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Its more RED in the Philippines

A civil society briefer on the growing HIV epidemic in the Philippines

A few days before the 2012 World AIDS Day, the UN Joint Programme on HIV and AIDS (UNAIDS) released a report that presents historic gains towards ending AIDS. All over the world, countries started to reverse the number of new HIV cases, with UNAIDS revealing that there are 700 000 fewer new HIV infections across the world in 2011 than in 2001. The new battlecry - Getting to Zero - has given momentum to global efforts to put an end to AIDS. But while majority of countries worldwide are reporting stable or decreasing HIV incidence rates, the Philippines is one of the only nine countries worldwide that is experiencing a rapid increase in new HIV infections. According to the latest HIV and AIDS Registry of the Department of Health, the country is now recording 9 to 10 new HIV cases everyday, a manifestation of a fast and furious HIV epidemic in the Philippines. The official estimate is higher: based on the projections of the Philippine National AIDS Council, a total of 22,800 Filipinos are living with HIV. In 2015, at the tail end of President Aquinos term, the number could reach 35,900 to 46,500. Why is the Philippine HIV situation going against global HIV trends? The current discourse on HIV has centered mostly on heavily stigmatized narratives about the changing sexual behavior of Filipinos, or on how social networking and access to internet have contributed to the rapid rise in new cases. That crucial issues in the countrys HIV response are in the sidelines of the national conversation means that the gaps in our HIV response have to be unpacked to give perspective and context to the HIV epidemic in the Philippines. Using evidence to understand the epidemic Thirty years into the AIDS pandemic, the Philippines should be well-armed with evidence-informed strategies to stop its growing HIV epidemic. However, various stakeholders, from the media to politicians, oftentimes resort to the usual whipping boys of the HIV epidemic - promiscuity, gay sex, and lately, social media. This reflects how evidence is often trumped by the stigma that surrounds the virus. The 2012 Global AIDS Response Progress Report submitted by the Philippine National AIDS Council to the UN presents crucial gaps and structural deficits in the countrys HIV response, to which the growing HIV incidence should be proportionately attributed. One concern is the low coverage of HIV prevention programs, especially among populations at a higher risk of HIV infection. 80% of new cases are attributed to unprotected male to male sex, and yet less than 25% of men who have sex with men and transgenders (MSM & TGs) are reached by existing prevention programs. It is therefore not surprising that condom use among MSM and TGs is only at 36%, and despite the prevalence of risky sexual behavior, only 5% have received an HIV test and even a lesser number proceeded to access life-saving antiretroviral treatment. Among injecting drug users (IDUs), on the other hand, three out of four share needles, a risky behavior that immediately exposes a person to HIV infection. Despite this, only 5% of injecting drug users have taken an HIV test, and the government currently has no data on the extent of the reach prevention activities among IDUs. In the case of sex workers, while coverage of prevention programs is relatively high for establishment-based sex workers (63%), the same cannot be said for freelance sex workers.

Evidence gathered from the experiences here and other countries should also determine the actions of Philippine authorities to stop the epidemic at its cusp. It should work towards investing more to scale up services - those that actually work, and discard those that do not - and it should engage the civil society and communities affected by or vulnerable to HIV to remove the stigma associated with the virus. Evidence says that if authorities embrace male-to-male sex as a reality and empower the MSM and TG community, if it decriminalize sex work and protect sex workers, if it addresses the issue of drug use from the perspective of human rights, it could create a climate where the Philippines can reverse its HIV epidemic and end AIDS. Unfortunately, the gap between evidence and action remains wide and difficult to cross. The barriers to the HIV response Low coverage due to low investment. That gap is nowhere more evident than in the level of Philippine governments spending for its HIV response. Investment in HIV services has largely been driven by external sources. Before 2010, 80% of HIV programs are funded through foreign grants, the main source of which is the Global Fund for AIDS, TB, and Malaria, a mammoth financial facility created to fight diseases detrimental to national development of many developing countries. Reliance on foreign grants has been the main feature of HIV investment in the Philippines, a situation that has stumped efforts to scale up its HIV response: the global economic crisis has clipped the finances of the Global Fund, and with the categorization of the Philippines as middle-income country, a World Bank donor country at that, foreign donors expect domestic spending for HIV and other diseases to increase. The effect is a decline in total spending (domestic and foreign) for HIV programs in the country despite the growing infection rate. (See table below)

