Wednesday, March 17, 2010



Posted on 05:23 PM, March 11, 2010

HIV-AIDS: the frightening reality

Everyday, two Filipinos are diagnosed with Human Immunodeficiency Virus (HIV), which leads to Acquired Immune Deficiency Syndrome (AIDS). Increasingly, the trend shows that these are young, mostly male, college-educated, urban professionals, more than female sex workers or returning OFWs as in the past.

Exacerbating the problem would be the lack of comprehensive knowledge about HIV/AIDS, particularly ignorance on the modes of transmission, and the continuing debate -- sometimes heated between Church and state officials -- over the ways to deal with the spread of infection.

‘AIDS epidemic’

The Philippine National AIDS/HIV Registry reports that as of January, there are 4,567 Filipinos infected with HIV. (Given that these are culled from voluntary screen tests and surveys, 2007 estimates were pegged at 8,000 cases; the projection for this year is around 9,000.)

The growth has accelerated of late, with 835 cases reported in 2009, the highest in 25 years. The Department of Health (DOH) calculates that without intervention, by 2012 there will be 32,000 Filipinos living with HIV/AIDS.

Dr. Eric Tayag, Director of the Epidemiology Center of the DOH, said in an interview with BusinessWorld that 804 of the 835 reported cases last year resulted from unprotected sex, two were mother-to-child transfers, and the remaining 29 undeterminable without the data provided. In January, 50 of the 143 new cases (a figure that surpassed previous benchmarks 126 in December 2009 and 85 in May 2008) were transmitted via injecting drug users (IDUs) -- an alarming occurrence given that only eight such cases were reported until now.

"In other countries, what has fueled the rapid spread of HIV was among injecting drug users, because sharing needles has a higher risk of HIV... and these IDUs are giving it to others through unprotected sex [also]. We have a downstream of infections. If we’re not able to halt the spread through IDU, it will now spread to other populations," said Dr. Tayag

Dr. Tayag divulged that the "nexus of HIV" are three highly urban areas, namely, Metro Manila, Cebu and Davao.

In Cebu, the at-risk population would be female sex workers and injecting drug users. (The drug of choice is not heroin, which is expensive, but nalbuphine, a synthetic opiod used commercially as a prescriptive analgesic and bought for P130 -- if one skimps and shares a needle.) In Metro Manila and Davao, infection is mostly driven by men having sex with men (MSM).

Young men at risk

Since 1984 when the first person with HIV was reported in the Philippines, the trend of transmission has been 55% heterosexual and 44% men having sex with men (or MSM), but three to four years ago, the trend began reversing. In 2009 alone, 73% or 588 of the reported new HIV cases transmitted via unprotected sex were MSM, whereas 27% or 216 were heterosexual. Majority of these cases are of younger male adults in the 20-24 or 25-29 age groups.

"The mode of transmission has shifted from predominantly heterosexual to MSM... MSM has increased because of access, what with the cellphone and the Internet... Before, they could only find their partners in obvious cruising sites like gay bars, bathhouses, run-of-the-mill movie houses. Now you don’t have to go there to get access. In the Internet, you remain anonymous, and you meet as many as you want," said Dr. Tayag.

Dr. Ferchito L. Avelino, Director III of the Philippine National AIDS Council Secretariat, blames the rising incidence in the MSM subgroup on a system he describes as being "in denial," with little or no support given to young people who now have an earlier introduction to sex but are not given he right information that would promote responsible sexual behavior. In a study he conducted in the mid-1990s, orientation to sex for the male was set at 19 and for the female at 17; now men are having their first sexual experience at 14.

"They are engaging in sex at an early age and the probability of them to get HIV is higher than for a person who started late... If you’re going to look at the HIV epidemic -- and we’re not even talking about sexually transmitted infections like gonorrhea, which also has scary numbers -- most of the HIV cases are 30 years old and below. Majority are within 20-30 years of age," he said.

"What has the society done to equip these young people before they reach the age of 20 to have a good decision in their lives?... What are our institutions doing, our schools, our family, our church?... [Many MSMs are saying that they are not homo-sexual] why? Because society says that if you’re homosexual, you’re [out], so how would you want to be accepted? Do they get the support? Do they get the information they need? Wala. (Zero.)"

‘Na-ikahon sila’

Dr. Maria Tarcela S. Gler, Training Officer Infectious Diseases at the Makati Medical Center, said that in the past two years, a minimum of one or two patients, a maximum of eight, are routinely diagnosed HIV positive each month. Out of the 46 patients she herself diagnosed, only two are heterosexual and female. The rest fall under the MSM subgroup, their ages ranging from 25-31, except for the youngest, at 23, who contracted HIV four years ago (he was 19 at the time).

