In various national international forums, HIV experts are baffled as to why HIV prevalence ha remained low, despite the obvious of almost all the ingredients for explosive HIV spread. The current epidemic has been described as "low" and "slow". There is, however, anticipation that an explosive epidemic will occur, as has happened in other countries in Asia (UNAIDS/WHO, 2003). This article describes the current HIV/AIDS situation in the country and the possible explanations for the current low rate. The response of the government and other sectors in the country to the HIV/AIDS problem is also described. Finally, the article presents the challenges still remaining for the Philippines.

CURRENT STATUS FO THE HIV/AIDS PROBLEM IN THE PHILIPPINES

In 1993 experts on HIV/AIDS projected that by the year 2000 there would be 100,000 HIV/AIDS cases in the Philippines (WHO-Western Pacific Region, 2000). This estimate was based on very limited information available at that time. In 1996, both passive and active HIV surveillance data showed a very low HIV prevalence, and based on available information, the Philippine Department of Health (PDOH) adjusted the estimate to 38,000 HIV infections by the year 2000 (WHO-Western Pacific Region, 2002).

THE HIV/AIDS REGISTRY

To keep track of the epidemiology of HIV/AIDS, the PDOH maintained a passive surveillance system, the HIV/AIDS Registry. The registry continuously logs Western blot-confirmed HIV cases reported by hospitals, laboratories, blood banks, and clinics. A total of 1,965 HIV-positive cases had been entered in the registry from January 1984 to December 2003 (Figure 1). Unfortunately, the number of subjects tested by year cannot be ascertained and, therefore, rates cannot be calculated. Likewise, data input into the registry is limited, because mandatory HIV testing is prohibited by Philippine laws, and voluntary counseling-and-testing services for HIV is limited. Thus, the registry may not be that sensitive to capturing potential HIV cases.

Data from the registry revealed that about four of every five cases acquired HIV through sexual intercourse, particularly heterosexual intercourse. About four of every five cases were in the economically productive age group of 20 to 49 years. Thirty percent of the cases were overseas Filipino workers (OFWs), with 61% being land-based and 39% being sea-based. The OFWs figured prominently in the registry, particularly because they are tested the most often to satisfy employment requirements set by the employers abroad.

Filipinos continue to seek employment abroad. The Philippine Overseas Employment Administration (POEA, 2001) indicates that overseas employment has increased at a rate of 5% annually. The total number of OFWs deployed rose from 660,122 in 1996 to 866,590 in 2001, with an annual remittance to the Philippines of up to $U.S. 6 billion. This accounts for about 7% to 8% of the Philippine government's gross national product. As of June 2002 the Commission on Filipino Overseas reported that over 7 million Filipinos were deployed in more that 120 countries.

In a study conducted among seamen who had worked abroad and returned to the Philippines, 35% admitted to having sex abroad; of those, 36% had unprotected commercial sex. These high-risk sexual encounters were mostly with female sex workers (FSWs) in countries such as Brazil, Vietnam, and Thailand. Likewise, the same study revealed that 85% of seamen had commercial sex with FSWs and consensual sex with unpaid partners in the Philippines. The threat that the seamen will serve as the bridge for HIV to the general population is highly likely.

HIV SEROLOGIC STUDIES

Because of the limitations inherent in passive surveillance, such as underreporting and delayed reporting and its inability to generate HIV prevalence rates, the PDOH established the HIV Serologic Surveillance (HSS) IN 1993. The core groups regularly monitored were both establishment-based female sex workers (EFSWs) and freelance female sex workers (FFSWs), men who have sex with men (MSM), and injection drug users (IDUs) in 10 key cities throughout the Philippines (Figure 2). These cities were selected based on the following guiding principles:

• Known HIF/AIDS cases frequenting the area and engaging in HIV risk practices
• Availability of "at-risk" or sentinel groups
• Presence of an accredited laboratory to perform serologic tests for HIV and syphilis
• Geographical representatives of the site
• Willingness of on-site staff to conduct regular HSS (National Epidemiology Center PDOH, 2003)

Figure 2

Using the modified lot quality assurance sampling method, a sample size of 300 for each group was calculated to confirm with 95% confidence that HIV seroprevalence is less that 1% if none of the individuals tested positive.

