Special Report: Promises broken; HIV advances (When drugs and Aids collide)

Search for people at risk crucial amid ‘high-level HIV epidemic’ in Cebu

IN 2011, the Philippines adopted the “Asean Declaration of Commitment: Getting to Zero New HIV Infections, Zero Discrimination, Zero Aids-Related Deaths.”

This, after the Association of Southeast Asian Nations’ (Asean) first regional report on the human immunodeficiency virus (HIV) revealed that HIV affected more than 1.5 million people in the 10-member region in 2010.

HIV is the virus that causes Acquired Immunodeficiency Syndrome (Aids).

The declaration aimed to accelerate progress in achieving the United Nations Millennium Development Goal (MDG) 6 of halting by 2015 and reversing the spread of HIV.

Signatories to the declaration pledged, among others, to reduce HIV transmission among injecting drug users (IDUs) by 50 percent by 2015, and to implement and expand risk and harm reduction programs for people who use drugs.

But in the Philippines, instead of halving, the number of HIV cases among IDUs has surged.
In the first nine months of 2015 alone, the HIV/Aids and ART (Antiretroviral Therapy) Registry of the Philippines already recorded 203 new cases of people infected with HIV through intravenous drug use, up 38 percent from 147 cases in the 12 months of 2010.

Of the 1,271 cases of HIV acquired through injecting drug use in the country since 1984, more than 99 percent were reported from January 2010 to September 2015.

As for expanding harm reduction programs, the Department of Health’s (DOH) program to provide community-based comprehensive services for people who inject drugs in Barangay Kamagayan, Cebu City has suffered a blow after Sen. Vicente Sotto III questioned the legality of the component involving the distribution of clean needles and syringes to drug users for violating Republic Act 9165 or the Comprehensive Dangerous Drugs Act of 2002’s prohibition on possessing drug paraphernalia.
So for now, stakeholders will just have to focus on other services to injecting drug users and other at-risk populations to prevent the spread of the virus.

Great overlap

Whatever the issues with strategy, one thing won’t change: the need to find the people at risk.

And soon, as the 2013 Integrated HIV Behavioral and Serologic Surveillance (IHBSS) of the DOH noted a “high-level HIV epidemic among IDUs in Cebu Province and expanding epidemics among males who have sex with males (MSM) and freelance female sex workers.”

The surveillance showed that 51.5 percent of male IDUs and 32.4 percent of female IDUs in Cebu City had HIV. In Mandaue City, 35 percent of male IDUs had HIV.

In Cebu City, 7.7 percent of MSM and 9.8 percent of freelance female sex workers (FFSW) had HIV, the report revealed.

Cebu City was singled out as having the greatest overlap in risk behaviors in the country amid the interconnectedness of its at-risk populations, raising the risks of infection.

“Thirty-one percent of female IDUs practice sex work and 12 percent of FFSWs inject drugs; 11 percent of male IDUs have recently had sex with another male,” the IBHSS said.

HIV is transmitted through sexual contact, needle sharing among injecting drug users, transfusion of infected blood products, and mother-to-child transmission.

Male-to-male sex

Dr. Ilya Tac-an, head of the Cebu City Health Department’s Social Hygiene Clinic, confirmed the high-risk interaction between MSMs and IDUs.

“Some IDUs are paid to have sex with an MSM,” she told Sun.Star Cebu.

Male-to-male sex was not unusual behavior even by heterosexual men, she said.

“In the early 2000s, a study of the clients of female sex workers (meaning males were surveyed) found that 50 percent had tried having sex with another man. Sometimes, they just experimented, or some were paid by males to have sex with them. It’s common. They say, ‘Magpabayad sa bayot (Get paid by a homosexual)’ so they have money to pay for disco.”

As for MSMs injecting drugs, this is rare.

The 2013 IHBSS shows that while many MSMs were drug users—22 percent of MSMs in Cebu City had used drugs in the past 12 months—only two percent of MSMs in the city had injected drugs in the last 12 months.

In Mandaue City, only one percent of MSMs had injected drugs, but 40 percent had used drugs over the same period.

The findings point to the urgency of reaching these key populations for HIV education, diagnosis and treatment.

Services

Jerson See, executive director of CebuPlus Association Inc., said there is a P49-million Global Fund grant that CebuPlus is now handling with the charity organization Save the Children as the primary recipient.

The project covers Cebu, Lapu-Lapu, Talisay, Mandaue, Toledo and Danao cities.

CebuPlus, as sub-recipient, targets to reach 9,161 MSMs (80 percent of the estimated MSM population in these areas), 1,702 transgender people and 4,838 IDUs to, among other things, “give them education, condoms, encourage them to get an HIV test and know their status,” See said.