In her interview with BusinessWorld, Dr. Gler admitted that her MSM patients are young professionals "in the middle-middle to upper-middle" income bracket, mostly working in information technology and call center agencies. However, she stressed that while recent anecdotal accounts have pinpointed workers in the BPO (business processing outsourcing) industry as a high incidence group, a formal epidemiologic study has yet to be done. It is risky behavior that ought to be factored in, notably unprotected sex with multiple partners. At least in her group of 46, most if not all of the men, became sexually active at 15 and define "sexually active" as having multiple partners.

"It is what it is. When they say ’I’m active,’ it’s a minimum of three partners a month. It’s probably misinformation. They start early...

"A big factor is education. They were all educated here. Sex education with HIV awareness would have made a difference, probably. We could follow what Thailand did -- they did mass education and mass testing, without discrimination, and condom-distribution. We would have no choice," Dr. Gler said.

Maria Cecilia AƱonuevo, Deputy Executive Director of the Remedios AIDS Foundation, Inc., also spoke against singling out workers in the BPO industry as automatically at high risk, never mind the alleged opportunity for sex with several acquaintances to choose from for workers in the graveyard shift.

"Na-ikahon sila ’nung may nag-disclose na taga-call center... pero ’di dapat ikahon sila, kahit sino basta sexually active nasa panganib (They were stereotyped after one call center worker disclosed he was HIV positive... but anyone sexually active could be at risk.)

This is consistent with the stand taken by AKMA-PTM, the party list group representing the 500,000-strong BPO and call center industry. While the group has set up its own HIV hotline (546-0691) manned by call center agents six days a week from 8 a.m-5 p.m., they resist being labeled as being at a higher risk than other industry groups. In the official Facebook page of AKMA-PTM, one finds the statement dated Feb. 11 at 8:29 a.m.: "Working in Call Centers have (sic) nothing to do with the HIV incidence. The only reason why Call Center agents would have the highest rate of infection is because they are at an age where being sexually active is the norm..."

Issues of vulnerability

Ms. AƱonuevo noted that the Remedios hotline receives seven to eight callers -- and the clinic has two to three walk-ins -- daily, with at least three new cases diagnosed per week. The vulnerable groups, she reiterated, are still men who have sex with other men, sex workers, and migrant workers. The last include medical practitioners, as well as domestic helpers and seafarers, who may have had only a 30-minute orientation on the hazards of HIV/AIDS pre-departure, and may have experienced molestation or entered prostitution for additional income while working abroad.

Sex workers, because of the nature of the job, put themselves at risk by having multiple partners (although the DOH maintains that 140 customers a month is extreme, on average prostitutes would have three partners in a week). The trouble is that most prostitutes have to be taught the negotiation techniques needed to convince their customers to use protection, as well as the proper way of actually using the condom. They also are unaware of the health facilities and programs that are available to them. Non-government organizations and the government have outreach activities pertaining to this group, with some success.

Meanwhile, men having sex with men remain the most vulnerable, again because they usually engage in unprotected anal sex with multiple partners, and have little or no knowledge of the implications of sexually transmitted infections (STIs), much less protective measures against contracting STIs.

And while the freelance sex worker may be walked up to on the street corner and the migrant worker a captured audience while processing employment requirements, the MSMs can only be reached via the peer education approach -- that a friend of theirs would refer them to a hotline or bring them to a clinic for testing.

"The MSMs have no groups, they are not organized, and you cannot access them as one. Probably what you can do is just like TB, to have X-rays for all pre-employment, but not discriminate, our rule is still voluntary HIV testing... The stigma is more painful than the test itself. How can we reach out to them, when they’re not organized, they’re not a group, they’re not out? Most of the cases [I’ve encountered] were not out, or they say they are bisexual," pointed out Dr. Gler.

Nuances of behavior

The situation calls for a concrete action plan from the government, with help from the private sector, and hopefully support (or at the least, non-interference) from the religious sector, as currently the preventive ABC campaign -- Abstain, Be faithful, Concrete and consistent use of condoms -- has been under attack.

The criticism from the religious sector is that condom-use in particular is encouraging pre-marital and extra-marital sex, and that the disease would not be as widespread if sex were done in the proper context of marriage.

The DOH defends its position by stressing that their responsibility is to allow for all possible contingencies and give the right information so that individuals can make the best decision applicable to their lives. Their primary drive is to promote safer sex, which means mitigating risky behavior. While pushing for abstinence first and faithfulness second, in the eventuality that the line is crossed and the individual is neither abstinent nor faithful, then a feasible alternative is needed to lessen the risk.

"There are behaviors that fall under a spectrum of no risk to highest risk, and those that fall in between. It is better for individuals to know the risk attributed to these behaviors so that finally they can make their choice," said Dr. Tayag, again emphasizing that the DOH is not encouraging morally lax behavior, but promoting responsible (if not necessarily morally correct) behavior. Between one risky action and another, the DOH would rather the individual choose the lesser evil -- however, s/he has to be fully aware of the threat involved.

