HIV in the Philippines: Still on the Rise REGINA BERBA MD MSc Philippine General Hospital and The Medical City
Once upon a time (circa 1984)! The Philippines is one of the exceptional countries that has not faced a large HIV epidemic! It is important to understand the reasons for low and slow rate. For lessons which can be learnt for effective control in similar settings. Farr & Wilson An HIV Epidemic is ready to emerge in the Philippines J Int AIDS Soc 2010 13:16
In 2010 HIV experts were baffled!!! likely reasons for the SLOW development of an HIV epidemic in the Philippines :! Country s geography is complicated! Injecting drug use is relatively uncommon! A Culture of sexual conservattsm! Sex workers tend to have few clients! Anal sex is relatively common Farr & Wilson An HIV Epidemic is ready to emerge in the Philippines J Int AIDS Soc 2010 13:16
2010! Lowest rates of condom use in Asia! Increasing casual sexual activity! Returning overseas Filipino workers from high prevalence settings! Widespread misconception about HIV/AID! High needle-sharing rates among injecting drug users Farr & Wilson An HIV Epidemic is ready to emerge in the Philippines J Int AIDS Soc 2010 13:16
Then in 2017: PHILIPPINES now the FASTEST growing HIV Epidemic in Southeast Asia!!!
The HARP Report
8! Cumulative HIV cases by mode of transmission, January 1984-May 2016 Male-male sex 19% Heterosexual 75% 0% 5% 0% 0% 1% Blood and blood products Sharing of needles Needle prick injury Mother-to-child Source: Prepared by www.aidsdatahub.org based on National Epidemiology Center Philippines. (2016). Philippines HIV/AIDS Registry: May 2016
A CLOSER LOOK into the FACTORS leading to the NON-STOP RISE HIV rates in the Philippines! Biologic: The Changing Virus! Social: The Social Networking! Behavioral: The New Freedom! Public Awareness: The Knowledge Gap! Program Response
BIOLOGIC FACTOR: Circulating HIV in the Philippines now MORE AGGRESSIVE than in previous decades Salvana et al 2017
Social Factors The Contribution of SOCIAL NETWORKING
HIV and AIDS Data Hub for Asia-Pacific! Key POPULATIONS AT RISK size estimates POPULATION SIZE ESTIMATES Populations Estimate Year of estimate PEOPLE WHO INJECT DRUGS 10,000-21,700 2015 FEMALE SEX WORKERS 66,000 2015 MALE SEX WORKERS 86,600 2015 MEN WHO HAVE SEX WITH MEN 531,500 2015 TRANSGENDER WOMEN 122,800 2015 Note: Estimates covered those aged 15+ years! Source: Prepared by www.aidsdatahub.org based on Philippines Global AIDS Response Progress Reporting 2016. 12!
HIV and AIDS Data Hub for Asia-Pacific! HIV prevalence among key populations, 2007-2015 50 HIV prevalence (%) 40 30 20 10 0 2007 2009 2011 2013 2015 FSW 0.1 0.2 0.3 0.4 0.4 MSW 1.1 0.4 MSM 0.3 1.1 1.7 3.3 4.9 PWID 0.1 0.2 13.6 44.9 29.0 TG sex workers 3.7 2.5 Source: Prepared by www.aidsdatahub.org based on Integrated HIV Behavioral and Serologic Surveillance (IHBSS) 2007-2015; www.aidsinfoonline.org 13!
HIV and AIDS Data Hub for Asia-Pacific! HIV prevalence among key populations, 2015 % 35 30 29 25 20 15 10 5 0 2.5 0.4 0.4 4.9 FSW MSW TG sex workers MSM PWID Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org 14!
