk for HIV, and also, anal cancer. (8)

Fear, denial, stigma and discrimination keep many away from the usual clinic setting of testing. There are many who would not want their test results disclosed in a clinic.

In a TV ad for HIV/AIDS awareness trying to draw out the public to submit for HIV testing, Dr. Garin's crowned her invocation with "Ang DOH ang bahala sa inyo!" The DOH will take responsibility for you — a typical "bahala na" political promise you hear from politicians.

In a country where the masa population venerates their celebrities and embraces as "truth" every delivered message on shampoos, soap, and noodles, celebrities and icons of the gay community can greatly help in delivering the urgency for testing of populations at risk, together with messages of awareness, prevention, safe sex practices.

After more than three decades, the stigma associated with HIV/AIDS has not abated. In a country that is 80 percent Catholic, the church's uncompromising position (a queer position for an institution likewise stigmatized for its homosexual population and plagued by a flood of sexual molestation charges)
against gays and their sexual practices contributes no small amount to the stigma and shame people with HIV feel.

But while the church rants and raves against homosexuals, the Philippines is also considered one of the most gay-tolerant and gay-friendly of countries, offshoot of the LGTB liberation and revolution of the past two decades, and the present ubiquity of of gays and cross-dressers on radio and television.

Despite the seeming gay-tolerance or gay-friendliness, discrimination against LGBTs is well and alive in its many forms: sexual, physical or verbal violence, discrimination in school, workplace, and many public venues, and even in health care settings.

For the LGBT who tests HIV positive, the stigma is inordinately increased with the infection linked to risk behaviors, deviant sex practices, irresponsibility, drug use, prostitution, promiscuity, together with the myths and misinformation of contagiousness.

Rather than suffer stigma and discrimination, many choose to withdraw into isolation without the benefits of treatment, resigning themselves to the certainty of progressive illness.

A home testing kit, which has become available in many countries, allows people access to testing in the privacy of home. Those who test positive might have to contend with denial, depression, hopelessness, and suicidal ideations. Fast access to support and counseling should be available, as well as 24-hour hot lines manned by trained counselors.

In the Philippines, where mental health is a neglected field of health care, PLHIV will likely suffer absence of psychological support. Most HIV-infected patients will suffer through a psychological spectrum of stigma, discrimination, social isolation, depression, hopelessness, helplessness, and suicidal ideations. In many studies, suicide rates among HIV-infected patients are consistently higher than in the general population. HIV care should address the suicide risk in PLHIV and provide mental health screening and access to counseling and pharmacological treatment.

There is now considerable science, replete with guidelines and protocols in the treatment of HIV disease and AIDS. While HIV is treatable with regimens available to rein it into chronicity, the cost will be prohibitive to many in this country.

A dollar estimate in 2014 puts the cost of HIV treatment in the U.S. at about $30,000 to $36,000 per year, with an estimated lifetime cost of $ 400,000 to $500,000, with the cost of treatment increasing as a patient gets sicker.

In the Philippines, 60% or P300 milion of the DOH's National HIV/STI Prevention Program budget of P500 million for 2015 is allotted for treatment. With 10,200 patients with HIV under the DOH's care, that divides into about P30,000 per patient (about $650) per year. With this budgetary constraints, I cannot imagine a DOH that can deliver quality care and treatment for PLHIV.

This concern is further underscored by Tricia Aquino's article: HIV Cases Reported 1984 - 2015 / PNoy gov't's inadequate program to combat HIV/AIDS hit amid worsening epidemic which reviews the many facets of the HIV problems and the daunting and ominous task for the DOH in combating the HIV problem.

There are about 10,200 PLHIV on retroviral therapy provided by the government every three months through 22 treatment hubs, drugs not commercially available locally, some forced to access them abroad "during times of shortages" which have occurred thrice, February and May 2014 and June 2015. Treatment compliance is most important, discontinuances and more than occasional missed doses provide the setting for viral resistance, with treatment likely to fail sooner than later. This is compounded by the fact that less effective regimens continue to be used "simply because it was what the government could afford"—again, certain to contribute to the nightmare of viral resistance and consequent treatment failures.

In a disease that requires daily compliance and uninterrupted treatment of expensive regimens, outcomes and prognosis will likely be determined by economic realities: Only the rich can afford and truly benefit from highly aggressive and expensive multidrug antiretroviral therapy, the prevention and management of opportunistic infections, pre- and post-exposure prophylaxis, and state-of-art clinical follow up and laboratory testing. The poor will be consigned to what the government, constrained by budget and unpredictable shortages, can dole out.

And, where pray tell are the 15,000 PLHIV who are not on record as receiving antiretroviral therapy? Perhaps, some could afford anonymity to privately access clinical evaluations and treatment. For the rest, it's a matter of time (five to ten years) and numbers (decreasing cell counts) before HIV disease becomes AIDS with its consequent opportunistic infections. And, to keep the numbers keepers in trepidation, how many of them continue to be sexually active?

