A growing threat

AT THE start of the new millennium, public health officials around the world were puzzled about the very low rate of Human Immunodeficiency virus (HIV) infection in the Philippines, despite the reported very low rate of condom use.

Without that first line of defense, experts could only guess at the reasons for the low infection rate.

From 1984 (when the first AIDS case was reported in the Philippines) to 2000, out of a population of 84 million, there were 1,450 people believed to be infected with HIV, the virus that causes acquired immunodeficiency syndrome (AIDS) — a condition in which the body’s immune system is attacked, weakened, and disabled by the virus, ultimately leading to death.

In recent years however, the health department has grappling with declaring an HIV infection epidemic in the country — especially in the sector it calls MSM, or men having sex with men.

Based on the official figures of the Department of Health’s National Epidemiology Center (NEC), about 7,031 people have been living with HIV between 1984 and June 2011.

The reported number of HIV positive cases has steadily increased every year — from 123 new cases in 2000, to 1,591 additional cases in 2010.

Last June alone, 178 new HIV cases were reported to the Philippine AIDS Registry (which is a collection of reports of laboratory-confirmed HIV tests from hospitals, clinics, and treatment centers).

Dr. Enrique A. Tayag, head of the NEC, said this figure was a 63% increase compared to the 109 new HIV cases reported during the same month last year.

“As much as 94% of the new HIV cases were males. The median age was 28 years old,” Mr. Tayag told reporters.

“A total of 83% of the new cases were males having sex with males,” he added.

Of the 178 HIV positive cases reported in June, Mr. Tayag said one was reported as an AIDS case — a single, 38-year-old male who acquired the infection through homosexual contact.

Through the years, Mr. Tayag said males have comprised 80% of the total infections through heterosexual, homosexual, and bisexual contact, with MSM triggering the bulk.

The health official noted that since 2007, homosexual and bisexual modes of infection surpassed heterosexual transmission — 181 cases as against 139; and from January to June 2011, it rose to 798 cases as against 175 cases.

Meanwhile, he said the most affected age group among males has become younger in recent years — from 45- to 49-years-old, to 20-29.

Mr. Tayag said nine out of 10 of the newly infected patients are single, and are mostly students and young professionals. This, he said, is a departure from the sectors that health experts call “most-at-risk populations” like freelance sex workers, drug users, and overseas Filipino workers (OFWs).

“More than a decade ago, statistics showed that most Filipinos with HIV or AIDS were either sex workers or OFWs,” Mr. Tayag said.

“Now, infected patients are getting younger and younger. Most are males, infected through sexual intercourse with the same sex,” he added.

But Mr. Tayag is the first to caution against discriminating against MSM after revealing the findings, saying: “The last thing that we want is to label HIV and AIDS as a ‘gay disease’.”

Crossover

If the feared epidemic among MSM ever crosses over to the public at large, public health consultant Dr. John V. Samonte can point to a few key factors that allowed it to happen.

“As the Philippines is a developing country with a less than ideal health care system, national HIV/AIDS policy is severely limited by budget constraints, and also by the public’s ingrained biases and unwillingness to see a doctor,” Mr. Samonte told BusinessWorld in an interview.

He said the reporting system for new HIV cases in the country is purely voluntary. Republic Act 8504 or the Philippine AIDS Prevention and Control Act of 1998 makes it absolutely clear that nobody can be forced to take an AIDS test against his will.

“Because of this it is safe to say that official government figures can only capture probably 50% of the actual number of people living with HIV,” the doctor said.

He said because of this unreliable data, the government is finding it hard to gauge its response to the HIV/ AIDS situation.

This is all the more problematic considering that the government has pledged to halt the spread of the disease by 2015, under its commitment to the United Nations (UN) Millennium Development Goals (MDGs).

In the 2010 Global AIDS Report released by the UN program on HIV-AIDS (UNAIDS), the Philippines was one of the seven nations in the world which reported new HIV infections of over 25% between 2001 and 2009, while other countries have either stabilized or shown significant declines in the rate of new cases.

The same report showed that among all countries in Asia, only the Philippines and Bangladesh were reporting increases in HIV cases while other were reporting a stable or decreasing number of new cases.

“While HIV infection rates have dropped globally over the last decade, recent predictions warn that the Philippines will see a five-fold increase in infections before President [Benigno S. C.] Aquino finishes his term,” Mr. Samonte said.

Dodging the bullet

Venereologist (a specialist in venereal diseases) Joselito Y. Chan said that while the number of new HIV cases is increasing, the Philippines could still be considered lucky that it has escaped the worst of the AIDS crisis.

“Although low condom use, an active sex industry, and widespread lack of knowledge about HIV have long warned [of] a dangerous outbreak, official figures put the number of persons at a little over 7,000 in a country with [an] over-90 million population,” Mr. Chan said in an interview.