HIV and AIDS Data Hub for Asia-Pacific! High HIV prevalence among key populations in selected cities, 2015 Male PWID Female PWID TG Women M/TSM Freelance FSW 45 42.8 40 35 % weighted 30 25 20 15 10 5 4.9 25.2 11.8 13.5 9.0 8.1 5.5 5.4 4.5 5.2 0 M/TSM = Males or transgenders who have sex with males! Source: Prepared by www.aidsdatahub.org based on National HIV and STI Surveillance and Strategic Information Unit, Epidemiology Bureau, DOH. (2016). 2015 Integrated HIV 15! Behavioral and Serologic Surveillance (IHBSS) Fact Sheets
HIV and AIDS Data Hub for Asia-Pacific! HIV prevalence among males who have sex with males in selected cities, 2007-2015 % 16 12 8 4 0 2007 2009 2011 2013 2015* Quezon 0.4 1.44 5.56 6.56 5.5 Manila 3.7 4.3 6.7 2.4 Cebu 0 1 4.7 7.7 13.5 Davao 3.67 2.67 5 5.4 Cayagan de Oro 1.9 4.7 8.1 * Data from the 2015 IHBSS is for a mixed survey sample of males or transgenders who have sex with males (M/TSM). In addition it has been adjusted using Time Location Sampling (TLS) weights, therefore it is not directly comparable to previous IHBSS rounds. Source: Prepared by www.aidsdatahub.org based on Integrated HIV Behavioral and Serologic Surveillance (IHBSS) Reports 16!
HIV and AIDS Data Hub for Asia-Pacific! HIV prevalence among males who have sex with males by age group, 2009-2015 % 10 8 6 4 2 0 2009 2011 2013 2015 15-19 yr 0.9 0.6 1.4 3.6 20-24 yr 1.3 3.5 4 6.2 25+ yr 1.1 2.8 6.2 8.9 NOTE: Data may not reflect national figures, but represent locations sampled in each round! Source: Prepared by www.aidsdatahub.org based on National HIV/AIDS & STI Surveillance and Strategic Information Unit. Epidemiology Bureau, Department of Health. (2016). The 17! growing HIV epidemic among adolescents in the Philippines.
HIV and AIDS Data Hub for Asia-Pacific! HIV prevalence among FSW by age group, 2011 and 2013 1 HIV prevalence (%) 0.8 0.6 0.4 0.2 0 0.8 0.7 0.5 0.4 0.4 0.1 0.1 0.1 0.1 0.1 0 0 0 0 0 2011 2013 2011 2013 0.7 RFSW FFSW 15-17 yr 18-24 yr 25+ yr All Note: FFSW = Freelance female sex workers; RFSW = Female sex workers in registered entertainment establishments; Data shown represents average HIV prevalence for surveyed sites. For FFSW there were 18 and 9 sites in 2011 and 2013, respectively. For RFSW, there were 17 and 10 sites in 2011 and 2013, respectively.! Source: Prepared by www.aidsdatahub.org based on National HIV and STI Surveillance and Strategic Information Unit, National Epidemiology Center, DOH. (2014). 2013 Integrated HIV Behavioral and Serologic Surveillance (IHBSS) Report. Manila, Philippines. 18!
HIV and AIDS Data Hub for Asia-Pacific! HIV prevalence among male PWID by age group, Cebu City and Mandaue City, 2011 and 2013 2011 2013 HIV prevalence (%) 60 50 40 30 20 19.3 45.0 39.8 51.4 26.9 48.2 10 9.5 4.4 0 15-17 yr 18-24 yr 25+ yr All ages Age group Source: Prepared by www.aidsdatahub.org based on National HIV and STI Surveillance and Strategic Information Unit, National Epidemiology Center, DOH. (2013). 2013 IHBBS 19! Briefer. Males who have Sex with Males (MSM) and Male Injecting Drug Users (IDU) - Preliminary report. Manila, Philippines.
HIV and AIDS Data Hub for Asia-Pacific! Reported HIV cases by mode of transmission, 1984-May 2016 100% 80% 60% 40% 20% 0% Needle prick injury Blood and blood products Mother to child transmission Injecting drug use Heterosexual Male-male sex Source: Prepared by www.aidsdatahub.org based on National Epidemiology Center Philippines. Philippines HIV /AIDS Registries, 2008 May 2016 20!
HIV and AIDS Data Hub for Asia-Pacific! Cumulative HIV cases by mode of transmission, January 1984-May 2016 Male-male sex 19% Heterosexual 75% 0% 5% 0% 0% 1% Blood and blood products Sharing of needles Needle prick injury Mother-to-child No data available Source: Prepared by www.aidsdatahub.org based on National Epidemiology Center Philippines. (2016). Philippines HIV/AIDS Registry: May 2016 21!
