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Part I Situationer
A. CURRENT EPIDEMIOLOGICAL PROFILE
A total of 2,200 HIV/AIDS cases have been reported as of December 2004. The HIV/AIDS Registry shows that 1,524 or 69 percent of the total reported cases were asymptomatic and 676 or 31 percent were AIDS cases. Forty-two percent of the AIDS cases (263) had already resulted in deaths at the time of reporting.
The average cumulative annual increase of cases is at 110. Most of the cases were reported in the years 1993 to 2004 during which time HIV sero-positive cases posted a significant increase (HIV/AIDS Registry, 2004). Morover, the number of cases reported per month also increased. While in the past tears, an average of only 10 cases were reported per month, current figures show an average of 20 cases per month reported from 200 to end of 2004.
Almost two-thirds (63 percent) of HIV seopositive cases were males and ninety percent were in the 20-49 age group. Two percent were less than 10 years old. Majority (85.0%) acquired HIV through sexual contact, with heterosexual contact being the most common mode of transmission. Two percent acquired HIV from their mothers. There were 640 (32.0%) HIV Ab seropositive OFWs, of which 38 percent were seamen. While reports indicate an increasing number of HIV infection among OFWs over the years, the data on the proportion of infected OFWs over the total number of cases must be treated with caution, since the sector is the most commonly tested and therefore reported, in compliance with the requirement of the OFWs' host country (2004 STI/HIV/AIDS Surveillance Technical Report).
In 2004 STI/HIV/AIDS Technical Report also revealed the following epidemiological characteristics:
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median ages for all the risk groups were in the twenty's with male respondents (clients of female sex workers, deep-sea fishermen and the injecting drug users) being older than the female respondents; |
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most of the respondednts were single, except for clients of female sex workers (CFSW) and deep-sea fishermen (DSF), who were mostly married; |
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most of the female sex workers were high school graduates or have reached high school level; MSMs and CFSW were college graduates; while fifty nine percent of the DSF were elementary graduates. |
B. RISKS & VULNERABILITIES
While the current epidemiological picture shows a low level of HIV prevalence in the Philippines, the evidence of high-risk situations and practices indicate that an AIDS epidemic may be hidden and growing.
STI PREVALENCE. One indicator of high-risk behavior is the alarmingly high prevalence of sexually transmitted infections (STI). The 2004 STI/HIV/AIDS Technical Report revealed increasing patterns of STI among selected groups. Syphilis rates among high-risk groups (HRGs) ranged from 1-4%, being highest among the freelance sex workers (FLSWs) and lowest among the registered female sex workers (RFSWs). The female sex workers, both registered and non-registered, reported signs and symptoms of STI more often than MSMs. A 50 percent increase of IDUs who reported signs and symptoms of STI was noted in 2003 compared to 2002.
STI Prevalence is also quite high among young females and males compared to the general population, being highest among youth in the 18-24 age group. (2002 RTI/STI Prevalence Survey in Selected Sites in the Country). A 2002 study conducted by Family Health International (FHI) in Angeles City provides an alarming picture of STI prevalence in high-risk areas. It showed a prevalence of gonorrhea and chlamydia ranging from 6.0 to 51 percent during three survey rounds among the various groups studied, and that 35 percent of the respondents cited pain in the lower abdomen and frequent urination as the most common signs and symptioms (2002 STI Prevalence Study in Angeles City Among Sex Workers).
CONDOM USE. Consistent condom use was generally low (<30%) among the HRG in 2003. Results of the 2003 Behavioral Sentinel Surveillance (BSS) showed that:
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only MSM posted improvement from 2002 to 2003 |
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condom use by female sex workers with their non-regular partners was higher compared to condom use with their regular-paying and regular non-paying partners |
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MSM practiced anal sex more with their regular non-paying partners while they practiced oral sex more with their non-regular partners and regular paying partners. |
Based on the 200 FHI STI Prevalence Survey in Angeles City, only 36 percent of the respondents said they used condom every time thay had sex. Among women, the proportion that consistently used condoms wwas highest among registered sex workers and lowest among Guest Relations Officers. Condom use among young people had also remained low even while the percentage of the youth population engaging in premarital sex has increased by 5 percent from its 1994 level. Based on the 2002 Young Adult Fertility and Sexuality Survey (YAFSS), 26 percent reportedly use condoms, but not consistently.
