For more than a decade and a half, I worked in the HIV/AIDS trenches, some of those years before the advent of antiretroviral therapy, when all we could do was guide patients through their illness, ministering with fringe amd exotic treatments, inventing hope while suffering through existential questions (Will I die? How much longer do i I have? Can i buy a car? Should I quit school?), prescribing medications I suspected were being hoarded, intended for suicide concotions, watching hope whittling away, slowly being consumed and ravaged by opportunistic infections, while I grappled with the frequent and all too foreseeable deaths. Since then, HIV prevention efforts and highly effective treatments along with PrEP have reversed its dreadful course. In many countries HIV has become a chronic manageable disease, perhaps, in some forseeable future, curable.

Worldwide, there has been a 39% decline in new infections since 2010, and a 60% decline since the 1995 peak. But in the Philippines, rather than a decline, there continues an epidemic upswings in number of new infections — the fastest growing HIV epidemic in the western Pacific, with 174% increase in HIV incidence between 2010 and 2017. In  August 2018 alone, 1047 new cases were reported. UNAIDS estiimates only 67% of people living with HIV known their status,  55% have CD4 count lower than 200 cells/μL at the time of diagnosis, 32% are on antiretroviral therapy (ART), and [only] 82% remain on ART 12 months after treatment initiation. Men having sex with men are disproportionately affected, accounting for 84% of new infections. (7)

In May 2024, DOH Health chief Teodoro Herbosa reported 55 new HIV cases per day, totaling 185,000, and tagged it with a dire prediction of cases breachimg 500,000 in 6 years: Numbers that betray an abject failure of government, the health care system, and education.

Alas, if the dire prediction of half a million infection happens, the Philippine healthcare system will be brought to its knees. Longevity and survival will be an affordable luxury only for those with deep pockets.

In the Philippines, treatment is not the key; rather, it is prevention.
While HIV treatment may be the key to the global effort to end AIDS as a public health threat, in the Philippines the key is prevention. Not post-infection antiretroviral therapy, but prevention of new infections. And the backbone of prevention is education, which encompasses real matter-of-fact sex education, which advocates safe sex practices, condom use, and HIV testing, and, yes, PrEP (pre-exposure prophylaxis). Seemingly ABCs for HIV prevention, this is the echoed admonition and reminder: Hindi mangyayari. Ang lakas ng simbahan. (It won't happen. The church is too strong.) All too prurient and unacceptable to the church, who wages its holy crusade against secular solutions for anything that pertains to sex, who will predictably chastise and preach with cathechismal passion on antiquated alternatives of chastity and abstinence, insisting that sex is a unitive and procreative activity only sanctioned in sacramental marriage.

Sex is that primeval, primordial, animalistic urge and incomparably pleasurable activity, nonpareil, that has further evolved into what it is today, fueled by a culture oozing with raging hormones, pheromones, and testosterone, in a graphic backdrop of sexually tittilating imagery and permissiveness. Abstinence, celibacy, and sacramental sex? No chance. Nada. Zilcho. Zero.

The church lexicon does not provide and will not provide for effectual sex education. HIV prevention and education requires secular teaching of an open-minded, explicit, and graphic sex education.

Sex education
The Philippines suffer from low HIV literacy and awareness. In a 2021 survey, only 76% of young Filipinos aged 15-24 have heard of HIV and AIDS, a 19% drop from 1994.  Only 19% of young Filipinos have comprehensive awareness of HIV. For many, it's peer-derived, social media or internet derived information riddled with misconceptions.

The standard sex education module which is being taught in schools, alas, is comically inadequate, puritanical to a fault. HIV prevention calls for an open-minded, explicit, and graphic sex education. For an illness that happens in an ecosystem of men-having-sex-with-men, sex tourism, male-and-female prostitution, IV drug using culture, transactional sex, a sanitized, pasteurized, church-cleansed language of sex education will not cut it. If your think it best to use "ari" for sexual organ, "bird" for penis, "flower" for vagina, or if you think using the word "utong" for nipple is vulgar or "bastos", then best you stop right here, click off, and go to Netflix for a fairy tale flick.

Anal sex
Sex education for HIV prevention requires use of a language that should unabashedly address practices of the gay and silahis culture. Anal sex is the riskiest sexual activity for HIV transmission, with risk esimated at 138 per 10,000 sex acts, or for an HIV-negative receptive partner, a risk of 1 in 72 of getting HIV for every receptive anal activity. Anal sex and condom use is a partnered issue in MWM sex education. Receptive anal sex (bottoming) is 13 times riskier for getting HIV than insertive anal sex (topping). The risk with receptive anal sex is up to 18 times higher than from receptive vaginal sex.