HIV and AIDS Data Hub for Asia-Pacific! Proportion of HIV cases among Overseas Filipino workers (OFWs) compared to Non-OFWs, 2000- May 2016 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 * OFW 60 79 96 93 86 92 130 106 122 164 174 271 342 508 650 680 270 Non-OFW 63 95 88 100 113 118 179 236 406 671 1417 2078 2993 4305 5361 7149 3532 * January - May 2016! Source: Prepared by www.aidsdatahub.org based on National Epidemiology Center Philippines. (2016). Philippines HIV/AIDS Registry: May 2016 22!
The Contribution of SOCIAL NETWORKING! WHERE DO POPULATIONS AT RISK MEET? SOCIAL MOBILITY Hernandez LI,Imperial RH MSMin the Philippines Identities, Sexualties and Social Mobilities: A Formative Assessment of HIV and AIDS Vulnerabilties ACTA MEDICA PHILIPPINA 2009 43:3
The Filipino Men Having Sex with Men (MSM)! MSM primarily responsible for HIV transmission in the Phil! Defined by their behavior towards SAFE SEX, their Masculinity and their Partner! More sexually active! More sexual partners! Take risks to maintain their machismo image! More likely to refuse to practice safe sex! SAFE SEX is viewed as UNMASCULINE for it hinders sexual provess Hernandez LI,Imperial RH MSM in the Philippines Identities, Sexualties and Social Mobilities: A Formative Assessment of HIV and AIDS Vulnerabilties ACTA MEDICA PHILIPPINA 2009 43:3
Where MSM congregate Hernandez LI,Imperial RH MSMin the Philippines Identities, Sexualties and Social Mobilities: A Formative Assessment of HIV and AIDS Vulnerabilties ACTA MEDICA PHILIPPINA 2009 43:3
Old Theaters was where they convened Hernandez LI,Imperial RH MSMin the Philippines Identities, Sexualties and Social Mobilities: A Formative Assessment of HIV and AIDS Vulnerabilties ACTA MEDICA PHILIPPINA 2009 43
Other places for MSM convergence Hernandez LI,Imperial RH MSMin the Philippines Identities, Sexualties and Social Mobilities: A Formative Assessment of HIV and AIDS Vulnerabilties ACTA MEDICA PHILIPPINA 2009 43
The Sex Clubs Hernandez LI,Imperial RH MSMin the Philippines Identities, Sexualties and Social Mobilities: A Formative Assessment of HIV and AIDS Vulnerabilties ACTA MEDICA PHILIPPINA 2009 43
The Emergence of Bath Houses and Sex Clubs Hernandez LI,Imperial RH MSMin the Philippines Identities, Sexualties and Social Mobilities: A Formative Assessment of HIV and AIDS Vulnerabilties ACTA MEDICA PHILIPPINA 2009 43
Defining MEN
The NOW Locate anybody anytime anywhere
The Asian MSM
BEHAVIORAL FACTORS The NEW FREEDOM
HIV and AIDS Data Hub for Asia-Pacific! Proportion of key populations who reported condom use at last sex, 2007-2015 % 100 90 80 70 60 50 40 30 20 10 0 FSW MSW MSM PWID TG sex workers 84 73 73 65 65 68 64 50 55 50 41 36 32 30 32 34 27 28 22 15 13 15 2007 2009 2011 2013 2015 Source: Prepared by www.aidsdatahub.org based on 1. UNAIDS Report on The Global AIDS Epidemic, 2010; and 2. www.aidsinfoonline.org 34!
HIV and AIDS Data Hub for Asia-Pacific! Proportion of males who have sex with males who reported condom use at last sex with male partner, selected cities, 2015 % weighted 100 90 80 70 60 50 40 30 20 10 0 63 61 55 55 54 53 53 52 52 51 51 50 44 42 40 40 39 Note: Survey included males or transgenders who have sex with males! Source: Prepared by www.aidsdatahub.org based on National HIV and STI Surveillance and Strategic Information Unit, Epidemiology Bureau, DOH. (2016). 2015 Integrated HIV Behavioral and Serologic Surveillance (IHBSS) Fact Sheets. 35!
