AIDS in the Archipelago: How the Philippines can Tackle its HIV Epidemic

In the wake of last year’s election of President Rodrigo Duterte, populism is far from the only rising danger in the Philippines: Around the nation, rates of HIV are soaring. But even though news of President Duterte’s national war on drugs has spread across the globe, little attention has gone to the rapidly rising incidence of HIV. In June 2016, 841 new cases were reported – the highest number in a single month in the Philippines since tracking began in 1984 and a nine percent uptick from June 2015. The daily incidence of HIV has nearly tripled since 2012, and according to the World Health Organization (WHO), the rising number of cases in the Philippines represents one of the fastest-growing epidemics in the world. Between the crackdown on drug usage and its reluctance to educate young people about safer sex practices, the Philippine government has been largely complicit in allowing the disease to spread across the archipelago. The need for new policies surrounding drug usage and health care to mitigate the increasingly rapid spread of HIV grows larger by the day: Without drastic reform of the country’s health care system and underlying stigma surrounding HIV, the Philippines could find itself facing an epidemic that would take years to control.

Today, HIV in the Philippines remains concentrated to a few subgroups of the population. Men who have sex with men make up the vast majority of cases, and HIV incidence among youths and drug users is also rising at a startling rate. However, there is good reason to believe that the country’s Department of Health may be underestimating the prevalence of the disease. The country currently employs a passive tracking system that takes into account only data reported from clinics and hospitals, meaning many cases slip through the cracks. Undiagnosed patients who are not aware of their HIV status can spread the disease to partners as well as people with whom they share needles, causing cyclic patterns of infection.

In both government and private health facilities, health care providers have failed to offer pre- and post-test counseling, broken confidentiality for HIV positive patients, and altered treatment of patients based on HIV status.

In order to understand the epidemic, it is important to understand the underlying risk factors that have been driving these higher incidence rates. Four key factors drive the epidemic. First, the age of first sexual contact is younger than previous generations. The Department of Health’s Commission of Population published the findings of the 2013 Young Adult Fertility and Sexuality Study, a nationwide survey of 15 to 24-year-olds that contains modules relating to sex, relationships, and risk behaviors. One third of participants stated they had engaged in premarital sex, an increase greater than 14 percent from 20 years ago. This group comes into direct conflict with the conservative attitude towards sex that stem from the country’s deep Catholic influence, which leads to a lack of open discussion about sex within families. Though high school students often demonstrate a desire to learn more about various aspects of sexuality, without an open discussion with their parents, they defer instead to friends, magazines, or online resources. This can lead to a circulation of false information regarding sex, condoms, and STIs. Troublingly, less than a quarter of those engaging in premarital sex for the first time used protection against STIs. An increase in premarital sex without an improvement in the country’s knowledge of risky sexual behaviors is a frightening warning sign for the country’s HIV epidemic.

The low rate of condom use among the broader Filipino population also drives the epidemic. The nation has one of the lowest condom usage rates in Asia with rates between 20 and 30 percent for the highest risk populations. According to a UNICEF report, the Philippines has the second lowest condom use in the region among men who have sex with men, a key population at risk for HIV. Various barriers to consistent condom usage exist, including the stigma attached to premarital sex, gender roles, and the Church’s teachings that discourage the “sinful” use of contraceptives.

Another risk factor in the epidemic is the high prevalence of misconceptions about HIV, which dilute the efficacy of education programs. Forty percent of women who participated in the 2013 National Demographic and Health Survey believed that HIV could be transmitted through sharing food or through mosquito bites, but only 57 percent knew that using condoms could reduce the risk of HIV transmission. One third of youth surveyed in the Young Adult Fertility Survey believed that HIV could be cured. Such misconceptions make it difficult to encourage preventive behavior.

Finally, the stigma and discrimination that those who have HIV experience discourage acknowledgement of the health crisis. Concerns about social isolation or loss of familial support weigh on the minds of those living with HIV. Though the law affords significant protections to those living with HIV, de facto discrimination still exists. In both government and private health facilities, health care providers have failed to offer pre- and post-test counseling, broken confidentiality for HIV positive patients, and unfairly altered treatment of patients based on HIV status. Social hygiene clinics and other public or private clinics fail to provide services and are not trained to provide comprehensive care to key subpopulations like men who have sex with men. Even if someone doesn’t face externalized stigma related to HIV, they are likely to internalize the stigma. Many feel ashamed or guilty of their HIV status, leading some to consider suicide or believe that they should be punished. People living with HIV fear insults, gossip, and verbal or physical harassment on account of their condition.

