Risks for HIV Infection in a Low Prevalence Country

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1 Risks for HIV Infection in a Low Prevalence Country Ofelia T. Monzon, M.D.,* Jose M. Capellan, M.D.,* Angelita Balis, M.S.,* Ernesto Sotocua, Jr., M.D.,** Cristina Costa, M.D.,*** Virginia Florentino, M.D.,**** Fem J. Paladin, M.S.* and Cynthia B. Lazo, MT* (*The Department or Health Research Institute for Topical Medicine; **N. Reyes Memorial Medical Center; ***Manila Health Department; ****Mandaluyong Health Department; Poster Presentation at the IVth International Conference on AIDS, Stockholm, Sweden, June 12-16, 1988) No Abstract Available [Phil J Microbiol Infect Dis 1989; 18(1):4-9] Key Words: HIV/AIDS, immunodeficiency, sexual transmission, STD Published reports from various parts of the world indicate that human immunodeficiency virus (HIV) infection is primarily transmitted through three major routes: sexual, blood/blood products administration, and maternal to child. 1 Of these routes, sexual transmission appears to be the most frequent mode of infection. The risk of acquiring HIV infection via sexual contact can be directly related to the probability that a sexual partner is infected and the type of sexual practice observed. Thus, in a country where HIV infection has not previously been known, the likelihood of native residents acquiring HIV infection will depend on sexual exposure to infected partners coming from other countries. This risk increases as the number of such partners increase especially in the presence of unprotected sexual contact (without condom usage) and anal sex. These behaviors extensively studied and reported from other countries are believed to increase the chances of acquiring HIV infection. 2 Testing for HIV infection in the Philippines began in Preliminary data gathered from a small number of homosexual/bisexual males reported the presence of such risky behaviors as anal sex and minimal condom usage. 3 In 1987, subsequent data from the continuing surveillance showed the presence of HIV infection in 0.17% of females and 0.14% of males. 4 To focus attention on behavioral changes needed to lessen transmission of HIV infection from the infected to uninfected Filipinos, this report contains relevant information on the subpopulation group at risk for both acquiring and transmitting HIV infection within this country, MATERIALS AND METHODS Subjects and females working in sex-oriented establishments in Manila, Quezon City, Makati, and Mandaluyong were recruited into the study. These subjects receive fees for sexual favors from their clients, in addition to a minimal stipend given by their employer. The establishments included bars, discotheques, massage parlors, and sauna baths. Methods The subjects were recruited at any of the following locations: at the VD Clinic of the Manila Health Department, at private sexually transmitted diseases (STD) clinics in the tourist area of Manila, and at their places of employments. Informed consents were obtained and questionnaires were administered by trained members of the investigating group. Information was elicited with regards to demographic data, length of employment, use of drugs including alcohol intake, sexual behavior and practices, number and country of origin of sexual partners in the previous six months, and past and current medical history. A brief physical examination with

2 special emphasis on the skin, mucous membranes, lymph glands and general condition was performed and blood was collected. Serological testing for HIV antibodies was performed at the Department of Health Research Institute for Tropical Medicine, Alabang, Muntinlupa, Metro Manila. Screening tests used were either an enzyme immunoassay or a gelatin particle agglutination test. Reactive sera underwent repeat testing and supplemental tests were performed with either immunofluorescent or Western blot method. Data collected were coded and analyzed using a test of significance. This report covers a period of 31 months ending April RESULTS A total of 694 males and 4,720 females were recruited into the study. Demographic information showed that 688 or 99% of the males and 4716 or 99.9% of the females were below 50 years of age with the majority belonging to the 18 to 50 years age group (Table 1). Six or 1% and 4 or 0.1% of males and females respectively were over 50 years of age. One hundred nineteen (17%) male subjects and 1625 (35%) females were either married, separated or had livein partners. Table 1. Demographic Data Age < 18 years 30 (4) 374 (7.9) years 658 (95) 4342 (92.0) > 50 years 6 (1) 4 (0.1) Civil Status Single 573 (83) 3066 (65) Married 107 (15) 591 (13) Separated/widowed/live-in partners 12 (2) 1034 (22) Education 10 yrs or less 369 (54) 3927 (84) 11 yrs or more 315 (46) 754 (16) Religion Catholic 639 (93) 4462 (96) Other/none 45 (7) 179 (4) Occupation Dancer/receptionist 306 (47) 2739 (59) Sauna bath masseur(e) 85 (13) 1611 (35) Others (manager, waiter, etc.) 234 (40) 290 (6) Length of Employment 0-6 mos 256 (52) 2184 (51) 7 12 mos 92 (19) 1098 (26) > 13 mos 144 (29) 983 (23) Five hundred seventy three (83%) males and 3066 (65%) females were single. Three hundred sixty nine (54%) of the males and 3927 (84%) of the females had 10 years or less of formal schooling and 315 (46%) and 754 (16%) of the males and females respectively had 11 years or over of education. As expected in this predominantly Catholic country, 639 or 93% males were Catholic; 4462 or 96% of the females were similarly Catholic with the remainder distributed among other religious sects. Three hundred six (47%) males and 2739 (59%) females were employed as dancers or receptionists. Eighty five (13%) males and 1611 (35%) females worked as sauna bath attendants. Two hundred thirty four (40%) and 290 (6%) of the males and females respectively had other job categories in the establishments such as managers, waiters/waitresses, etc. Majority of.the subjects had been employed 12 months or less: 256