HIV and AIDS Data Hub for Asia-Pacific! Proportion of MSM who reported condom use at last sex with a male partner in the last 12 months, by age group and city, 2014 % 100 15-17 yr 18-24 yr 25+ yr Total 90 80 70 60 50 42 42 40 35 32 33 29 30 21 20 10 2 7 9 7 0 Mandaluyong Taguig Parañaque 39 Source: Prepared by www.aidsdatahub.org based on Special MSM IHBSS 2014 as part of Big Cities Project (BCP) reported in National HIV and STI Surveillance and Strategic Information Unit, National Epidemiology Center, DOH. (2014). 2013 IHBSS Report. Manila, Philippines. 36!
HIV and AIDS Data Hub for Asia-Pacific! Proportion of male entertainment establishment workers who reported condom use at last sex by partner type and by city, 2015 % weighted 100 90 80 70 60 50 40 30 20 10 0 97 98 94 90 88 88 79 80 70 55 54 50 Angeles City Manila City Pasay City Quezon City with male client with non-paying male partner with female client Source: Prepared by www.aidsdatahub.org based on National HIV and STI Surveillance and Strategic Information Unit, Epidemiology Bureau, DOH. (2016). 2015 Integrated HIV Behavioral and Serologic Surveillance (IHBSS) Fact Sheets. 37!
HIV and AIDS Data Hub for Asia-Pacific! Proportion of males who have sex with males who engaged in transactional sex in the last year, selected cities, 2015 100 Sold sex Bought sex % Weighted 80 60 40 70 70 56 52 48 47 47 42 53 49 45 38 38 35 33 33 29 20 0 Note: Survey included males or transgenders who have sex with males! 38! Source: Prepared by www.aidsdatahub.org based on National HIV and STI Surveillance and Strategic Information Unit, Epidemiology Bureau, DOH. (2016). 2015 Integrated HIV Behavioral and Serologic Surveillance (IHBSS) Fact Sheets.
HIV and AIDS Data Hub for Asia-Pacific! Sexual behavior and condom use among MSM in the last 12 months, 2011 and 2013 % 100 80 2011 2013 60 40 20 34 30 24 48 39 38 NA = data not available! 27 26 35 0 Had sex with a female NA Used a condom during last vaginal sex Sold sex NA Used concom during last paid sex Bought sex NA Used condom during last paying sex Bisexual behavior Engaged in commercial sex as sex worker Engaged in commercial sex as client Source: Prepared by www.aidsdatahub.org based on National Epidemiology Center Philippines. Integrated HIV Behavioural and Serologic Surveillance Reports for 2011 and 2013 39!
Public Awareness THE VERY WIDE KNOWLEDGE GAP
HIV and AIDS Data Hub for Asia-Pacific! Proportion of key populations with comprehensive HIV knowledge, 2011-2015 % 100 80 83 2011 2013 2015 66 67 60 40 20 51 47 49 42 41 35 35 36 31 31 24 21 31 50 0 RFSW * Male PWID ** MSM *** MEW # FFSW ## TG ### * FSW in Registered Entertainment Establishments ( average for 17 sites in 2011, 10 sites in 2013, and$only$manila$city$in$2015) ** Average for 4 sites in 2011, Cebu City in 2013 and 2015 *** Average for 18 sites in 2011, 21 sites in 2013, and 35 sites with mixed samples of MSM and TG in 2015 # Male Entertainment Establishment Workers (only Quezon City in 2011, average for 3 sites in 2013, and 4 sites in 2015)! ## Freelance FSWs (average for 18 sites in 2011, 9 sites in 2013, and$only$cebu$city$in$2015) ### TG SW in Cebu City (2013) and TG women in Cebu City (2015) Note: 2015 data is weighted! Source: Prepared by www.aidsdatahub.org based on Integrated HIV Behavioral and Serologic Surveillance (IHBSS) Reports 41
