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Odd numbers of a ticking bomb

HIV/ Aids in the Philippines

The Philippines has the unenviable distinction of having the fastest-growing human immunodeficiency virus (HIV) epidemic in the Asia-Pacific region. Recently released data from the United Nations Programme on HIV and AIDS (UNAIDS) shows that in the last six years new infections soared by 140%. By contrast, new infections in Asia Pacific during this period fell by 13% annually.

During the term of the country’s previous administration, 2010 to 2016, new cases of the disease in the Philippines went up from 4,300 cases to 10,500. However, UNAIDS points out that while the percentage increase is high, the baseline figure still remains low in a regional context.

But that last point hangs on one simple assumption – that reported cases reflect an accurate account of the number of people actually infected with the virus in the Philippines. And that’s where there could be serious cause for concern. Historically, these figures have been inexplicably low. In other words, there could be a far bigger HIV/AIDS problem out there than anyone cares to admit – or possibly is even aware of.

The 140% leap over the last decade is one reason. This would suggest that over that period Filipinos have become increasingly less aware about this disease and/or that they have for some reason changed their sexual behaviour to more risky forms of sex, or they’ve become increasing more sexually active, or a combination of these possibilities.

But is any of that really likely? All-male sex is not a new trend sweeping the archipelago – there’ve always been gay and bi-sex males there like most other places. Why should there be such a big change in sexual-partner preference in the space of just one decade? As for Filipinos becoming more sexually active; who’s to know, perhaps they have. But again, is it likely that they’re become significantly more so than people in other parts of the region?

Furthermore, AIDS awareness has definitely increased in the Philippines – thanks in part to increased government spending and to renewed efforts by the Department of Health (DOH) and the tireless work of the AIDS Society of the Philippines.

That said though, a great deal more needs to be done if the country is to have any chance of defeating what the Dr Rossana Ditangco, head of the AIDS Research Group – at DOH’s Research Institute for Tropical Medicine – is describing as a “national emergency”.

Dr Ditangco has called for a new approach to tackling the problem. With the present strategies, she says, “we can’t control the rapid rise of HIV infections”.

One of the main problems is that there’s clearly insufficient authentic data on the true extent of the problem. What we do know, however, is that the most at-risk group in the Philippines – and the one that’s contributed most to the number of new infections – is men having sex with men (MSM).

But given the awareness campaigns, which draw particular attention to the dangers of casual MSM activity, it would be odd indeed if this demographic was dramatically increasing. It may be more visible than it was 10 years ago, but that’s not the same thing as it expanding.

We believe that the main problem with the government’s historic approach to HIV/AIDS in the Philippines is that the scale – at least the potential scale of it – has been repeatedly grossly underestimated.

And the thing that makes us uneasy about this is the statistics themselves – the numbers that are extrapolated from reported and documented cases. Let’s look at some of these. The following are 2015 statistical estimates from the UNAIDS database plus 2016 population numbers and national infection rates which we’ve added for context.

The Philippines, with a population of 103.9 million, has 42,000 people living with HIV. That’s an infection rate equivalent to 0.04% of the total population. (Estimate range: 30,000-120,000 cases of infected individuals). Deaths from AIDS: 1,000.

And here’s how those figures compare to other countries in Southeast Asia.

Cambodia: population 16.1 million; 74,000 living with HIV. 0.46% of total pop. (Estimate range: 67,000-82,000). Deaths from AIDS: 2,000

Malaysia: population 31.2 million; 92,000 living with HIV. 0.29% of total pop. (Estimate range: 80,000-110,000). Deaths from AIDS: 7,200

Myanmar: population 54.8 million; 220,000 living with HIV. 0.40% of total pop. (Estimate range: 200,000-260,000). Deaths from AIDS: 9,700

Thailand: population of 68.3 million; 440,000 people living with HIV. 0.64% of total pop. (Estimate range: 400,000-490,000). Deaths from AIDS: 14,000.

Vietnam: population 95.5 million; 260,000 living with HIV. 0.27% of total pop. (Estimate range: 230,000-290,000). Deaths from AIDS: 8,900

Indonesia: population 273.8 million; 690,000 living with HIV. 0.29% of total pop. (Estimate range: 600,000-790,000). Deaths from AIDS: 35,000.

Just for the exercise, we’ve taken the average ‘% of total pop’ of these six countries – which is 0.39% – to see what number that gives us if we attributed that percentage to the Philippines total population. The answer is 401,700. Of course, there’s nothing scientific about this whatsoever; it’s just us playing with numbers. But in the context of these other countries, it doesn’t seem so wildly out of place, whereas to us, the official number does.

The point is, when you look at all those figures – particularly the ‘% of total pop’ numbers – the Philippines appears to be a total anomaly. How can a country with a population of 103 million have 76% less cases of people living with HIV than a country, Cambodia, with a population of 16 million?