Many will eventually come home to roost, to severely burden a health care system already unable to provide for the treatment concerns and needs of present day PLHIV. But while quality care will be unaffordable to many, nurses and health care assistants can be trained to provide an alternative to expensive hospitalizations through home care for the management for many of the disabling opportunistic infections, hospice care and end care.

Predictable Failures and Windows of Opportunities
In the 2012 WHO report on leading causes of death in the world, AIDS ranked 6th with 1.5 million deaths. In the same year there were 300 reported AIDS deaths in the Philippines. In a 2014 World Health Ranking of the top twenty causes of deaths in the Philippines, coronary heart disease ranked number 1 with 87,881 deaths and peptic ulcer disease ranked 20 with 6,234 deaths or 1.20% of total deaths.

In that context, HIV in the Philippines is far from becoming the epidemic it has become in other countries —and perhaps, that presents another window of opportunity. However, religious, political and social realities in the Philippines threaten to hinder a real comprehensive effort against HIV/AIDS disease. Treatment will suffer the economic realities of a third world country, the unavailability and unaffordability of standard aggressive and life-extending therapies for many. Mental health issues should be addressed with non-judgmental compassion. Education and prevention efforts will continue to be forefront and should urgently focus on the high risk populations and their high risk behaviors, outreach the population of HIV-diagnosed who have chosen to withdraw into anonymity.

HIV/AIDS is a disease of the younger populations, where death, once unfamiliar, has become common place. Education, condom use, and safe sex practices can drastically stem the rise of the HIV infected. And between infection and death, education and treatment will provide hope for a life lived much longer and with greater fulfillment than what was once not possible in the early years of the HIV epidemic.

Sadly, many in civil society will continue to wear blinders, comforted by the notion that they are far removed from the dangers of a scourge that they believe afflict only high risk populations, and confident and hopeful, for now, that government, despite the failures of the past, can stem the rising tide of the HIV threat.

by Godofredo U. Stuart Jr., M.D.                                                                                      September  2015

Additional Sources and Suggested Readings
Psychosocial predictors of high-risk sexual behavior among HIV-negative homosexual men. / Perkins DO, Leserman J, Murphy C, Evans DL. / AIDS Educ Prev. 1993 Summer;5(2):141-52.
"Gay statistics" in the Philippines by consensus / September 15, 2006 / Lagablab
Is the Philippines really Asia's most gay-friendly country? / Magda Mis / Source: Thomson Reuters Foundation - Fri, 16 May 2014 16:21 GMT
HIV Cases Reported 1984 - 2015 / PNoy gov't's inadequate program to combat HIV/AIDS hit amid worsening epidemic / Tricia Aquino, | July 26, 2015 9:22 AM
Anal Sex More Popular Than Possibly Expected Among Heterosexual Couples: Center for Disease Control and Prevention Report / HUFFPOST GAY VOICES
Women's Experiences of Pain During Anal Intercourse: A Survey of 2,002 Respondents / Ilana Rosen, SIECUS Program Research Intern /
Prevalence and Correlates of Heterosexual Anal and Oral Sex in Adolescents and Adults in the United States / Jami S. Leichliter1, Anjani Chandra3, Nicole Liddon1, Kevin A. Fenton2 and Sevgi O. Aral1 / The Journal of Infectious Diseases Volume 196, Issue 12Pp. 1852-1859.
Anal sex: An 'extraordinary taboo' / Melby, Todd / Contemporary Sexuality November 2007, Pg. 1 Vol. 41 No. 11
Exploring dynamics of anal sex among female sex workers in Andhra Pradesh / Saroj Tucker, Rama Krishna, Parimi Prabhakar, Swarup Panyam, and Pankaj Anand / Indian J Sex Transm Dis. 2012 Jan-Jun; 33(1): 9–15. / doi: 10.4103/0253-7184.93787
Age Differences among Female Sex Workers in the Philippines: Sexual Risk Negotiations and Perceived Manager Advice / Lianne A. Urada, 1 ,* Robert M. Malow, 2 Nina C. Santos, 3 and Donald E. Morisky / AIDS Res Treat. 2012; 2012: 812635. / . doi: 10.1155/2012/812635
Sexuality-based compartmental model of spread of HIV in the Philippines / Guido David* and Fenina Mae Gomez / Philippine Science Letters, VOL 7, NO1, 2014
Almost 700 HIV cases in PH highest since '84 / Rappler
Kwentong BeBot / Lived Experiences of Lesbians, Bisexual and Transgender Women in the Philippines / Rainbow Rights Project
The Cost of Treating HIV: One Man's Monthly Medical Bill / Adam Wenger | Published on December 16, 2014 / Healthline
HIV/AIDS: Stemming the Rising Tide / Lila Ramos Shahani ( | Updated April 20, 2015 / CONJUGATIONS PhilStar
Three-Fifths of Filipino Youth Believe They Are Immune to HIV/AIDS, Survey Finds / KHN Morning Briefing / KHN:Kaiser Health News

Also read:
The Comic Failure of Language in Sex Education
Predictable Failure of HIV Education in the Philippines
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