Number of Sexual Partners. The number of sex partners of female sex workers varies from one to 80 per week based on the BSS conducted from 1997-2003. However, the median was two per week for RFSW and four per week for FLSW. Some MSM reported as many as 55 sex partners per month but the norm was two per month. Since 1998, the median number of sex partners per month for the IDU was. (2004 STI/HIV/AIDS Technical Report).
Young People's Sexuality. Vulnerability of young people is laso a major concern. Based on the 2002 YAFSS, the proportion of young people engaging in premarital sex increased from 17.8 percent in 1994 to 23.1 percent in 2002. Among those sexually active in the 15-27 age groups, 34 percent reported having multiple sex partners. The percentage of young men and women engaging in unprotected sex was 70 percent and 68 percent, respectively. The percentage of young people who believe that there is no chance for them to contract HIV/AIDS was 60 percent.
Among the general population, the 2003 National Demographic and Health Survey revealed widespread lack of knowledge on HIV/AIDS. While almost all men and women have heard about AIDS, only about half know the two major methods for preventing transmission of HIV (using condoms and limiting sex to one uninfected partner). Among HRGs, the 1997 to 2003 BSS revelaed that most study participants knew of at least three correct ways of preventing HIV transmission. However, the aggregate results showed no HRG posting significant improvement in knowledge over time and no HRG attained the targets of the AIDS Surveillance and Education Project (ASEP) for this variable.
Sharing of Needles. The 2004 Technical Report of the National HIV/AIDS Sentinel Surveillance System (NHSSS) showed that most surveillance sites reported use of prohibited drugs by HRG, but few are cases of injecting drug use. Although the proportion of IDUs sharing injecting equipment has been decreasing, the use of bleach and water in cleansing these equipments has also been decreasing since 2002.
Consultations with the sub-national or regional and local stakeholders confirmed the increasing number of individuals practising high-risk behavior; low level of awareness on HIV/AIDS prevention among most-at-risk groups, young people and the general public, and strong discrimination and stigma against people living with HIV/AIDS (PLWHAs).
C. THE NATIONAL RESPONSE
The recognition that HIV/AIDS poses a serious public health and development challenge has brought about substantial achievements that, while admittedly limited in scope, have resulted in a more comprehensive and purposive national response.
POLICY
Policy response has improved as the country gained better understanding of the dynamics of HIV/AIDS in the Philippines, progressing from the limited view of HIV/AIDS as a communicable disease to a social development problem that demanded multi-sectoral and inter-agency action. Guided by the World Health Organization's (WHO) Global Programme on AIDS in the mid-a980s, the first policy on HIV/AIDS was formulated, follwoed by the establishment of the National AIDS and STD Prevention and Control Program (NASPCP) under the Department of Health (DOH). With the passage of Republic Act 8504 in 1998, key government agencies formulated policies in support of a comprehensive national HIV/AIDS response embodied in RA 8504:
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Policy Guidelines in HIV/AIDS Prevention and Control |
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Policy and Strategies for STD/HIV/AIDS in the Workplace |
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Integration of HIV/AIDS Education in All Schools Nationwide |
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Guidelines on the Entry of People with HIV/AIDS to the Philippines |
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Policy Guidelines on HIV/AIDS Testing Among Children |
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Memorandum circular enjoining all Local Government Units (LGUs) to implement RA 8504 |
In some LGUs, there is strong support from both the executive and legislative branches for local HIV/AIDS response. Local AIDS Councils (LACs) were created and local budgets were allocated for HIV/AIDS programs.
Through RA 8504 provided a clear, legal basis for action, various national government agencies have not yet operationalized thair mandates through concrete HIV/AIDS-related programs and services. This implies that further articulation of the law is needed. In the regional consultations, several areas reported that the law has not been well disseminated and fully understood by key stakeholders.
PREVENTION
Information, Education & Communication (IEC) Through the ASEP (1993-2003), various IEC initiatives of non-government organizations (NGOs) proved effective in reaching groups most at risk of HIV infection. Utilizing Behavior Change Communication (BCC) as an overarching framework, these strategies employed one-on-one risk reduction counseling, community outreach and peer education complemented with IEC materials, and mass media campaigns.
