HIV Infection Rates in the PH Are Skyrocketing; Here's What We All Should Be Doing
A key principle in HIV response is “know your epidemic”. Knowing what drives HIV infections makes for better interventions that are tailored to the behavior of the groups who are most at risk. It also allows government and health organizations to effectively manage limited resources.
Health experts help us get to know the HIV epidemic in the Philippines so we can understand the reasons behind the country’s skyrocketing HIV infection rates.
There were 10,500 HIV cases reported in 2016—up from 4,300 in 2010. Currently, with 31 new HIV cases reported every day, the Philippines has the fastest growing HIV epidemic in the Asia Pacific region, with estimated HIV incidence having risen more than 25% since 2001. Department of Health (DOH) data as of December 2017 indicates that there are 50,725 people living with HIV (PLHIV). At this current rate, the DOH forecasts that the total number of HIV infections could reach 142,400 by 2022.
The Philippine epidemic is concentrated among a young population. More than half of total reported cases fall between the ages 25-34. More than 80% of reported mode of transmission is among men who have sex with men (MSM) and transgender women who have sex with men. It is important to understand the MSM is used to describe a behavior so this includes gay men, covertly gay men (they outwardly present themselves as straight but may have a wife or a girlfriend), and bisexual men.
Epidemiologists and the Department of Health (DOH) have been closely monitoring the rise in reported cases—which may also be a function of increased testing, but also the HIV virus itself.
As Dr. Edsel Salvaña, director of the Institute of Molecular Biology and Biotechnology at the National Institutes of Health at the University of the Philippines, explains, “The HIV virus has the potential to transform itself into a new and different virus each time it affects a cell. There are over 100 different subtypes and recombinant (a mixture of the genetic material of two subtypes) forms of HIV, with new subtypes being discovered every day.”
One subtype that health experts are monitoring is the HIV subtype CRF01_AE ,or AE for short. According to Salvaña, subtype AE is different from the Western subtype B in that it seems to be more aggressive. “Those infected by the HIV subtype AE are younger, get sicker faster, and are more likely to develop drug resistance to ARVs. We are also seeing a faster progression to AIDS under sub-type AE.”
Dr. Genesis Samonte, the head of the DOH Epidemiology Bureau, says, “We have been monitoring HIV subtypes in our surveillance reports since 2009 to make sure that it does not turn into a public health concern. The subtype AE is the predominant subtype in the Philippines."
Both Salvaña and the DOH agree that the current state of HIV in the Philippines requires vigilance and action, specifically government interventions combined with a positive change in sexual health behavior.
1. Condoms need to be used earlier and more—like always. The average age for the first sexual encounter is 16--but first condom use starts at 18. That’s two years of unprotected sexual activity, during which you are exposed to sexually transmitted infections like HIV.
Data shared by the DOH shows that the highest level of condom use among men who have sex with men (MSM) is 46%. This is way below the DOH target of 80%, and the UNAIDS recommendation of 90% condom use.
Condom use needs to start with the first sexual encounter. Studies have shown that those who use condoms during their first sexual encounter are more likely to consistently use condoms throughout their adult life.
NGOs like LoveYourself are also working on creative innovations to solve the condom accessibility problem.
The SafeSpacesPH app identifies “sex-positive” places like bars, coffee shops and restaurants where anyone can access free condoms and lubricant without embarrassment. Condom dispensers are installed in these “depots” and anyone can access without fear of being judged.
2. More people need to go on Anti-Retroviral Therapy (ART). The DOH has noted that the “lost to follow up” numbers are increasing. PLHIV on life saving anti-retroviral therapy are not able to stick to their regimen. “Lost to follow up” refers to people who are living with HIV (PLHIV) and are on antiretroviral therapy, but are unable to continue their treatment for one reason or another.
ART is a daily medicine regimen that works to suppress the HIV virus and stop the progression of the HIV. Adherence to ART, meaning taking it religiously every day, can extend a PLHIV life for many years. Think of Magic Johnson who disclosed that he was living with HIV in 1991. Twenty seven years after, Johnson continues to live a long, healthy and normal life.