Despite the Phillipines’ best effort to legislate meaningful change, action against HIV still needs much more work.

This stigma has several discrete harms. For one, internalized stigma creates barriers to seeking health care services, including medicines or treatments for non-HIV related ailments. It frequently is comorbid with depression, lowering the quality of life of HIV patients and sometimes resulting in outcomes as tragic as suicide. Finally, people experiencing higher amounts of internalized stigma are less likely to disclose their HIV status to sexual partners, causing the disease to spread further and faster.

Historically, two laws summarize the Philippines’ response to HIV. The first is the AIDS Prevention and Control Act of 1998. The law has three major components: the creation of a state-run educational campaign to increase awareness, the banning of compulsory HIV testing and discrimination based on HIV status, and the establishment of the Philippines National AIDS Council, which works to oversee HIV prevention and control initiatives. However, the law requires those under 18 to secure parental consent before undergoing any HIV testing or treatment. This rule, combined with common attitudes in the Philippines against premarital sex, has led youth who are sexually active but unmarried to believe they must conceal their sexual activity. Subsequently, the true number of HIV cases may be obscured because of the unwillingness of those under 18 to ask for parental consent for testing. In 2015, Senator Miriam Defensor Santiago led an effort to allow those between 15 and 17 years old to get tested and treated for HIV without parental consent. Unfortunately, Senator Santiago passed away in September 2016, and her initiative has been left in legislative limbo.

The second law is the Responsible Parenthood and Reproductive Health Act of 2012, otherwise known as the RH Law. The RH Law provides universal access to free or subsidized contraception through government health centers and requires sex education in public schools. Although this law seems as though it would reduce the spread of sexually transmitted HIV, the national initiative relies on local support, and the policy has not been universally accepted. The Reproductive Health Law’s divisive nature has resulted in uneven execution by local politicians. For example, the City of Manila bars funding from being used for the provision of contraceptives, Sorsogon City banned supplying contraceptives outright, and Balanga City’s public health officials and clinics are prohibited from distributing the supplies provided by the national government. But even where there exists a sufficient supply of condoms and support to provide them to the public, distribution can still be limited by a lack of proper infrastructure. The Philippine Commission on Human Rights found that heath facilities and workers were often overburdened and unable to distribute contraceptives.

Similar challenges have applied to the implementation of sex education programs. School-based initiatives are particularly important in quelling the incidence of HIV, given that youth populations bear the second highest burden of HIV by age range. From 2005 to 2009, the 15 to 24-year-old age group accounted for 12 percent of HIV cases. Today, a staggering 27 percent of cases are in this range, suggesting that successful sex educational policies will prove necessary for reducing the country’s HIV risk. However, the RH Law’s education initiative has been largely ineffective. Students in over 1,000 Catholic schools in the country still receive no sex education, barring them from learning safer sex practices. To address this issue, a group of Catholic teachers developed the Population and Development Education Teaching Modules for Catholic Schools to combine sexual health with Catholic values. Unfortunately, even an explicit effort to integrate Catholic ideals into a sex education program was not enough to earn approval for teaching in private schools. The Catholic Bishops Conference of the Philippines reviewed the program and rejected its implementation unless crucial parts of the curriculum were changed or removed, continuing to deprive youth at these schools of key lessons in sex education.

In public schools, the Department of Education has not adopted standards for comprehensive sex education, and teachers have yet to be trained for proper delivery of age-specific education in the K-12 curriculum. This lack of standardization means that it is up to schools to develop and implement sex education curricula, raising questions of consistency and quality. Additionally, though the Department of Health wanted to begin the distribution of condoms in schools this year, the Department of Education vetoed the initiative, citing concerns about parental consent.