Integration of HIV/AIDS into the elementary, secondary and vocational curricula is continuously being pursued, with teaching modules being revised to be life-skills based. Breakthroughs have been achieved in targeting the workplace. The tripartite partnership of the DOLE, employers and labor groups is an effective strategy in the promotion and adoption of HIV/AIDS programs in the workplace. Seminars among fisher folks, drivers, men and women in uniform and human resource groups have also been done. Media, legislators, Parents-Teachers Associations and in-school youth were also provided with STI/HIV/AIDS orientation.
The current response has been adequate in programmatic scope. but inadequate in terms of coverage. This is especially true with IEC. A national communication plan exists but this has not been utilized such that there remain many missed opportunities in improving their overall cost-effectiveness. A number of IEC initiatives have been undertaken but evaluating the effectiveness of these initiative media mix has not been consistently pursued. There is also the absence of an inventory and clearing house of STI/HIV/AIDS materials to facilitate adaptation across areas.
Advocacy Since the first prominent case (Dolzura Cortez) in 1992, more HIV infected Filipinos have come out into the open and volunteered personal testimonies about their condition. These efforts put a human face to the disease and made advocacy, resulting in the adoption and institutionalization of HIV/AIDS-related programs by some of its member-agencies. Advocacy efforts aimed at the media were significant, with training/orientation given to members of various associations of media practitioners, resulting in more sensitive and responsible reporting of HIV/AIDS cases. A "Media Manual for HIV/AIDS Reporting" and "Popularizing the IRR of RA 8504" was developed in 2001 to help bring about a clearer understanding of the disease among media practitioners and make them effective partners in HIV/AIDS prevention.
However, advocacy activities aimed at mobilizing support from various agencies and sectors have not been creatively sustained at the national, sub-national and local levels. The participation of the private sector in HIV/AIDS efforts also remains minimal. The religious sector (e.g. CARITAS, Salvation Army), which has a strategic value for care and support, have not been optimally tapped even as opportunities exist for their participation. Best practices have not been fully documented and disseminated.
Training Capability building efforts had been strengthened over the years as the necessity for prevention efforts became increasingly felt. For service providers that also include the HIV/AIDS Core Teams (HACTs), training on comprehensive and syndromic STI management had been conducted. For the labor sector, there is Occupational Safety and Health (AIDS 101) for key regional implementors that include DOLE and TUCP trainors. There were also efforts to promote HIV?AIDS prevention among specific occupational groups considered exposed to higher levels of risks (e.g. tattoo artists and embalmers). Initial efforts targeting men and women in uniform were pioneered in 1999 and again in 2002, building the capacities on HIV/AIDS prevention among enlisted personnel in the Armed Forces of the Philippines (AFP) and Philippine National Police (PNP).
For the education sector, the Department of Education (DepEd) is scaling-up the reach of its School-based AIDS Education Program (SAEP) through curriculum integration and training of Subject Area Supervisors at the district and division (provincial or city) levels. For those working with families and communities, the Department of Social Welfare and Development (DSWD) produced and disseminated, through capability-building workshops for social workers, a user-friendly guidebook for community volunteers and leaders on HIV/AIDS which covers both prevention and care support. It also has a peer-counseling project that trains peer facilitators on HIV/AIDS prevention information and counseling. More effective means of mainstreaming HIV/AIDS into the counseling and pre-departure services are being enhanced. For OFWs, a training module on HIV/AIDS and migration has been developed and administered to an initial batch of trainees which include Foreign Service Institute (FSI) personnel deployed abroad, and representatives from other agencies like the Overseas Workers Welfare Administration (OWWA), the Philippine Overseas Employment Administration (POEA), DSWD and DOH.
Owing to limited fiancial resources, the reach of these training initiatives has been likewise limited. Manuals have not been produced in adequate quantities and dissemination through training has been selective.
Prevention Services. The implementation of the STI Prevention and Control Program has been intensified. Social marketing on STI treatment and care using the syndromic management approach was piloted in eight sites with very promising results. In most cities, the capacity to provide services, such as diagnosis and treatment of STI, counseling and referral system exists. Parallel efforts were also undertaken to develop the capacity of the San Lazaro Hospital's (SLH) STI/AIDS Cooperative Central Laboratory (SACCL) and Research Institute for Tropical Medicine (RITM) in conducting HIV testing.
Condon use promotion has been done aggressively through the ASEP and program initiatives of NGOs in partnership with DKT International. Selected LGUs also piloted the 100% Condom Use Program (CUP) initiated by the WHO in 2000. The 100% CUP seeks to reduce the spread of HIV infection by increasing condom use among PUIPs. Program interventions have consisted of providing PIPs with information and condom supplies. With regards to IDUs, small-scale harm reduction efforts have been initiated in two cities - Cebu and General Santos.