A bird-and-the-bees kind of sex education for the general public—using ari or bird or flower—is comic and absurd. For the HIV risk populations, beyond farcical and harebrained. But how to teach and warn of the inherent dangers of anal sex in a country with such diversity of dialect? Is puwit too vulgar to use? Is kantot too filthy a word? The two Tagalog words translate into "anal sex". But those Tagalog words will not suffice in other provinces and regions. For the gay community, using "anal sex" will be limp teaching words. The gay dictionary provides a diverse regional vernacular for anal sex:  Barukbukan, binarok sa puwet, pinuwet, gerger, ginerger, ratrat, niratrat, itot, initot.

The mechanics of increased transmission of HIV with anal sex should be translated into culturally comprehensible language, especially the trauma involved with anal sex, anal tears and abrasions, local inflammation within the rectal mucosa, which will facilitate transmission of HIV from the infected ejaculate.

Issues of multiple sex partners and transactional sex should be addressed. Among urban and rural gays interviewed, partner-counts varied from five to 30. There is also an increasing younger generation of 14-year olds sexually engaged in active transactional gays.

Condoms
While condom use has proven to be highly effective in reducing the incidence of HIV tranamission via anal sex, its use continues to suffer from its pleasure-reducing quality. Imagined or real, it is a simple, readily avaialbe, on-demand, risk-reducing protection. Condom use should be pushed for its life-preserving use, using comprehensible analogies of motorcycle helmets, seat-belts, sacrificing some degree of diminished pleasure for safe sex and post-rectal-coital peace of mind. The church should not further burder its pleasure-reducing attribute with sin and guilt.

Studies have shown that male and female condoms are impermeable to micro-organisms as small as viruses. Both male and female condoms have been demonstrated to be highly effective in preventing HIV. When used correctly and consistently, male condoms are estimated to be 90% effective in reducing HIV transmission, and female condoms 94% effective when used correctly with every intercourse. The advice should also include for heterosexual anal sex. For those who practice anal sex, lubricants are recommended to prevent the condoms from slipping or tearing. Condoms must be used consistently and correctly to achieve the high levels of protection against HIV discussed here. Besides HIV, condom use also significantly reduced transmission of sexually transmitted diseases, including gonorrhea, chlamydia, and syphilis, diseases more easily transmitted than HIV. To boot, male and female condoms have 87% and 95% efficacy in preventing pregnancy, respectively. In females, regular condom use—75% of encounters—reduced risk of genital herpes by half, with also significant reduction in the transmission of HPC (human papilloma virus), which may be associated with certain types of cervical, anal, and penile cancer. When condoms fail to protect individuals against STI/HIV transmission, it is usually a result of incorrect or inconsistent use, rather than product failure. (3) A detailed-101 on condom use is an essential part of HIV preventive education, which should touch on issues of proper use, condom reuse, storage, expired rubbers, wrong size, and need of lubrication.

The Medical Economics of Condom Use: Male condom use can reduce HIV transmission by 90%. Anal transmission risk is 138 per 10,000 sex acts. At  3-4 condoms for a P100,  and 10,000 condomed sex acts and 138 prevented new cases, it's an estimated P1800-2000 per prevented case. Ergo, condoms should be pushed as de riguer for anal activity. HIV/STD clinics should provide them for free from condom jars, and made avaialbe free or discounted in all LGBTQ hangouts, gay bars and activity venues. Kudos to DOH-CAR, LoveYourself Inc, Safe Spaces and other private organizations who are pushing for and dispensing free condoms in toilets, clinics, offices, and non-judgemental nooks and crannies.

HIV Testing
HIV testing is essential in HIV prevention efforts. Among the gay individuals I have interviewed, none have had HIV testing, for fear of knowing and stigmatization. Education should hammer the importance of knowing one's HIV status. How laboratory monitoring can guide a positive individual through a usually predictable course of disease, to warn of opportunistic infections, when to start treatment, rather than wait for the HIV to mutate into AIDS, ravaging with opportunistic infections in the milieu of devastated immune system. That even if positive, infected individuals are usually symptom free for 6 to 8 years or longer, during which time untested positive individuals indulging in unprotected sex can unknowingly spread the virus.