In the past 10 years, the national aggregate HIV prevalence for FSWs and MSM had been less than 1% (Table 1). In most of the surveillance sites, HIV-positive subjects had been detected inconsistently through the years. Thus it may be concluded that HIV prevalence may still be less that 1%; however, this may not be true anymore among EFSWs in the cities of Quezon and Angeles, where detection of HIV-positive subjects annually was the norm rather than the exception. In these cities, the HIV seroprevalence among EFSWs may be between 1% and 2%.

TABLE 1 HIV Prevalence by Year in the Philippines, 1993-2003

	EFSW			FFSW			MSM
Year	Sample	HIV+	%	Sample	HIV+	%	Sample	HIV+	%
1993	615	1	.16	209	0	.00	701	0	.00
1994	1,760	2	.11	707	0	.00	653	0	.00
1995	2,391	3	.12	1,048	0	.00	359	1	.28
1996	3,069	2	.06	1,610	0	.00	720	0	.00
1997	3,027	4	.13	1,999	0	.00	723	1	.14
1998	2,670	5	.19	2,368	1	.04	518	0	.00
1999	3,003	2	.07	2,614	0	.00	457	0	.00
2000	3,002	4	.13	1,834	3	.07	784	0	.00
2001	3,000	3	.10	2,666	0	.00	783	1	.13
2002	3,000	4	.13	2,845	2	.07	1,120	0	.00
2003	3,000	1	.03	2,707	0	.00	900	1	.11

Note: EFSWs=establishment-based female sex workers; FFSWs=freelance female sex workers; MSM=men who have sex with men. Nonprobability sampling method employed in study participant selection

It is difficult to conclusively determine HIV prevalence among IDUs in the Philippines, since serosurveillance of IDUs is only conducted in Cebu City. Due to the detection of one HIV case in Cebu City in 1996, currently, it cannot be concluded with 95% confidence that HIV seroprevalence among IDUs in Cebu City is still less than 1%.

The worst scenario projected for the IDUs in Cebu City would be 1-3% HIV seroprevalence (WHO-Western Pacific Region, 2002).

In addition to the core risk groups for surveillance, seroprevalence studies sere also conducted among male military recruits from 1996 to 2001, with sample sizes ranging from 255 to 906. This group was considered as a surrogate for the male general population. No study participant tested positively for HIV or syphilis.

The WHO commissioned one-shot surveys through the United States Agency for International Development (USAID)-funded AIDS Surveillance and Education Project to obtain baseline HIV seroprevalence among subpopulations other than those regularly tested through the HSS. These groups included:

• Returning male overseas Filipino seafarers (Sunas et al., 2002)
• Male truckers in Central Luzon (Mateo,Magpanta, et al., 2003)
• Pulmonary tuberculosis patients in the National Capital Region (Mateo, Pacho, et al.,2003)
• Male prison inmates in the National Capital Region (Mateo, Quizon, et al.,2003)

All study participants in these surveys tested negatively for HIV (Table 2).

TABLE 2. HIV Seroprevalence among Selected Subpopulations

Group	Sampling	Sample Size	Condom Use (%)	Syphilis Rate (%)	HIV Prevalence (%)
Seafarers (Sunas et al., 2002)	Probability	420	55	0	0.0 - 0.9
Truckers (Mateo, Magpantay, et al., 2003a)	Nonprobability	350	6-12	2	0.0 - 1.0
Tuberculosis patients (Mateo, Pacho, et al., 2003b)	Probability	387	<1	2	0.0 - 0.9
Prison inmates (Mateo, Quizon, et al., 2003c)	Probability	380	2	5	0.0 - 1.0

