The City at the Heart of the Philippines’s HIV Epidemic

New infections in the country have skyrocketed, even as they’re declining worldwide. Cebu City, one of the hardest-hit areas, is struggling to control the drug use that’s spreading the virus.

CEBU CITY, PHILIPPINES—The dealer’s hands move quickly as he dispenses small vials from the waistband of his shorts, his front pockets bulging from the weight of coins and small bills. From his back pocket, he hands out syringes or collects them. Occasionally, he uses the t-shirt slung over his shoulder to wipe away the beads of sweat that made his goatee glisten.

The shanty where he works—a small room full to bursting with people—is home to one of Cebu’s many “shooting galleries,” a place where people gather to purchase and inject the narcotic pain reliever Nubain. At this particular gallery, a small glass capsule containing 1 mL goes for Php 150, or around $3. For individuals on a tighter budget, the dealer can squeeze out a single squirt for Php 20 ($0.50). Those who bring their own supply of the drug only have to pay a fee to use the shooting gallery, a charge of Php5-Php10 ($0.10 – $0.20).

An unused needle sells for another Php20 ($0.50), but few people who came through the shooting gallery chose to purchase one—the dealer also supplies free “service needles,” new and slightly used syringes on rotation that any customer can use. It’s common for groups of customers to split the cost of a vial of Nubain between them, and share a service needle as they use it. The Philippine Department of Health (DOH) says that the typical shooting gallery has three to five service needles on rotation at a time, each of which can be used four to six times before it gets too blunt. According to Genesis Samonte, the head of the department’s HIV surveillance unit, one shared needle can infect four to six people with HIV or hepatitis C.

Public-health experts say shooting galleries like this one are to blame for the high rate of HIV in Cebu City, one of the highest in a country that’s already struggling to combat the virus—even as new infections have declined worldwide, they’re on the rise in the Philippines. (In most other parts of the country, the primary means of transmission is sexual contact rather than drug use). In October, the DOH reported a total of 29,079 HIV infections in the country. More than 24,000 of those cases were detected in just the last five years. At this current rate, the DOH predicts that the number of HIV infections in the Philippines could reach 133,000 by 2022.

But HIV prevention is a difficult undertaking in Cebu City, which has plenty of places to go shoot up on Nubain or “milkshake” (an injectable combination of Nubain and crack cocaine) but few places to access a clean needle.

In 2014, the Cebu HIV/ AIDS Registry reported that 74 percent of the city’s 1,366 recorded HIV infections were due to needle-sharing. The DOH estimates that more than 50 percent of the roughly 6,000 intravenous-drug users in Cebu and its neighboring cities are positive for HIV. Needle disposal has become a public-health problem: In some areas, used syringes dot the streets.

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Since the Philippines’s first reported case of HIV in 1984, the country has remained “low-incidence,” meaning less than 1 percent of the population is infected with HIV. Even with low condom use and a sizable population of citizens who work overseas—both factors that typically contribute to a higher rate of HIV—the health department recorded only 2,410 new HIV infections between 1984 and 2005.

As a result, HIV was low on the Philippines’s list of public-health priorities during the earliest years of the virus, as the government focused its efforts and funding on other infectious diseases like tuberculosis and malaria. It wasn’t until 1998 that the country passed the Philippine AIDS Prevention and Control Act, creating educational programs about the disease and funding prevention efforts.

The disease continued to spread slowly in the following years, with the rate of new infections increasing by about 10 percent each year. But in 2009, public-health authorities saw a spike: Infection rates jumped 58 percent from the previous year. There was a similarly dramatic increase the next year, and again the year after that. In October 2015, the DOH’s HIV/AIDS registry counted just over 29,000 cases in the country since 1984—with more than 24,000 of them reported after 2010.

“The rate of infection in the last five years has eclipsed the rate of infection over of the last 30 years of the virus,” says Zimmbodilion Mosende, the strategic information adviser for the UNAIDS office in the Philippines.

The registry also reported a total of 1,359 deaths since 1984, but because of the stigma of HIV, many public-health workers believe the true figure is much higher.

Although most of the country’s new infections come from sexual contact, current policies can make it difficult for health workers to promote safe sex: Testing and contraceptives are off-limits to minors, for example, unless they have parental consent.
And in Cebu City, where, the primary mode of transmission is intravenous drug use, other laws have made it just as difficult to develop prevention programs targeted towards users. The Dangerous Drugs Act was amended in 2009 to criminalize the possession and distribution of drug paraphernalia like syringes. As a result, Cebu’s local public-health organizations had to discontinue their needle-exchange programs; the city also passed an ordinance limiting the sales of needles and syringes without a prescription.

The following year, HIV cases among injecting drug users in Cebu jumped from less than 1 percent to 53 percent.

The United Nations defines a “concentrated epidemic” as an area where infection rates are higher than 5 percent of the population. Surveillance data released by the health department last November showed that Cebu was one of eight Philippine cities that breached this percent threshold.

“The 5-percent prevalence rate is like a tipping point,” Samonte explains. “The moment you reach 5 percent, you reach a critical mass of people who can infect others and the epidemic will rapidly spread.”

But as public-health officials call for aggressive needle-exchange programs in Cebu, some local government officials continue to fiercely oppose them.

“The answer to this problem is not distributing clean needles,” says Alice Utlang, the executive director of the Cebu City Office of Substance Abuse Prevention (COSAP). “The answer is rehabilitation.”

But advocates say rehabilitation isn’t enough to combat what’s becoming an urgent problem. Cebu only has two public drug-rehabilitation centers, both of which are already crowded, and the cost of treatment puts their services out of reach for many people at risk for HIV.

“Our objective is harm reduction. While we are weaning them off the drugs, we can stop the spread of the virus through a needle exchange program,” says Ilya Tac-An, the head of the Cebu City’s STI/HIV Detection Unit.

In the meantime, Tac-An and her team make do with their current limitations. They’ve enlisted former drug users to lead education programs that discourage needle sharing, and teach both users and dealers how to clean used needles using bleach and water.

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In the meantime, the city’s drug problem is creating a sort of ripple effect, increasing the risk of infection for non-IV-drug users as well.

Over at Cebu City’s Vicente Sotto Hospital, which offers free HIV testing and treatment, Chamberlain Agtuca, is worried: In recent years, he’s seen a growing number of women come into his clinic for treatment, most of them pregnant.

“Before, we had maybe one case per year—if any at all,” Agtuca says. But “since the start of the year, we have had 10 pregnant women test positive for HIV.”

“Many of these (pregnant) women do not have an HIV risk profile. They are not engaged in sex work nor do they inject drugs,” he adds. But many of them received the virus from sexual partners who were infected via needle-sharing. (UNAIDS estimates that 50 million women in Asia who are in long-term monogamous relationships are at risk for HIV infection through intimate-partner transmission.)

“We did not see this coming. But when more male injecting-drug users get infected, they will infect their female partners,” Samonte says. “The [drug use]-HIV issue does not end with the users.”