How can a country like Malaysia, whose population is less than one third of the size of the Philippines, have 50,000 more cases of people living with this disease, as well as seven times the number of AIDS-related deaths? Vietnam, a country with a comparable population to the Philippines (though 8% smaller), has an HIV population of 260,000. That’s six times and change more than the Philippines. Of course, all these things are possible; but are they likely?

Now let’s turn to other places in the wider Asia Pacific. Like all but Indonesia above, these are countries with much smaller populations than the Philippines.

Papua New Guinea: population 7.9 million; 40,000 living with HIV. 0.50% of total pop. (Estimate range: 37,000-44,000). Deaths from AIDS: 1,000.

Chile: population 18.3 million; 32,000 living with HIV. 0.17% of total pop. (Estimate range: 22,000-45,000). Deaths from AIDS: 500.

Sri Lanka: population 20.9 million; 42,000 living with HIV. 0.20% of total pop. (Estimate range: 28,000-65,000). Deaths from AIDS: 200.

Australia: population 24.6 million; 27,000 living with HIV. 0.11% of total pop. (Estimate range: 24,000-30,000). Deaths from AIDS: 200.

Peru: population 32.2 million; 66,000 living with HIV. 0.20% of total pop. (Estimate range: 56,000-79,000). Deaths from AIDS: 1,600.

What are we supposed to deduce from that – that Filipinos are more celibate than, say, Thais and Burmese? That they practice safer sex considerably more than Peruvians, Chileans and the people of Papua New Guinea?  Whichever way we cut it, the figures don’t look right.

If they’re even remotely correct, they seem to defy all logic and all societal understanding. Of course they’re all estimated, but those estimations are based on known facts: specifically, the number of actual cases. These are of people who’ve been diagnosed as HIV positive – numbers captured by the clinics, test centres and health workers, as well as the number of recorded deaths. These are the only facts available.

But all that’s predicated on the assumption that the known cases provide enough accurate data to assess the size of the HIV universe in the Philippines. The point is, what if they don’t? What if they’re a serious understatement of that universe’s true size?

How could that happen? Well, one of the major problems those involved in promoting HIV/AIDS education have faced in the Philippines over the years, are the cultural barriers to addressing this disease. First, for all the brashness on the surface, deep down the Philippines is a very conservative country – particularly once outside the main conurbations of Manila and Cebu.

At its core, it’s also deeply Catholic; consequently guilt and shame are factored into how individuals confront this issue – which all too often has been by not confronting it. Health-sector workers and volunteers have plenty of anecdotal evidence to support that.

Certainly, these factors will have a bearing on whether to undergo an HIV test – or even on whether to seek advice. Even people diagnosed with HIV conceal it from their families or workmates – such is the strength of the social stigma.

The Roman Catholic Church doesn’t help – and not least when it comes to MSM transmissions. Homosexuality is regarded as a mortal sin by the Church, meaning that the soul will spend time in Purgatory before it can be cleansed of it. Just to clarify; this refers to the act of homosexuality. Homosexual orientation is regarded by the Church as an “objective disorder” while the act of homosexuality is regarded as a “moral disorder”.

This deep conservatism, boosted by the Church’s moral teaching, probably makes it more difficult in the Philippines than many places in this region for people to seek help. They fear being ostracised – by their families, their communities and their workmates. Then there’s the shame and the guilt. And that’s likely to be very much the case for the MSM sector – the one that’s being cited for fuelling the recent increase, not just in the Philippines but across Asia Pacific.

According to DOH data, last year of all newly reported HIV cases a whopping 83% of them were from this group – more specifically they were predominantly 15 to 24-year-old males. Two out of every three new infection came from this age bracket.

However, in 2015 only 16% of men and transgendered women who have sex with men were getting tested. Certainly that’s a vast improvement on 2011 when just 5% of this demographic sought tests, but it shows how little is really known about this universe.

The significance of this particular age group in the Philippines is that its size is substantial. Let’s compare it to those of other counties of Southeast Asia.

In the Philippines, 15 to 24-year-old males comprise 19.17% (19.92 million individuals) of the population. With the exception of Indonesia, it has more people in this age bracket than anywhere else in Southeast Asia. Here are the numbers: Cambodia, 15 to 24-year-old males  account for 19.02%, (3.06 million); Myanmar, 17.73%, (9.71 million); Indonesia, 17.03%, (46.63 million); Malaysia, 16.86%, (5.62 million); Vietnam, 16.69%, (15.93 million); Thailand, 14.47%, (9.88 million).

All this raw data would suggest, at least, that the extent of the HIV/AIDS problem in the Philippines might have been badly miscalculated. The problem is, given the limited factual data, it’s very hard to tell what the true situation is. But one thing we’re fairly sure of is that the figures which the DOH and UNAIDS are working with need far greater scrutiny. This is a ticking time bomb.

The war against HIV/AIDS is a long and difficult one. But one thing that holds true for this war as for any other is that before you can defeat the enemy, you must first know your enemy’s strength. And, plainly, we don’t.

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