HIV BEHAVIORAL SURVEILLANCE

In tandem with HSS, HIV Behavioral Surveillance (HBS) was established in 1997. Results of the HBS showed a glaring gap between knowledge on HIV/AIDS prevention and control and the practices of high-risk groups across sites. The HBS showed that consistent condom use among the high-risk groups was low, most IDUs still shared injecting equipment, and only a small proportion of "sharers" used bleach and water to clean injecting equipment. The HBS also revealed that the practice of anal sex among MSM is on rise, and that MSM's health-seeking behavior, when confronted with sexually transmitted diseases (STDs), is far from ideal. For example, they still resort to consulting their friends rather than seeking consultation from qualified health personnel.

DESCRIPTION OF THE EPIDEMIC AND POSSIBLE EXPLANATIONS

Currently, HIV prevalence in the Philippines is low, and transmission is slow. According to The 2002 Technical Report of the National HIV Sentinel Surveillance System (NHSSS) (PDOH,2003), the possible factors that inhibit the rapid spread of HIV in the Philippines include (a) a network of sex workers that is not as extensive as networks found in countries with high HIV prevalence; (b) low injection drug use, even though prohibited drug use may be high; (c) sex workers tend to have fewer clients per night than those in Thailand and Africa; (d) the availability of social hygiene clinics that regularly examine and treat infected EFSWs, and (e) the early and accelerated multisectoral responses mounted against the threat of HIV/AIDS. The low HIV prevalence may also mean that the virus has not yet reached the critical level in the population to promote rapid spread.

In 2000 the WHO sponsored a consensus workshop, and it was agreed upon by the participants that 13,000 HIV-positive cases was a more realistic estimate (WHO-Western Pacific Region, 2000). In September 2002 another HIV consensus workshop was held, and based on available information, the official estimate for 2001 was 6,000 HIV infections (WHO-Western Pacific Region, 2002). The data used for the estimations were the projected population size and rates of HIV/AIDS infection among commercial sex workers, IDUs, and the general population.

IMPLICATIONS OF THE CURRENT SITUATION

The low prevalence/slow transmission scenario may not continue for long, because the ingredients for an explosive epidemic, including low consistent condom use rate among sex workers (less than 30%), the increasing practice of an anal sex, and the high prevalence of STDs, are already present. The most recent estimate for chlamydia and gonorrhea infection among the general population is 7.7% and 1.7%, respectively (Wi et al., 2002). Much more alarming is the 2002 NHSSS report stating that sharing of needles among IDUs in Cebu City may be as high as 77% (PDOH, 2003).

RESPONSE OF THE PHILIPPINE GOVERNMENT

The Philippine government has confronted the problem of HIV/AIDS aggressively. Despite the characterization of the epidemic as "low" and "slow," the government realized that it needed to act with a sense of urgency and imperativeness for national action. The response of the government draws from the experiences of other countries; for example, that of Vietnam, which is now experiencing high numbers of HIV/AIDS cases but only as recently as 1997 had case numbers comparable to the Philippines. It has been recognized that the underlying conditions for a serious epidemic to explode exist in the country.

A highlight of the response was the enactment of the Philippine AIDS Prevention and Control Act of 1998 (Republic Act No. 8504). This law called for a comprehensive nationwide HIV/AIDS educational and information campaign, full protection of human rights of known and suspected HIV-infected persons, promotion of safe and universal precautions in practices and procedures that carry risks of HIV transmission, eradication of conditions that aggravate spread of HIV infection, and recognition of the role of affected individuals in promoting information and messages about HIV/AIDS.

The law also called for the reconstitution and strengthening of the Philippine National AIDS Council (PNAC). The creation of PNAC is a formalization of the organized multisectoral response of the country. It now is comprised of 26 members representing different national and local government agencies, legislature, medical/health professionals, concerned nongovernmental organizations (NGOs), and the organization of persons affected by HIV/AIDS. The PNAC serves as the central advisory, planning, and policy-making body for the comprehensive and integrated HIV/AIDS prevention and control program.