3 (52%) males and 2184 (51%) females had been employed 6 months or less; 92 (19%) and 1098 (26%) males and females respectively were employed between 7 to 12 months. 144 (29%) and 983 (23%) of the male and females subjects had been working longer than 13 months. Information on social habits and drug use revealed that 527 (77%) males and 2328 (50%) females were either active or recent smokers and 622 (90%) males and 2751 (58%) females admitted to regular or recent alcohol intake (Table 2). A history of drug use was elicited from 402 (58%) and 1663 (36%) of male and female subjects respectively. Drugs taken were mostly oral or inhaled drugs with rare subjects admitting to experimentation with IV drugs in the past. Agents taken consisted of marijuana, liquid cough preparations, valium, heroin, cocaine, demerol, and LSD. were significantly more represented among the smokers, and those admitting to alcohol and drug intake, p < A history of such STD's as gonorrhea, syphilis, venereal wart, and herpes was elicited from 199 (29%) males and 1209 (26%) females (Table 3). Histories of hepatitis, malaria, blood transfusion or blood donation were elicited in small numbers of subjects of both sexes. Table 2. Social Habits and Drug Use Smoking No 157 (23) 2364 (50) Yes and previous* 527 (77)** 2328 (50) Alcohol intake No 67 (10) 1949 (42) Yes and previous* 622 (90)** 2751 (58) Drug Use *** No 286 (42) 2934 (64) Yes (1 or > drug) 402 (58)** 1663 (36) *Stopped use in past 6 months **p<.001 ***Any of the following: marijuana, valium, cough preparations, heroin, cocaine, demerol, LSD. Table 3. Past Medical History Sexually Transmitted Disease No 486 (71) 3429 (74) Yes (1 or > episodes) 199 (29) 1209 (26) Gonorrhea Syphilis 7 16 Venereal wart Herpes 8 19 Hx of hepatitis 45 (6) 193 (4) Hx of malaria 16 (2) 118 (2) Hx of blood transfusion 7 (2) 121 (5) Hx of blood donation 34 (8) 27 (1) subjects studied were usually heterosexual in orientation although most admitted to bisexual practices in the course of their employment in gay bars (Table 4). Thus, there were 146 (22%) heterosexual males and an additional 394 (59%) who admitted bisexual practices. There were 125 (19%) homosexual subjects. On the other hand, there were 4364 (98.3%) females who were heterosexual, 62 (1.4%) who were bisexual and 13 (0.3%) who were homosexual. There were significantly more homosexual/bisexual males, p<.001, than females.

4 Table 4. Sexual Behavior Homosexual 125 (19)* 13 (0.3) Bisexual 394 (59)* 62 (1.4) Heterosexual 146 (22) 4365 (98.3)* * p <.001 M vs F Most subjects admitted to having less than 30 sexual partners per month in the past 6 months: 618 (96%) males and 3540 (80%) females; 25 (4%) and 889 (20%) of males and females respectively had over 31 sexual partners per month; 367 (58%) males and 1355 (31%) females stated their partners were Filipinos. However, 324 (42%) males and 3044 (69%) females had sexual partners originating from another country. More female than male subjects were significantly represented in this group, p <.001. A subgroup, 288 or 36% of all males and 1189 (27%) of females had both Filipinos and non-filipino partners. More males admitted to anal sex than females, p <.001. Two hundred twelve or 34% of the total number of males admitted to anal sex with 124 (59% of this subgroup) being receptive partners, 43 (20%) the insertive partner, and 45 (21%) receptive/insertive roles. Anal sex was admitted to by only 48 (1%) of the females interviewed (Table 5). Table 5. Number of sexual partners and their country of origin No. of Partners/Mo in past 6 mos 30 and less 618 (96) 3540 (80) (3) 321 (7) (.9) 259 (6) > 97 2 (.1) 309 (7) Country of origin of partners Filipino only 367 (58) 1335 (31) Foreigner only 36 (6) 1855 (42) * Both 288 (36) 1189 (27) * p <.001, F Vs M Table 6. Sexual Practices Anal Sex No 410 (66) 4288 (99) Yes 212 (34)* 48 (1) Receptive 124 (59) 48 Insertive 43 (20) - Both 45 (21) - Condom Use No/Not regular 270 (94) 1089 (70) Yes 17 (6) 462 (30) Use by year /42 (5) 44/1273 (3) /143 (4) 270/1608 (17)* /58 (6) 148/736 (20) P <.001 Condom use was not elicited or its use was minimal in 270 (94%) males and 1089 (70%) of females. The rate of condom use was examined per year during the course of the study. No