! 2009 2010 2011

Year

Total spending 573,122,069.90 563,684,723.90 545,365,110.07

(Source: PNAC National AIDS Spending Assessment) When the HIV and AIDS Registry was already recording an increase in HIV infection in 2007, national government allocation for HIV programs through General Appropriations (GAA) was stagnating, if not declining. In 2007 and 2008, the allocation in the GAA was only P74M annually, and it slightly increased to P81M in 2009. By 2010 and 2011, the allocation went down to P65M annually, and it was only increased for 2011 as a reaction to the announcement of Global Funds cancellation of its next round of grants. It spent a total of P163M in 2011, but only 67% of which went to prevention and treatment programs. For 2013, the total allocation is P145M, around P95M of which would go to various HIV programs, P30M to surveillance, and P20M for the secretariat of the Philippine National AIDS Council. The resources that it expects to receive domestically and even from international sources are severely insufficient compared to what it needs. In 2012, the Philippine National AIDS Council approved an Investment Plan that lays down the amount of resources that the country needs to implement its HIV and AIDS roadmap, the AIDS Medium Term Plan. A targeted package of interventions in high incidence areas - NCR, Cebu, Davao and Angeles City - would require P5.9B in total, amounting to a funding gap of P548 annually.

An old legal framework responding to a new HIV epidemic. When the Philippines enacted its HIV and AIDS law, the AIDS Prevention and Control Act of 1998 (RA8504), it was lauded as a model legislation because of its strong adherence to human rights-based approaches. It institutionalized various elements of the response in prevention, HIV information and education, health services, surveillance, human rights and governance, and it established a secretariat to support the Philippine National AIDS Council (PNAC), which was created under the Executive Order No. 39. But RA8504 is a law that was created to address an HIV epidemic that had a different context. When the law was crafted and enacted, HIV incidence in the Philippines was low, and establishment-based sex workers and migrant workers were seen as the potential drivers of the epidemic. Thus, the design that was established by the law reflected the prevailing epidemic. With the rising HIV incidence beginning 5 years ago, the gaps in the legal framework became more evident. The law paved the way to a system that can address a small-scale general population HIV epidemic, which is no longer the situation now. It also heightened the ambiguities of the functions of the members of PNAC, and which government structure - national or local, health sector or multisectoral - has the main obligation to steer and implement the response. The current law is likewise unclear about investment: it has established a limited program within the Department of Health but did not contemplate the need for resources for a more comprehensive program. The appropriation language in the law is limited to the functions of the PNAC secretariat only. Lastly, the law is now superseded by other legislations that have effectively limited the response. The Dangerous Drugs law, for instance, is understood to prevent the government from applying evidence-informed harm reduction strategies to curb HIV infection among IDUs. The AntiTrafficking law, on the other hand, has been used by law enforcers to criminalize certain sexual behaviors and identities: the presence of condoms has been used by policemen as evidence for prostitution, an act prohibited by the Anti-trafficking law, to rationalize illegal raids conducted in establishments frequented by MSM and TGs. An epidemic surrounded by stigma and discrimination. While the legal framework provides for protection for constitutionally guaranteed human rights of people living with HIV, stigma and discrimination remain a major barrier to the response to the epidemic. The law criminalizes discrimination and prohibits mandatory testing to prevent the stigmatization of communities affected by and vulnerable to HIV infection, and yet these legal remedies are hardly accessed due to the persistence of stigma. A report by Achieve and Pinoyplus, two HIV CSOs, on RA 8504 and its effectiveness against stigma and discrimination shows that eight out of ten Filipinos living with HIV have experienced strong to serious discrimination.1 An Asia Pacific Stigma Index conducted in 2011 reveals that PLHIV in the Philippines experience loss of job or rejection of job application (38%), verbal abuse and threats (21%), denial of health services (8%) and physical assault (8%).2 Populations vulnerable to HIV also face continuing stigma and discrimination. Prejudices against male-to-male sex have defined how health facilities that provide HIV services relate with MSM and TG clients, while public and private institutions, from schools to law enforcement agencies and the media, have consistently blamed gay sex - despite the evidence saying that the culprit is unprotected gay sex - as the cause for the rise in the new HIV cases in the country. The criminal status of drug users and sex workers have also rendered them vulnerable to abuses, making it difficult for HIV services to reach them and for them to access HIV programs. Stigma and

An article on the research jointly conducted by Achieve and Pinoy Plus may be found here: http:// www.achieve.org.ph/content/achieve-address-access-legal-services-plhivs-ght-stigma-and-discrimination
2

People Living with HIV Stigma Index: Asia Pacic Regional Analysis (2011)

