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.
The Gay and Bisexual Community
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)
Other High Risk Venues
HIV/AIDS AND SEX EDUCATION
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.
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."
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.
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.
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.
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.
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
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|
Sources and Suggested Readings
The Comic Failure of Language in Sex Education
Predictable Failure of HIV Education in the Philippines