The PNAC has outlined the framework for the government response to the HIV/AIDS epidemic in its 2000-2004 accelerated medium-term plan (PNAC,2000). Strategic targets in this plan include the close networking of organizations, institutions, and individuals with PNCAC; local governments activating their own HIV/AIDS prevention plans; inclusion of HIV/AIDS information in the secondary and tertiary educational programs; and provision of adequate care and support for those infected with HIV/AIDS. To achieve these goals, the following complementary strategies were formulated: a management and advocacy strategy to create a social environment for sustained HIV prevention, a research and surveillance strategy to understand the HIV epidemic and the factors contributing to its spread, small-scale trials to identify effective interventions among the most vulnerable group, large-scale prevention programs to implement proven effective interventions, and care and support for those who are already infected.

Several government departments have implemented the provisions of the HIV/AIDS laws into their activities. The Department of Education, Culture and Sports, along with the Commission on Higher Education and the Technical Education and Skill Development Authority, have developed HIV/AIDS modules to be integrated into the school curriculum. Workplace education on HIV/AIDS and observance of nondiscrimination have been mandated by the Department of Labor and Employment (2003). The Department of Social Welfare has supported the training of social workers to deal with people living with HIV/AIDS (PLWHAs) (Remedios AIDS Foundation, 2002). Predeparture seminars for overseas workers are required by the Philippine Overseas Employment Agency.

LOCAL RESPONSES

The vital importance of local responses is recognized by leaders in the campaign for HIV/AIDS prevention. The PNAC plan (PNAC, 2000) states that national mobilization means the mobilization of local responses on a nationwide scale. The Philippine HIV/AIDS law Republic Act No. 8504 stipulates that local governments provide community-based HIV/AIDS prevention, control and care services and integrate these into their development plans. Examples of local responses include the experiences in General Santos City (Mascardo & Lastimosa, 1998), Negros Occidental (Cristobal & Melocoton, 1998), and Davao City. Functional multisectoral AIDS councils have been established in these cities. These councils involve city governments, health offices, social welfare offices, police, academic institutions, religious groups, youth groups, and NGOs. Each sector's limitation to respond to the HIV/AIDS problem is recognized. Aside from the creation of AIDS councils, local ordinances on STD/HIV/AIDS prevention and control have been enacted in some cities. An important indicator of city government response is the allocation of local funds to STD/HIV/AIDS prevention activities. To date, 18 of 48 cities in the country have active AIDS councils.

One component of the United Nations Development Programme's (UNDP) activities is capacity building of local governments in developing, sustaining, institutionalizing multisectoral, participatory responses to HIV, and formulating supportive local policy (United Nations Development Program website).

NONGOVERNMENTAL ORGANIZATIONS

NGOs have been at the forefront of the Philippine's response to the HIV/AIDS problem. The activities of NGOs vary from information, advocacy, education, and caring for PLWHAs, to behavioral and biomedical research. The Health Action Information Network (2002) reported the activities of 70 NGOs working on HIV/AIDS (Table 3). The majority of these NGOs engage in advocacy (78.6%), information (77.1%), and training and education (68.6%). More than one third have libraries/research centers. About one fourth provide care and support for PLWHAs, including clinical services such as HIV and STD testing, or conduct social/behavioral research. Biomedical research activities, however, are not common among these NGOs.

Many of these NGOs have benefited from capacity-building efforts of other NGOs with support from international donor agencies. The Philippine HIV/AIDS NGO Support Program has assisted many of these NGOs in designing and implementing their prevention and control activities (Alcoreza & Saniel, 1998). At the same time, they have been instrumental in obtaining funding for some of the NGOs' projects (Philippine HIV/AIDS NGO Support, 2002). The Control of HIV/AIDS/STD Partnership Project in the Asia Region has provided capacity building in terms of research and opportunities to attend international training, study tours, and conferences (Tempongko, 2002). International donors include, among others, the UNDP, UNAIDS, and USAID, the Australian Agency for International Development, the German Technical Cooperation, the International HIV/AIDS Alliance, and the David and Lucille Packard Foundation.