“While official numbers almost certainly reflect under-reporting, the situation in the country has not yet reached the dangerous levels seen a decade ago in Thailand, or Cambodia, or, more recently, in Indonesia,” he added.

However, he said that given the general lack of knowledge and stigmatization of HIV, the official figures probably hide a far more serious situation.

“While we have RA 8504 which provides an excellent framework for containing a possible AIDS outbreak and reducing future risk, the problem though, has been the implementation of the law. For starters, few high schools and colleges offer any education on HIV, while public officials often suffer from the same lack of knowledge as the wider population,” Mr. Chan said.

For example, he cited that the prevailing attitude toward condom use is especially worrying. “It seems that the official policy toward condom use is outright hostility,” Mr. Chan said.

He cited a 2004 report by the group Human Rights Watch that documented numerous abuses, including alleged police confiscation of condoms from sex workers, and public crackdowns on condom distribution and promotion.

“On top of this, there is the politically powerful Catholic Church which strongly lobbies against condoms,” Mr. Chan said. “Even [boxer and Saranggani congressman] Manny Pacquiao speaks for men when he calls condom use ‘sinful’,” he added.

“Terrible health-seeking behavior”

Dr. Romeo Ruiz-Santos, a specialist in infectious disease medicine, said that at the rate new HIV positive cases are being spotted in the country, the Philippine government could be spending P1 billion annually by 2015, just to buy the anti-retroviral drugs needed to treat Filipinos with HIV.

Mr. Ruiz-Santos, however, noted that Filipinos in general have “terrible health-seeking behavior.”

He estimates that there are over 100 new cases of HIV diagnosed every month, but enrollment rates at treatment hubs like the Philippine General Hospital and the San Lazaro Hospital average only 20 to 22 a month.

“That is about a hundred cases not enrolling for treatment, although it is free,” he said. “By the time they seek treatment, probably five to eight years down the line, it might be too late to help.”

Based on the most recent Integrated HIV Behavioral and Serological Surveillance conduced by UNAIDS, less than half of infected freelance sex workers went to a doctor, and only a third of the MSMs sought treatment when they experienced symptoms. “Basically, the majority self-medicated or let it pass,” he said.

This is particularly alarming, Mr. Ruiz-Santos said, since these untreated infected people greatly increase the possibility of spreading the virus even more.

“So while we have laws to mitigate a possible AIDS crisis, the government has yet to define its AIDS prevention strategy, and set standards of quality,” the doctor said.

“Anti-AIDS programs remain unfunded and have not been able to keep up with the increasing pace of HIV transmission,” he added.

Mr. Ruiz-Santos said a comprehensive national public health strategy should be put in place to combat HIV/AIDS.

“Thailand and Cambodia, after implementing national public health campaigns, saw infection rates fall steadily year after year. A similar effort in mass education, national condom promotion, and readily available testing and treatment promises comparable results for the Philippines,” he said.

Gay rights advocate Eric Romualdez said there should be a more aggressive approach to reach out to MSM, particularly in bars and clubs where they usually congregate.

And with the limited resources, the government can tap the Internet and social media to send HIV/AIDS prevention messages.

“Preventive messages should be tailored to the age range within the MSM subgroup. For example, a young professional might not be able to relate to a message meant for college students, or a straight-acting gay guy might react differently to a message intended for a transgender,” Mr. Romualdez said in a telephone interview.

He also laments the prevailing stigma attached to HIV/AIDS. “People do not want to talk about it. It is still not accepted in our society. Filipinos do not want to open up about sex. Many still think that if you talk about HIV/AIDS, you are gay, or you are promiscuous,” he said.

“And then there are those who think that if we do not talk about HIV/AIDS, it will just magically go away. Unless we get over our denial, we cannot expect progress in our efforts to beat the virus,” he added.

Rep. Arnel Ty, party list representative of the LPG Marketers’ Association (LPG-MA), has been pushing for highly aggressive measures to suppress HIV and improve the welfare of the growing number of Filipinos living with the virus.

“At the rate new infections are soaring, we are easily looking at 200 new cases monthly for the rest of the year, 330 new cases monthly by 2012, and 550 new cases monthly by 2013,” Mr. Ty said in a statement.

Mr. Ty recently filed a bill seeking to add more teeth to RA 8504, including P400 million in fresh funding to fight the disease.

“The 13-year-old law has been rendered outmoded by the changing times and the rapid expansion of the disease that is predominantly spread through risky sexual contact,” the sectoral representative said.

There remains much to be done to build a comprehensive approach against HIV/AIDS that health experts prescribe for the Philippines.

Still with stakeholders — from the government, the private sector, NGOs, multilateral agencies, and the public in general — in agreement to set aside differences in order to work together, then the road to greater understanding of HIV/AIDS is less difficult, but a steady uphill trudge nonetheless. –JEFFREY O. VALISNO, Sub-Editor