Going off ART or not taking it regularly has two implications: first, your viral load could increase to a level where you can develop life threatening opportunistic infections (due to a weakened immune system) and also transmit the virus and two, a PLHIV can develop drug resistance to the drug. It is similar to what happens if you don’t take your entire cycle of antibiotics.
Samonte stresses the importance of sticking to an ART regimen as one way of avoiding drug resistance: “There are two types of drug resistance: acquired and transmitted. Acquired is if you don’t take your ART or go off it and thus, build a resistance to it. Transmitted is if the subtype you are infected with is already drug resistant,” she said.
Another important function of ART is that it can suppress viral load to a point where HIV in the body is undetectable. “Generally, three to six months after starting treatment, a person living with HIV has an undetectable viral load and cannot transmit HIV to other people. Currently, only 32% of PLHIV were on ART in 2017,” says Dr. Lui Ocampo, country director of the Joint United Nations Programme on HIV and AIDS (UNAIDS).
Given this, the DOH is working to get more people on ART immediately after they test positive for HIV and also working to get more of the PLHIV numbers on ART.
The World Health Organization recommends a Treat All Policy where anyone who tests positive for HIV immediately goes on ART, regardless of their viral load (which is the amount of the HIV virus in your body). According to Dr. Gerard Belimac, program manager at the DOH Disease Prevention and Control Bureau, the DOH is targeting to implement a Treat All Policy by year end.
3.We need more HIV responses tailored for people who inject drugs. HIV can be transmitted in body fluids like semen, vaginal fluid, breastmilk and blood. For people who inject drugs, sharing needles infected with HIV is one of the most effective and fastest ways of transmitting the virus.
From 1984 to 2009, transmission through sharing of infected needles was less 1% of the total HIV cases reported. This number spiked in 2010 comprising 9% or 147 of the total cases reported that year. While the numbers are still low, it is best to keep that way. Among the modes of transferring the virus—semen, vaginal fluid, breastmilk and blood—sharing needles infected with HIV positive blood is one of the fastest ways of transmitting the virus.
The government’s crackdown on illegal drugs is hurting the HIV response for people who inject drugs. “Existing drug laws already result in the lack of needle-syringe exchange programmes. The strong government approach against drugs is pushing people who inject drugs (PWID) underground, limiting their access to prevention, testing, and treatment services. Outreach workers are also affected, which prevents them from providing services,” said Ocampo.
In the case of the men arrested in a BGC hotel, one disclosed his HIV status but was not readily able to access treatment while he was detained.
UNAIDS and other NGOs are calling for a comprehensive harm reduction program that will address the health and social issues that lead to drug dependence through an evidence-based public health approach. This includes policies and various community based outreach programs that will reduce harmful consequences of injecting drug use, such as increased vulnerability to HIV.
4. More people should go on PReP. PReP stands for pre-exposure prophylaxis, a daily pill that when taken every day has been shown to reduce the risk of HIV infection by up to 92%. In someone exposed to HIV through sex by an infected partner (like a wife infected by an HIV+ husband through intimate partner transmission), or injecting drug use, PReP can work to keep the virus from establishing a permanent infection.
“PReP should be seen as a combination prevention effort. PReP, together with consistent condom use, can greatly reduce the risk of HIV infection,” said Belimac.
PReP in the Philippines is currently in a demonstration project stage, with 200 people enrolled. “It is important to note that we are no longer testing the efficacy of PReP which has already been proven. The objective of the demonstration project is to test its acceptability and application in the local setting and the capacity of service providers to implement it,” said Belimac.
The next step for the DOH will be to evaluate the results of the demonstration project and the roll out of PReP to a wider base.
5. We should fight stigma and discrimination surrounding HIV. “Stigma and discrimination are preventing people from accessing services, particularly for key populations as well as young people, which is resulting in delayed diagnosis and initiation of treatment,” said UNAIDS’s Ocampo.
Legislation wise, steps are being taken to make HIV services more accessible to young people. Currently, there is a move to amend and modernize the existing HIV Law. One of the provisions in House Bill 6617 is to lower the age of consent for voluntary HIV testing to 15. Congress passed the bill on its third and final reading last December. Public pressure is needed to get this bill passed in the Senate and finally made into law.