A notable development among NGOs is the holding of regional HIV/AIDS conferences in the Visayas (Melocoton, 2002) and Mindanao (Alliance Against AIDS in Mindanao, 2002). This is a clear indication that there are now many active players in the HIV/AIDS arena, even outside of metropolitan Manila.

TABLE 3. Activities of 70 NGOs involved in HIV/AIDS in the Philippines

Area of Activity	Number	Percent
Advocacy	55	78.6
Information	54	77.1
Training and education	48	68.6
Research center/library	25	35.7
Care and support for PLWHA	18	25.7
Clinical Services	17	24.3
Social/Behavioral research	17	24.3
Biomedical research	4	5.7

Note. PLWHA=people living with HIV/AIDS.

CHALLENGES

Although some of the responses of the Philippines appear to be effective in controlling the spread of HIV/AIDS, several challenges still confront the country. The Health Action Information Network (2002) has listed several of these and noted that full implementation of the 2000-20004 accelerated medium-term plan has not yet been accomplished. Local government responses are still limited to only those areas that have been traditionally expected to first experience a full-blown epidemic. Although this has not yet occurred, other less vulnerable localities may feel no urgency to prepare themselves.

There is a need to stem the rise in STD cases. Because of the similarities in the transmission of HIV with STDs, this should remind the authorities that HIV need only be introduced into small but sufficient numbers to start an explosive spread. The experiences in Vietnam and Indonesia (UNAIDS/WHO, 2003) demonstrate that the epidemic can spread quickly. The Philippines needs to be prepared if an explosive outbreak occurs.

Related to the problem of STDs is low condom use, specifically among the younger population that is beginning to be sexually active. Reasons for low condom use should be explored, whether they be lack of knowledge or poor attitudes. There is also the presence of societal constraints, such as the resistance of the Catholic Church to condom promotion. It seems, however, that there may be some ground where these conflicting views of the use of condoms can be reconciled; for example, condoms might be promoted for protection rather than for contraception (Keenan, 2001).

A recent report cited the rising incidence of STDs and low condom use among high-risk groups to be among the factors that characterize 21 localities in the Philippines that have large pools of transient, full-time, part-time, and occasional participants in commercial sex, making them vulnerable to an explosive spread of HIV/AIDS infections (Taguiwalo et al., 2001). It also noted the inadequacies of these localities in responding to these threats, due to the low quality of social hygiene services, the low level of effort to educate those at greatest risk, scarcity or absence of locally institutions prepared to meet the spread, and lack of awareness of this threat and the importance of an early effective response.

A rising number of HIV cases are occurring among overseas workers. There is no effective surveillance of this population, because their infection status is only discovered once they reapply for another work stint abroad. By that time they could have spread the virus to their partners. Because this population has been known to engage in high-risk behaviors outside of the country, these individuals should be encouraged to undergo testing upon their return and to obtain their results immediately so they can protect their partners and seek treatment if they are indeed infected.

Among PLWHAs, however, access to affordable drugs remains a problem. Many turn to NGOs for support. The government should realize this need among this population and help them find ways to secure less costly drugs for HIV.

RECOMMENDATIONS

HIV/AIDS may not have gained a strong foothold in the Philippines as yet. It is imperative, however, that all sectors of society seize the opportunity of acting now rather than acting in the face of a major crisis. Full implementation of the 2000-2004 accelerated medium-term plan should be pursued. Some of the strategies have not yet been fully utilized. Regular HIV surveillance activities should be continued and implemented properly to serve as an early warning of increases in HIV prevalence and to guide decision makers in the formulation and prioritization of interventions. In particular, more effective surveillance among overseas workers should be established, and wider surveillance coverage among MSM and IDUs should be implemented. HIV intervention measures such as behavioral change, communication, treatment of STDs, and condom promotion and social marketing should be an integral part of HIV prevention and control plans.