HIV and AIDS Data Hub for Asia-Pacific! Proportion of key populations with comprehensive knowledge of HIV by age group, 2013 % 100 15-17 yr 18-24 yr 25+ yr Total 80 60 40 20 25 18 21 13 50 47 43 20 40 34 35 40 35 25 24 19 56 50 50 40 39 33 36 17 0 FFSW RFSW MSM Male PWID * TG sex workers * * In Cebu city ** Male Entertainment Establishment Workers FFSW = Freelance female sex workers RFSW = Female sex workers in Registered Entertainment Establishments! MEW ** Source: Prepared by www.aidsdatahub.org based on National HIV and STI Surveillance and Strategic Information Unit, National Epidemiology Center, DOH. (2014). 2013 Integrated HIV Behavioral and Serologic Surveillance (IHBSS) Report. Manila, Philippines. 42
HIV and AIDS Data Hub for Asia-Pacific! Proportion of key populations with comprehensive HIV knowledge, selected cities, 2015 100 80 60 40 89 60 60 54 35 35 31 67 51 83 31 67 56 43 41 38 34 20 6 0 Manila Pasay Quezon % weighted Angeles Mandaue * Cebu** Cebu* Cebu Angeles Manila # Cebu ## Pasig Manila Zamboanga Davao Cebu Quezon Angeles MEWs PWID TG Women FSW M/TSM MEWs = Male entertainment establishment workers; M/TSM = Males or transgenders who have sex with males # Female sex workers in registered establishments; ## Freelance female sex workers; * Male PWID; ** Female PWID! Source: Prepared by www.aidsdatahub.org based on National HIV and STI Surveillance and Strategic Information Unit, Epidemiology Bureau, DOH. (2016). 2015 Integrated HIV Behavioral and Serologic Surveillance (IHBSS) Fact Sheets. 43
EDUCATION AS STRATEGY needs a lot of support and technical assistance
THE MEDICAL CITY 2016-2017 PROJECT: DANCE TO THE LIGHT DANCE FOR HOPE
THE MEDICAL CITY 2016-2017 PROJECT: DANCE TO THE LIGHT DANCE FOR HOPE
THE MEDICAL CITY 2016-2017 PROJECT: DANCE TO THE LIGHT DANCE FOR HOPE
The Government Program
HIV and AIDS Data Hub for Asia-Pacific! Proportion of key populations reached with HIV prevention programmes, 2007-2013 % 100 90 80 70 60 50 40 30 20 10 0 79 63 55 29 54 32 19 14 14 23 23 11 2007 2008 2009 2010 2011 2012 2013 FSW MSM PWID MSW TG sex workers Source: Prepared by www.aidsdatahub.org based on 1. National Epidemiology Center Philippines: Integrated HIV Behavioral and Serologic Surveillance (IHBSS) 2007, 2009, 2011 and 2013; 2. UNAIDS. (2012). Annexes - UNAIDS Report on the Global AIDS Epidemic 2012; and 3. www.aidsinfoonline.org 53!
HIV and AIDS Data Hub for Asia-Pacific! Proportion of key populations who received an HIV test in the last 12 months and knew their results, 2007-2015 % 100 80 60 40 20 0 37 34 24 24 24 16 19 16 16 12 15 17 7 9 4 5 5 7 5 1 2007 2009 2011 2013 2015 FSW MSM PWID MSW TG sex workers Source: Prepared by www.aidsdatahub.org based on 1) UNAIDS Report on the Global AIDS Epidemic, 2010; and 2) www.aidsinfoonline.org 54!
HIV and AIDS Data Hub for Asia-Pacific! Proportion of key populations who received an HIV test in the last 12 months, selected cities, 2015 100 80 % weighted 60 40 20 34 16 10 23 18 15 19 16 8 41 28 27 26 26 25 22 22 0 Quezon Angeles Pasay Cebu * Cebu** Mandaue * Cebu Angeles Cebu Taguig Mandaluyong Davao Cagayan de Oro Caloocan Muntinlupa Marikina Pasay MEWs PWID TG Women FFSW M/TSM MEWs = Male entertainment establishment workers; M/TSM = Males or transgenders who have sex with males FFSW = Freelance female sex workers; * Male PWID; ** Female PWID! Source: Prepared by www.aidsdatahub.org based on National HIV and STI Surveillance and Strategic Information Unit, Epidemiology Bureau, DOH. (2016). 2015 Integrated HIV Behavioral 55! and Serologic Surveillance (IHBSS) Fact Sheets.