discrimination curtail the reach and effectiveness of HIV services, and they also prevent communities affected by or vulnerable to HIV from organizing themselves against the epidemic. An unsustainable response. Other than being reliant on foreign grants, the Philippine response needs to focus towards a more strategic direction. Without a comprehensive approach to the epidemic, it is unlikely for the country to stop the epidemic. For the 2013 budget for HIV services, the government has guaranteed a P35M allocation for antiretroviral treatment to cover the needs of around 6,056 Filipinos living with HIV. Along with the existing out-of-patient package from PhilHealth, the scaling up of domestic funding for treatment is a welcome development. But for the spending for treatment to be sustainable and strategic, it must be accompanied by an increase in resources for prevention as well, an issue that has been evaded by the government. To date, however, resources for evidence-based behavior change interventions that can curb sexual transmission of HIV are scanty and insufficient. Without an effective preventive interventions, incidence would continue to increase, and the demand for treatment would inevitably rise as well. Political leadership in the response. In the context of a multisectoral response involving the government and the civil society in a devolved governmental system, political leadership becomes all the more important, whether in steering various agencies and communities towards the strategic direction of the response or in ensuring that HIV programs in the country are efficiently resourced. Political leadership also entails that the sectors involved in the response are able to marshal the symbolic and material resources of their constituents to address the barriers to the response, whether this involves the government allocating public resources or civil society groups engaged meaningfully in mobilizing communities for HIV programs. The rising HIV incidence in the country has compelled the political leadership to step up in its role, but the action remains slow. The Philippine National AIDS Council remains to be weak in steering the response, an indication of which is the state of the countrys Fifth AIDS Medium Term Plan (AMTPV): as in the previous AMTPs, the current one is poorly implemented. That we are facing an HIV problem should not surprise anyone since the countrys roadmap to end AIDS remains to be a plan. Civil society Five-Point Agenda Blaming social media, gay sex, or promiscuity for the growing HIV epidemic in the Philippines therefore disregards the fundamental and structural problems of the HIV response. To stop AIDS, the issues of low investment, an inadequate legal framework, stigma and discrimination, unsustainable response and a tepid political leadership cannot be skirted. The Network to Stop AIDS-Philippines (NSAP) believes that reforms in the response should focus in the following areas: 1. Investing in the response. The current level of spending on HIV is inadequate, and scaling up the response will not happen without any substantial increase in domestic funding for HIV. Based on the projections of NSAP, a total of P220M must be spent initially to slowly increase the coverage of HIV services to 60% - 80% among vulnerable and at-risk populations. Of the proposed P222M, P139M will go to prevention. P39M of this will be for the diagnosis and treatment of sexually transmitted infections, P34M for the procurement of behavior change collaterals (condoms, etc.), P59M for the allowance of peer educators, and P6M for voluntary counseling and testing. P58M will go to treatment, care, and support, which covers the purchase of anti-retrovirals and support for programs for Filipinos living with HIV. P25M will go to activities that would strengthen

facilities and mechanisms that deliver HIV services at the national and local levels. P5M of this amount will be to monitor and improve impact and effectiveness of existing HIV services. 2. Overhauling the legal framework. A bill revising the current law on HIV is pending before Congress, the House version of which has already been approved by the Committee on Health and has just passed the Committee on Appropriations. The bill provides for the upgrading of HIV programs to make sure that theyre evidence-based and can actually respond to the current epidemiological profile. It also strengthens the Philippine National AIDS Council to correct existing ambiguities in the structure. It establishes and institutionalizes the National HIV and AIDS Strategic Plan and ensures public funding for the roadmap. 3. Ending stigma and discrimination. The government has to invest its political stock to remove stigma and discrimination associated with HIV, including those experienced by communities vulnerable to HIV. The government must provide a seamless mechanism for redress to those affected by stigma and discrimination, and that requires the strengthening of communities so that they can engage in such mechanisms. This also entails amending the Dangerous Drugs law, reviewing the Anti-Trafficking Law, and decriminalizing sex workers and removing other unjust and ineffective legal barriers faced by most at-risk communities. 4. Ensuring sustainability of response, from prevention to treatment, care and support. Sustainability is not solely about resources, but also having the strategic perspective in utilizing existing resources. Thus, the response cannot be focused on treatment alone. Aggressive spending for evidence-based prevention must be undertaken to ensure that demand for treatment is met and treatment services are sustainable. 5. Improving political leadership to steer the response. Strategies to address the epidemic must be steered by a political leadership that recognizes the need to step up its own actions and ,more importantly, empower communities so that they can engage and participate meaningfully in the response. This must be done in the context of reforming the Philippine National AIDS Council to transform it into a more effective multisectoral vehicle to stop AIDS in the Philippines.

The Network to Stop AIDS-Philippines (NSAP) is comprised of civil society organizations that are working in the national HIV response: Action for Health Initiatives (ACHIEVE), Inc; Alliance Against AIDS in Mindanao, Inc. (Davao); B-Change Foundation; Cebu Plus Association Inc. (Cebu); CrossBreeds, Inc. (Bacolod); Gayon Albay, LGBT Org. Inc. (Bicol); Health Action Information Network (HAIN); Lunduyan Foundation; Mindanao AIDS Advocates Association, Inc. (Davao); Philippine NGO Council for Population and Development (PNGOC); Pinoy Plus Association; The Red Whistle; Sisters Plus (Angeles, Pampanga); TLF-SHARE Collective, Inc.; United Western Visayas Inc. (Iloilo); Vida Vivo Zamboanga (Zamboanga); and Youth AIDS Filipinas Alliance (YAFA).