5 significant increase in condom use was noted among the males with 2 (5%), 6 (4%) and 9 (6%) using condoms in 1986, 1987 and 1988 respectively. On the other hand, a trend to increasing condom use could be seen among the partners of the females; 44 (3%), 270 (17%), and 148 (20%) of females claimed regular condom use by their sexual partners. This apparent increase between 1986 and 1988 appeared to be of significance, p <.001 (Table 6). HIV antibodies were detected and confirmed on supplemental testing among 3 (0.4%) of the 694 males and 5 (0.1%) of 4,720 females subjects studied. All HIV infected subjects were asymptomatic and were classified as belonging to the CDC Group 2 clinical classification. DISCUSSION HIV infection is felt t o have been introduced in the Philippines in this decade, most likely at least ten years later than such countries as the United States and Africa where the number of full blown cases of AIDS are the highest worldwide. Inasmuch as HIV infection is mostly a behavioral disease with sexual behavior and sexual practices influencing the chances of acquiring infection, information on prevailing risky behaviors among the indigenous population would be of importance in establishing the risks of both acquiring and transmitting infection once acquired. The behavioral information obtained from the subjects studied in Metro Manila demonstrate the route by which HIV infection have been most likely introduced into this country: Among the individuals working in the tourist oriented establishments, sexual favors were frequently dispensed during the course of their employment. In these establishments, foreign visitors usually solicited such sexual favors. The data obtained illustrates the presence of relevant social,, sexual/and medical in formation which also influence the probability of these subjects acquiring infection. Thus, histories of STD infections were elicited from 29% of the males, and 26% of the females. Intake of behavior modifying agents, many sexual partners, sexual partners of foreign, origin (42% M and 69% F) non-regular/no condom use (94% M and 70% F) and anal sex mostly among males (34%) were also seen in these individuals. Interestingly, condom use appeared to be increasing among the partners or the female subjects during the period of the study. The reasons for this were not investigated although an increasing awareness of HIV infection and the need for protective barriers as a means of decreasing chances of infection may have resulted from increasing awareness of condom role. Among the social aspects of the study, the frequent use of behavior modifying drugs, although not intravenously taken may cause the individual to adopt practices considered risky. The general impression that intravenous drug abuse was not a common practice in the Philippines was borne out by the inability to detect intravenous drug addicts among the subjects studied. These observations were supported by the absence of the usual stigmata of chronic intravenous drug administration noted on physical examination. Of paramount importance is the demonstration of HIV infection among these groups studied coupled with the demonstration of risky behaviors. The likelihood of spread from the infected subjects to the general population is further enhanced by the observations that a sizable number of the subjects were highly sexually active with exposure to both Filipino and foreign partners, that a subgroup were either married or had live-in partners, and that unprotected sexual contact was very common. Finally, the female subjects studied were mostly in the reproductive age group pointing to another possible route of transmission once HIV infection was acquired and the subject became pregnant. CONCLUSION HIV infection has been demonstrated among 0.4% of males and 0.1% of females working in bars, discotheques, sauna baths and massage parlors in Metro Manta. The presence of risky

6 sexual practices such as many sexual partners, sexual partners originating from other countries, non-regular or no condom usage, and anal sex mostly among the males enhance the risk of acquiring HIV infection. Implications for spread of HIV infection from these groups are seen as exposure to both Filipino and non-filipino partners, the demonstration of a subgroup who were either married or had live-in sexual partners, and unprotected sexual contact were elicited from the study subjects. These information need to be utilized in prevention/intervention programs designed to limit the spread of HIV infection in the Philippines. Intravenous drug use, and blood donations as risk factors did not appear to be prevalent among the individuals surveyed. Acknowledgement We thank the following individuals for their support: Drs. D. Ganzon and F. Alconis in Ermita, Manila; S. Mohammad, N. Dayalo, D. Dayao, S. Tan, N. Ledesma and C. Ellama of RITM; J. Pardo of Abbott Philippines, R. Fulgar of Organon Teknika, H. Navarro, Philab, L. Romero and T. Tolentino of Wellcome Philippines. We express appreciation for the continuing support and the generous supply of HIV antigen slides provided by Dr. T. Kurimura of Tottori University, Yonago, Japan; and M. Ikeda of Fuji-rebio Inc. for Serodia kits. This study was supported in 1986 by the World Health Organization Western Pacific Regional Office. REFERENCES 1. Selik RM, Haverkos, HW, Curran IW. Acquired immune deficiency syndrome (AIDS) trends in the United States Am J Med 1984; 76: Piot P, Quinn TC, Taelman H, et al. Acquired immunodeficiency syndrome in a heterosexual population in Zaire. Lancet 1984; 2: Monzon OT, Pascasio FM, de la Rosa L, et al: Human immunodeficiency virus antibodies in homosexual/bisexual males in the Philippines. Phil J Microbiol Infect Dis 1986; 15(2): Monzon OT, Capellan JM, Navarro-Almario E, et al Behavioral risk factor: Surveillance in a population group at risk for HIV infection in the Philippines. From Proceedings of the 1st International Congress on AIDS and STD's in Asia, Nov , 1987, p