The target is the most at risk children and youth, meaning young sex workers, young MSMs and young IDUs, he said.

The program, called “Strengthening the HIV/Aids Prevention, Community Linkages and Response in the Philippines,” started in October 2015 and will end in December 2017.

The Global Fund is a Geneva-based financing institution that works to accelerate the end of Aids, malaria and tuberculosis as epidemics.

CebuPlus

CebuPlus operates from the Cebu City Health Department (CHD) building where the Cebu City Government has given the association a space and electricity for free.

Founded in 2009 as a support group for people living with HIV, CebuPlus brought in HIV negative people as well in 2011 after the group saw the need for an HIV prevention program for MSMs and transgender people, which required more manpower.

“It principally operates in Cebu Province, but the vision for operation is the Visayas,” he told Sun.Star Cebu. “We do prevention activities, treatment care and support. And since 2010, we have been providing temporary shelter for people living with HIV who have been neglected by their families or who come to Cebu for treatment and need a place to stay. This is in partnership with the Daughters of Charity of the Asilo de la Milagrosa.”

“We do psycho-social counseling and give access to medical treatment,” he said.

The Cebu Wellness Lounge run by CebuPlus at the CHD building is a male sexual health clinic that offers free testing for HIV, syphilis and hepatitis B, he said.

“If the MSM complains of a sexually transmitted infection, we refer him to the City Health (Social Hygiene) Clinic. All our staff are DOH-trained counselors,” he said.

CebuPlus was recently subcontracted to run the Mandaue Wellness Center as well. This center is focused more on MSMs and transgender people, rather than IDUs, he said.

Identification

Dr. Tac-an said the CHD is working to better identify HIV cases so it can intervene early.

“A lot of doctors don’t diagnose that these people died of Aids. The common causes of death are tuberculosis (TB) and pneumonia,” she said.

The last stage of HIV is Aids, when opportunistic infections and diseases, like TB and pneumonia, develop as immune-suppression deepens in the HIV infected.

But with the International Classification of Diseases (ICD), most doctors are now familiar with HIV. “If the patients keep coming back, and they are still young, they will already ask to have the patient tested for HIV. They have the suspicion already, unlike before,” she said.

The ICD is a standard diagnostic tool for epidemiology and health management to monitor the incidence of diseases and other health problems in countries and populations, said the World Health Organization (WHO).

Consenting minor

To help identify potential HIV positive people, Sen. Miriam Defensor-Santiago last June filed amendments to the Philippine Aids Prevention and Control Act of 1998 to allow minors aged 15 to 17 to consent to HIV testing even without written consent from their parents, and to receive the results of the HIV test themselves.

Santiago said the Philippine National Aids Council (PNAC) had cited this age restriction as the reason less than one percent of males under 18 at risk of contracting HIV had ever been tested.

She proposed requiring only the minor’s consent if the minor was living independently; was pregnant, already a parent, or had suffered a miscarriage; had no contact with parents or guardians; had a clinical condition that suggested HIV infection; if knowledge of HIV status was in his best interest, or if the minor was part of the key at-risk populations determined by the PNAC.

Nearly a third of persons diagnosed with HIV in Central Visayas from 1984 to September 2015 were from 15 to 24 years old.

Treatment

Dr. Tac-an said that in the past, all HIV patients were referred to the Vicente Sotto Memorial Medical Center (VSMMC) for treatment and the CHD was “supposed to focus on prevention only.”
But today, those who need treatment can go to the CHD as well, as it is now a satellite treatment hub. Antiretroviral drugs are provided by the Department of Health for free.

“Lapu-Lapu and Mandaue are not treatment hubs, but the DOH plans later that social hygiene clinics will become treatment hubs too,” she said.

DOH 7 senior health program officer Boel Espinas said treatment hubs in Central Visayas like the Cebu City Social Hygiene Clinic and the VSMMC (both in Cebu City) and the Gov. Celestino Gallares Memorial Hospital (in Tagbilaran City, Bohol) also provide free HIV testing.

He said testing is also available in the social hygiene clinics of Lapu-Lapu, Mandaue, Danao, Talisay, Toledo and Naga cities; in the Minglanilla Rural Health Unit I; and in the Negros Oriental Provincial Hospital (NOPH) for free.

Some private hospitals and labs like Chong Hua Hospital, Perpetual Succour Hospital, Cebu Doctors’ University Hospital and Hi-Precision Diagnostics also offer testing, “but for a fee,” he said.

Espinas said the DOH is now working for NOPH and Silliman University Medical Center Foundation Inc., both in Dumaguete City, Negros Oriental, to become satellite treatment hubs as well.