Of all preventive measures provided thus far, it is condom-use with an 85%-90% chance -- according to PNAC, near-perfect effectiveness -- of preventing HIV/AIDS infection. However, of all risky behaviors, anal sex is the highest risk, given that the muscles in the rectum are not as lax as in the vagina, the rectal mucosa or lining is thinner and more prone to tears that could serve as the passage of the virus, and even condoms are more easily damaged during anal sex.

But the point is that the sexual act is built on a number of variables. Unprotected anal sex between two monogamous, healthy partners -- whether homosexual, heterosexual or possibly bisexual (62% of MSMs in a survey vowed they were hetero-sexual) will not result in any viral infection. But even someone engaging in unprotected sex in the missionary position within a conventional marriage could contract HIV/AIDS if the spouse is already infected -- in which case, the choice is either complete abstinence or condom-use.

Dr. Tayag believes in refining (or rather, redefining) the preventive measures presented to the individual. Abstinence and faithfulness, for example, are irrelevant to the sex worker. "When you say ’abstain’ for example, this can mean abstaining from more risky sexual behavior. You can have penetrative sex as long as you abstain from unprotected sex. You abstain from anal sex but you indulge in vaginal/penile and other less risky sexual activity like kissing or fondling, the other variants, oral sex," he said.

Abstaining for the injecting drug users could be abstaining from dangerous drugs -- ergo, anything directly injected into the blood stream -- and going into rehabilitation and submitting to psychosocial behavior change. It could mean the D in the ABC campaign, which is "don’t share your needle."

Faithfulness, meanwhile, could mean serial rather than absolute monogamy, faithfulness to only less risky sexual activities, or, yes, faithfulness to your needle rather than using someone else’s or allowing it to be shared.

The church, of course, will likely have much to say about this redefinition of generally acceptable preventive measures.

The virus is the enemy

The Catholic Bishop’s Conference of the Philippines (CBCP) is open to discussing solutions to the epidemic, evinced in the 1st National Catholic Forum on HIV/AIDS today, March 12, in Tagaytay City, but it remains to be seen whether this crucial first step will result in a united front during the AIDS Summit on April 12, when all stakeholders would iron out a feasible action plan for combating the disease.

"Let us work together where we can work together, and acknowledge that there are certain people who will not go for certain strokes... We cannot go on having this debate and just ignore the fact that everyday, two Filipinos are getting infected with HIV... Rather than throwing hurting words at each other, let’s work together. The church has so much to contribute in this intervention," ventured Dr. Avelino.

Information dissemination is one avenue that the Church and government may be able to come to terms (E for Education in the ABC campaign, as they say). "We are calling on the family, on the community, to equip the young people with information that is unbiased, age-specific -- that means you don’t teach them the birds and the bees at Grade Six. In early 2000, we taught sex education in relation to HIV... piloted this in two government-run schools where incidence of pregnancy is high. During the time we did the program, there was no pregnancy, and there were no sexual diseases and infections among the students. These are third year and fourth year high school students, right before they enter college. I hope we could replicate the program," said Dr. Avelino.

Political will is key. Dr. Avelino cited the recent shelving of an ordinance to organize a local AIDS council in Legazpi, supposedly because the mayor was under pressure from the religious sector. Dr. Tayag is noncommittal about any damage to the campaign wrought by any disapproval from the church but allowed for the possibility.

"We don’t know. If those people who will have the bigger responsibility in terms of making this a policy [is influenced], then it can damage. The repercussions, for example, with the presidentiables, if it becomes a policy with them that, no, you cannot use condoms to halt the spread of HIV...," said Dr. Tayag.

The next few months are critical, he said, in determining the public preventive measures to take. Fact is that if the HIV incidence worsens, coupled with piggybacking opportunistic diseases, then the government is looking at premature deaths and an economic drain. Demand for anti-retroviral drugs will also go up; presently, only select individuals -- around 1,500 HIV-infected Filipinos, most of them with a double burden of TB and HIV or Hepatitis C and HIV -- are given the drugs for free.

"It depends on the situation; we can be very, very restrictive... For injecting drug use, if it goes up, do we criminalize [nalbuphine], should we allow them needles without being labeled a drug pusher?... Right now we feel that if we are able to share this information to those who frown on certain preventive measures, they will have a better understanding, and we will all realize that it’s the virus that is the enemy. We can work together."

The Remedios AIDS Foundation Inc. is located at 1066 Remedios St. Malate, Manila. The clinic is open for laboratory work from 9 a.m. to 6 p.m. on Tuesdays to Saturdays, and for consulation from 3 to 7p.m. on Saturdays. The AIDS HOTLINE is (632) 524-05-51, operating from Mondays to Saturdays, 9 a.m. to 6 p.m. Face to face counseling can be had at the Malate office from 2 to 6p.m., Tuesdays to Fridays.