HIV and AIDS Data Hub for Asia-Pacific! Proportion of key populations who know where to get tested for HIV, selected cities, 2015 % weighted 100 80 60 40 20 98 99 100 100 99 95 87 90 89 87 83 86 86 82 74 61 51 0 M/TSM Transgender women Male PWID Female PWID Registered FSWs Freelance FSWs MEWs Angeles City Cebu City Mandaue City Manila City Pasay City Quezon City M/TSM = Males or transgenders who have sex with males; MEWs = Male entertainment establishment workers! Source: Prepared by www.aidsdatahub.org based on National HIV and STI Surveillance and Strategic Information Unit, Epidemiology Bureau, DOH. (2016). 2015 Integrated HIV Behavioral and Serologic Surveillance (IHBSS) Fact Sheets. 56
HIV and AIDS Data Hub for Asia-Pacific! Number of ART sites and number of people on ART, 2004-2015 Number of people on ART 14,000 12,000 10,000 8,000 6,000 4,000 2,000 16 23 16 12,533 40 30 20 10 Number of ART sites - 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 0 Number of health facilities that offer ART Number of people on ART Source: Prepared by www.aidsdatahub.org based on 1. UNAIDS. (2016). HIV Estimates 2000-2015; and 2) Global AIDS Response Progress Reporting 57!
ART scale up, 2004-2015 HIV and AIDS Data Hub for Asia-Pacific! 15,000 12,533 100 12,000 80 Number 9,000 6,000 3,000 13 16 21 27 60 40 20 ART coverage (%) 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 0 ART coverage (%) Number of people on ART Source: Prepared by www.aidsdatahub.org based on 1) UNAIDS. (2016). HIV Estimates 2000-2015; and 2) Global AIDS Response Progress Reporting 58!
HIV and AIDS Data Hub for Asia-Pacific! Estimated number of adults living with HIV, adults receiving ARVs, and adult ART coverage, 2015 140,000 100 Number 120,000 100,000 80,000 60,000 40,000 20,000 42,000 12,492 30 80 60 40 20 % ART coverage 0 Estimated number of adults living with HIV Adults receiving ARVs (number) Adult ART coverage (%) 0 Source: Prepared by www.aidsdatahub.org based on 1) UNAIDS. (2016). HIV Estimates 2000-2015 59!
HIV and AIDS Data Hub for Asia-Pacific! Estimated number of pregnant women living with HIV, pregnant women receiving ARVs, and PMTCT coverage, 2015 1000 100 Number 800 600 400 200 0 <500 Estimated number of pregnant women living with HIV 32 Number of pregnant women receiving ARVs * 10 PMTCT coverage * (%) 80 60 40 20 0 PMTCT coverage (%) * Effective regimen! Source: Prepared by www.aidsdatahub.org based on 1) UNAIDS. (2016). HIV Estimates 2000-2015 60!
HIV and AIDS Data Hub for Asia-Pacific! Estimated number of children living with HIV, children receiving ARVs, and child ART coverage, 2015 1000 100 Number 800 600 400 200 80 60 40 20 ART coverage (%) 0 Estimated number of children (0-14 yr) living with HIV Number of children (0-14 yr) receiving ARVs ART coverage (%) 0 Source: Prepared by www.aidsdatahub.org based on 1) UNAIDS. (2016). HIV Estimates 2000-2015 61!
Other CRITICAL ISSUES
HIV and Duterte? Lancet June 2017
Well thought of but needs updating
Our Catholic Church: An important ally
HIV and AIDS Data Hub for Asia-Pacific! Review in slides! Philippines! Last updated: September 2016 www.aidsdatahub.org!
HIV and AIDS Data Hub for Asia-Pacific! Acknowledgement to: www.aidsdatahub.org Data shown in this slide set are comprehensive to the extent they are available from country reports. Please inform us if you know of sources where more recent data can be used. Please acknowledge www.aidsdatahub.org if slides are lifted directly from this site. 67!