Pre-exposure prophylaxis (PrEP)
PrEP (emtricitabine-tenofovir disoproxil fumarate) is a medicine that can be taken by adults or adolescents without HIV before high-risk sex and IV drug use. When taken as prescribed it can reduce the risk of getting HIV from sex by 99% and injection drug use by at least 74%. It is available in three forms: oral pills - Truvada and Descovy; long-acting injectable - Apretude, a long acting injectable PrEP, administered once every two months; and the vaginal ring - a monthly vaginal topical rings with slow-release antiretroviral. PrEP is highly effective in preventing HIV transmission. In a 2021 study, among key HIV prevention indicators, the greatest improvement was in people taking PrEP.  A study on PrEP use in the general MSM population could prevent a substantial number of HIV infections; but, alas, expensive (P1500-2500/30 tablets) and of limited availability (Metro Manila). Despite its addition to the treatment armamentarium, the uptick of new HIV cases continue. And worse, besides cost and limited availability, its promise as a game-changer has been threatened by the discovery of counterfeit tablets.

That scary 18%
According to UNAIDS estiimates . . . [only] 82% remain on ART 12 months after treatment initiation. That 18% of HIV positive patients who stopped ARV treatment should scare the bejesus out of us. The cessation of antiretroviral treatment predictably results in viral count spikes and mutations. This is a scary number of infected individuals, unlikely to adopt a celibate social life, that will predictably contribute a significant number in the HIV rising epidemic count! What government efforts are in play, if any? What tracking efforts are done, if any?

Worse, in May 2024, DOH Health chief Teodoro Herbosa reported 55 new HIV cases per day, totaling 185,000, and the dire prediction of cases breachimg 500,000 in 6 years. In that dreadful scenario, I have doubts that our healthcare system can provide quality care and drug therapy for the HIV-infected population.

Sex Education and the Meddlesome Church
Sex education can be a powerful instrument in preventing and curtailing the spread of HIV. It should not be encumbered by the Church. The church, most likely, more than any other institution, through centuries of colonial rule and indoctrination, contributed most to the inculcation of vulgarity to the vernacular sex words and its removal from mainstream use, words essential for sex education. The colonial indoctrination has insiduously sanitization of our language that a word like "utong" is considered "bastos", even in the boondocks of Tiaong.

The church can not be a guiding light for sex education and HIV prevention. Its declarations regarding homosexuality, condom use, same sex relationships and unions have been conflicted, confused, and hypocritical, met with criticism and controversy, and creating doctrinal dilemmas for many. It considers homosexual acts as "intrinsically disordered" "acts of depravity", contrary to natural law—severe admonitions from a holy institution that harbor estimates of more than 50% or 4 out of  5 Vatican priests as gay (5), where HIV infections and AID-related deaths—more than 300 as far back as 2001—have been reported. With ecclesiastical blinders, the United States Conference of Catholic Bishops continue to preach against contraceptive practices, advocating for "responsible parenthood and methods of natural family planning". Even coitus interruptus (withdrawal) is forbidden (!) because it does not respects the unitive and procreative meaning of sex within marriage.

The blame
The Church has repeatedly blocked government initiatives, including a proposed law in parliament that would have made it easier for the public to access state-funded contraceptives. The Church also fought a reproductive health law passed in December 2012 that would have expanded sex education in public schools and made contraceptives available for free at public health clinics. The church continues to campaign against LGBTQ rights worldwide, advocating for chastity and celibacy, or sex in keeping with its procreative ends.

While I ponder the statistics and predictions on HIV morbidity and deaths, I am reminded: Hindi mangyayari. Ang lakas ng simbahan. (It won't happen. The church is too strong.)

How much suffering and how may deaths could have been avoided with unexpurgated sex education and if condom use was pushed early on in the epidemic? Is the church solely responsible? Perhaps not. For there is the government that kowtows to the pontifications and demands of the church that insists on antiquated, anachronistic, improbable solutions for modern-day secular concerns that cries for secular resolution. True sex education and HIV preventiion should be the unencumbered concern of government amd educators, out of reach of ecclesiatical tentacles. This epidemic demands for a true separation of church and state.

For HIV prevention, sex education is key: One that passionately advocates for condom use and safe sex practices, that expounds on anal sex, in a culturally sensitive and comprehensible language, and, when possible, taught by compassionate LGBTQs. Educators should be educated on HIV and AIDS, and the effective ways of communicating prevention. Mobile outreach programs should reach out to cities and towns heavily infected by HIV, to engage and coordinate with community gay groups for sex education programs, HIV testing and post-testing counseling, and PrEP use.

For  the infection, yes, treatment is key. For HIV prevention and the continuing upswing of new infections, education is key, focused on safe sex practices, condom use, and PrEP use. That will save lives. The church should not meddle in secular problems that require secular solutions. Instead, it should concern itself with saving souls, hearing confessionals and dispensing forgiveness for lives saved by "sinful" HIV prevention methods.

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