It appears that despite the Philippines’ best efforts to legislate meaningful change, action against HIV still needs much more work. In order to create a comprehensive response, the Philippines needs to be willing to use three guiding principles when forming any plan of action to combat HIV. First is pledging a full commitment to comprehensive initiatives that incorporate what The Joint United Nations Programme on HIV/AIDS calls “combination prevention strategies.” Combination prevention constitutes the “simultaneous use of complementary behavioral, biomedical, and structural prevention strategies” to achieve change. Investing only in programs like condom provision or education ignores the broader societal context in which the disease is surging, including stigma and gaps in sexual attitudes within families, that ultimately render these programs ineffective on the scale of individual behavioral change. The Philippines’ current approach emphasizes the individual’s ability to make rational choices, but only by incorporating structural interventions to address stigma can effective prevention programs be developed. The country must also recognize that deeper interventions may have little effect in the short-term. Ingrained social attitudes do not change overnight, but a long-term shift will substantially reduce HIV risk.

Further, the Philippines should recognize that no “one-size-fits-all” approach to an HIV epidemic works. Rather, tailoring initiatives to the needs and beliefs of different groups is necessary for achieving desired behavioral change. Both the national and local governments should be willing to include viewpoints from key subpopulations in planning any response to HIV or in the adaptation of existing programs. The factors driving the epidemic are not mutually exclusive, but rather act in unison. A lack of openness regarding sex impacts beliefs about condoms, which decreases their use, and further spreads HIV.

There has been a rise in infected women who do not use drugs but who have contracted HIV through sex with infected injection drug users.

The second principle is engaging with key stakeholders in the discussion of HIV reduction through education. The opposition to the Reproductive Health Law demonstrates the strong bias against condoms and sex education when framed as a method of population control because of the strong tradition of religious conservatism. However, framing the provision of condoms and sex education solely as a way to reduce cases of HIV may invoke a more positive response. The Catholic Bishops Conference of the Philippines (CBCP) has demonstrated concern about the rising cases of HIV, asking the government to declare a “youth epidemic,” and the CBCP published news releases that called for caring for those with HIV with a deeper sense of spirituality. Most importantly, however, the CBCP also called for a targeting of structural factors that cause the rapid spread of HIV. The Catholic Church, a powerful player in the country, could be a great ally in the fight against the burgeoning epidemic by helping to increase HIV testing and reducing negative connotations attached to HIV. The Church may not completely reverse its views regarding condom usage, sexual education, and premarital sex, but national and local governments should still attempt to enlist its help in any way possible, even if the effect is not wholesale reversal of Church policy.

Finally, the Duterte administration should roll back its war on drugs and acknowledge that stigmatizing drug use further inflames the growing number of HIV cases in the country. The extent of the impact the war on drugs has had on the HIV epidemic is currently nebulous. However, while only five percent of current HIV cases are a result of injection drug use, there is good reason to believe such cases will rise as drug users continue to be harshly persecuted across the country: A 2014 study conducted by the Philippines National AIDS Council found that just a third of injection drug users utilize sterile injecting equipment, uncovering a huge risk factor that stands to exacerbate the current epidemic. Needle exchange programs could solve this problem by providing clean needles that, according to the WHO, would substantially lower the risk of HIV with no impact on the overall rate of drug use. Unfortunately, the Duterte administration has increased pressure to stop the distribution of clean needles, indicating the potential for increased HIV rates among drug users in coming years. There are also ramifications for those who don’t use injection drugs: In Cebu City, there has been a rise in infected women who do not use drugs but who have contracted HIV through sex with infected injection drug users. At the very least, the war on drugs may push users away from getting tested, increasing the number of undiagnosed cases in the country. By pursuing a hardline stance on drugs, Duterte may let an epidemic among isolated subpopulations ultimately initiate a population-wide contagion that would ordinarily have taken decades to come to fruition.

Though the Philippines has not yet reached a generalized HIV epidemic, its profusion of red flags indicate that immediate and decisive action is needed. Investing in condoms and education programs is only part of the solution. The government must supplement these measures by pushing for structural interventions; while only precautionary in the present, they may delay or even prevent a future generalized epidemic. Equally important is tackling social norms and cutting through bureaucracy to coordinate efforts among multiple actors and tiers of government. This is certainly easier said than done, but it is necessary to create the most effective response against the spread of HIV. Without a quick and thorough response, the rising tide of an HIV epidemic may become impossible to stop.