However, efforts like condom use promotion, harm reduction and provision of social hygiene services, which are aimed directly at preventing transmission of the virus among HRGs have produced unclear results. implying inadequacies in both the quantity and quality of interventions. Services from most socail hygiene clinics (SHCs) are lacking in quality due to lack of adequately trained personnel and insufficient logistics like reagents. Also, the location and layout of many SHCs negate stigma reduction and discourage health-seeking behavior.
TREATMENT, CARE AND SUPPORT
Care and support services have been and are now being provided, although to a limited number of PLWHAs. Care and support services have been extended to PLWHAs seeking services from RITM and SLH. Other institutions offering support services include (a) Pinoy Plus Association, Inc.; 9b) Remedios AIDS Foundation; (c) Positive Action Foundation Philippines, Inc.; and (d) Bahay Lingap, a halfway home for HIV positive individuals. Other significant work include the development of HIV/AIDS clinical management guidelines for hospitals, the training and establishment of HACTs in 56 DOH-related hospitals and about 40 provincial hospitals, incorporation of antiretroviral (ARV) drugs into the National Drug Formulary, development of Care and Support Manula for Social Workers, and training of 103 social workers for community-based care and support.
Current financing relies primarily on donations and personal expense of PLWHAs themselves. Aside from the prohibitive cost of ARV drugs, there is also the inaccessibility of basic drugs like pain-relievers and medicines for opportunistic infections. It is also possible that the low coverage of drug treatment is caused by the reluctance of PLWHAs to seek services for fear of stigma and discrimination.
Treatment, care and support (TCS) are also geographically inaccessible as these services are available only in DOH medical centers (SLH, RITM and other government-retianed hospitals) and the Philippine General Hospital (PGH). The travel time and the additional transportation costs make it difficult to a number of PLWHAs to access them. The quality of laboratory services in some facilities is also deteriorating due to old equipment, fast turnover of personnel and limited reagents and other supplies. The establishment of HACTs in public hospitals has not resulted to clear improvements in the quality of care given to PLWHAs. Based on a study majority of the complaints about insensitive and discriminatory care of PLWHAs were directed at health service providers themselves.
LGUs reported that several hospitals do not have TCS system in place. While members of the HACTS have undergone training in support systems, they seldom function as such. Although a manual on care and treatment on HIV/AIDS has been developed, this has not been throughly disseminated. There is also no assurance that these protocols are adhered to, due to lack of monitoring. The capability of priovate hospitals to manage PLWHAs is also inadequate since training has been confined mainly to public hospitals.
Community support systems have been initiated by NGOs and the DSWD, but limited resources (e.g. trained social workers, limited funds for training and monitoring) impinge on their capacity to strengthen and expand. There is also no care and support program focusing on children.
LOCAL RESPONSE
Institutionalising local response to HIV/AIDS has been recognized as vital in bringing about substantive and sustainable progress in the fight against HIV/AIDS. PNAC. undertook a rapis situational assessment in 2002, which identified 48 areas as highly vulnerable to an AIDS epidemic.
Local response is present in at least 18 sites of donor-assissted projects (ASEP and the Policy Project of the Future Group). In these LGUs, local AIDS ordinances has been enacted for the establishment of LACs and allocation of budget for an HIV/AIDS program. An additional 11 LGUs have started to develop HIV/AIDS prevention programs through the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) project.
While the criteria for determining high-risk areas have been developed, and high-risk zones and localities have been identified, the political and fiscal barriers at the local government level had limited the reach of resources from the national level (both from GOP and donors). This has made the sustainability of the gains uncertain in at least 18 sites where local response initiatives had been implemented. The consolidation and packaging of the various definitions and categories of risk areas into an official issuance by PNAC, is also absent or at best, unclear. Such issuance can serve as a guide for localities to mount a local response. Questions were also raised as to the appropriateness of the criteria and the process in assessing the LGUs' degree of risk to HIV/AIDS.