For now, those living with HIV in provinces without treatment hubs just get, depending on the assessment of their condition, three to six months’ worth of medication at a time, from treatment hubs in other provinces in the region.

Road to 2030

Last July, the Joint United Nations Program on HIV/Aids (UNAIDS) said the targets of MDG 6—halting and reversing the spread of HIV—had been met because “between 2000 and 2014, new HIV infections dropped from 3.1 million to two million, a reduction of 35 percent.”

But in the Philippines, the infection is only gaining ground, as new HIV infections skyrocketed from 123 to 6,011, an almost 50-fold increase, over the same period.

Other pledges

The Philippines has also failed to meet two other pledges in the 2011 Asean Declaration: reducing sexual transmission of HIV by 50 percent by 2015, and providing antiretroviral therapy (ART) to 80 percent of people living with HIV who are eligible for treatment.

New HIV cases among MSMs alone more than quadrupled to 4,864 in the first nine months of this year, from 1,147 cases in the whole of 2010; and new cases acquired through heterosexual sex tripled to 821 from 274 over the same period.

In terms of treatment, the DOH’s Epidemiology Bureau said only 41 percent of the 28,428 HIV cases nationwide were on ART as of September 2015. ART delays the replication of the virus so patients can stay healthy longer. Lowering the amount of the virus in the blood lowers the risk of passing it to others.
In 2013, the World Health Organization recommended the start of ART when a person’s white blood cells dropped to a certain threshold. But last September, it announced new guidelines, saying anyone with HIV should begin ART as soon after diagnosis as possible. It also recommended preventive antiretroviral treatment for people at “substantial” risk of HIV.

The new WHO policies are aimed at averting more than 21 million deaths and 28 million new infections globally by 2030, the year the UNAIDS targets to end the Aids epidemic.

Review needed

Amid the global downtrend in the Aids epidemic, the acceleration in new HIV infections in the Philippines sticks out as an anomaly.

The United Nations Development Program in the Philippines said the social stigma associated with HIV is one reason HIV testing and detection are low.

The stigma attached to some risk behaviors for HIV, like drug use, compounds the problem.
In June 2011, the Philippines was among 192 countries that “committed to reviewing legislation and creating enabling legal and social environments” that support effective HIV responses, according to the 2012 policy brief “Unsafe injecting drug use, a growing source of HIV transmission in the Philippines: Implications to policy.”

Citing the Philippines as among the countries that “criminalize some aspects of proven harm reduction services for injecting drug users,” particularly the possession of syringes and needles, the brief recommended reforms in drug policies to attune them to present realities, like the increasing incidence of HIV cases in the country, the large number of drug dependents without access to treatment, and the inadequacy of prisons to handle drug-related cases.

Jails run by the Bureau of Jail Management and Penology had a 398 percent congestion rate in September 2015, as 93,961 inmates lived in quarters meant for just 18,881 inmates.

The uproar over the syringe and needle distribution by the Cebu City Health Department also seems incongruous given that Section 12 of RA 9165 penalizes the possession of paraphernalia intended for injecting or introducing dangerous drugs into the body, unless one is a medical practitioner or otherwise authorized to possess such paraphernalia—putting the CHD in the cross-hairs of law enforcers for distributing such to unauthorized people.

And yet, pharmacies in the city freely dispense the same syringes and needles to anyone who wants to buy them.

Access

Public discussion is needed on the issue of HIV/Aids and drugs.

In the meantime, the virus is claiming dreams and lives.

“The problem is many are asymptomatic. If wa silay gibati, dili sila magpakita sa doctor. Inig abot sa-amo, TB and pneumonia na,” Dr. Tac-an said. (If they don’t feel unwell, they don’t see the doctor. When they come to us, they have TB and pneumonia already.)

“The time between infection with the virus and the onset of symptoms of Aids (the incubation period) ranges from a few months to 10 years or more. Infected persons can spread the virus during the incubation period,” said the Arkansas Department of Health.

In Cebu City, 97 percent of the 1,875 cases of HIV positive individuals recorded from 1984 to September 2015 were asymptomatic at the time of reporting, according to the DOH 7.

Crucial

This underscores the need to make testing and treatment venues more accessible to the public. Above all, a sustained information campaign on risk behaviors and the need for tests is crucial to end the HIV epidemic.

This report comes too late, though, for a young professional who was rushed to a Cebu City hospital last October for what he thought was just a severe headache. He was shocked to learn that he had HIV and that he was already in the final stage, Aids.

Missing targets is not just about losing face before the international community. It’s about losing people we know and love.

(Last of three parts)