SURVEILLANCE AND RESEARCH
The early establishment of the surveillance system, particularly the conduct of sero-prevalence surveys among most-at-risk groups starting the mid-a980s, the establishment of the HIV/AIDS Registry in 1991, and the NHSSS in 1993 gave decision-makers and program planners a better understanding of the common modes of HIV transmission in the country, the age range and sex of people infected and the groups most-at-risk to the virus. The NHSSS-BSS introduced in 1997, continues to provide vital information on the knowledge and trend of sexual bahavior of groups most-at-risk. This has been institutionalized in 10 sites where pre-disposing conditions exists for the prevalence of high-risk behavior.
Though in operation since 1993, the NHSSS covers very limited number of sites as well as limited sample size and may, therefore, not be representative of the true picture in newly emerging high-risk localities. Also, the HIV/AIDS Registry is constrained by under-reporting, delayed reporting and multiple recording of cases. At the local level, the problem is more serious with a number of provinces having no functional STI surveillance mechanisms. This is especially true in poor, rural provinces, including tourist-destinations.
Outside of sentinel surveillance, a good number of important studies had been undertaken in the last 10 years, but the findings have not been fully dessiminated. More recently, groundbreaking research had been undertaken to learn more about the disease, the socio-demographics of people infected, the burden of the disease and the reasons why it is spreading. A research agenda has been formulated, but due to resource constraints, most of the proposed studies were not pursued.
MONITORING AND EVALUATION
Monitoring and evaluatingthe thrusts of the national response has been inadequate. Efforts have been limited to partial assessments that do not provide the complete picture. No evaluation has been done to ascertain compliance with the provisions of RA 8504. For example, the establishment of an HIV/AIDS program in the workplace is not enforced due to inadequate number of personnel in the DOLE. Furthermore, there is no data on whether curriculum integration in learning institutions at various levels is actually being pursued. There is also no definitive information on whether hospitals are following the protocols for treatment, care and support.
An HIV/AIDS monitoring and avaluation (M & E) system has recently been developed by the PNAC. However, operationalization of the M & E system requires substantive resources.
RESOURCE MOBILIZATION
Resources for HIV/AIDS in the Philippines were mobilized mainly from the following sources:(1) government's annual budget allocation through the DOH, (2) local public financing and (3) external funcing from multi-lateral and bilateral agencies. Since the first case was officially reported in 1984, external resources were mobilized to implement special projects as follows:
USAID-funded ASEP starting 1996,
European Union Support for HIV/AIDS and STD in the Philippines,
AusAID-funded "Model Community Health/STD Facilities in Commercial Sex Areas in the Philippines",
Provision of technical and equipment assistance by the Japan International Cooperations Agency (JICA) for the development of SACCL as center for HIV testing and for the Prevention and Control of STD,
Southeast Asian Ministers of Education Organization (SEAMEQ) - GTZ's Control of HIV/AIDS/STD Partnership Project in the Asian Region (CHASPPAR),
Development of strategic plans, establishment of M&E system on HIV/AIDS and various catalytic projects funded through the Programme Acceleration Funds of the Joint United Nations Programme on HIV/AIDS/STD (UNAIDS), as well as various activities of other UN agencies such as WHO, United Nations Population Fund (UNFPA), United Nations Children's Fund (UNICEF) and the International Labour Organization (ILO).
The country has likewise started tapping the private sector. In a few areas, resources of LGUs are now being mobilized thru LACs. Initial efforts have also been done to reach inter-faith coalitions whose support can be mopbilized particularly for treatment, care and support.
NATIONAL RESPONSE COORDINATION
The PNAC was created to oversee an integrated and comprehensive approach to HIV/AIDS prevention and control in the Philippines. Despite the limited staffing of the PNAC secretariat and inadequate financial resources, PNAC was able to accelerate the national response in various aspects, particularly in the areas of local response, education and workplace initiatives.
There had been attempts to establish sub-national coordination mechanisms to consolidate regional and local responses. At the sectoral level, the DOLE has created an inter-agency committee. At the LGU level, LACs had been established, although in limited areas.
The creation of PNAC, while commendable, has created expectations that have not been fulfilled. Other factors that have impinged on its ability to perform its tasks are the unclear delineation of roles and functions between the secretariat and the PNAC members and working committees, and the absence of staff with multi-disciplinary expertise that the national response requires.
Due to the aforementioned weaknesses, the Council has not been spared from communication, reporting and relational problems. Regular feedback or updates to NGOs, LGUs and other members, and submission of accomplishment reports by member agencies on HIV/AIDS is not a regular practice.
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