"There! That's how you deal with the big noise, " says Hayhurst. "The relief that a cushion and a scream like this can give you is amazing. And, nobody can really hear you."

Hayhurst, an Australian nurse and AIDS educator, dispensed this advice to family members and volunteer-caregivers of Filipinos living with HIV/AIDS during a closed-door workshop organised here this week by the Remedios AIDS Foundation, a local non-governmental organisation.

During the workshop, Hayhurst encouraged caregivers -- mostly relatives of Filipinos living with HIV/AIDS -- to explore their own feelings and not to deny them. "It's normal to have negative feelings (about HIV/AIDS). You don't have to feel guilty or shamed when you feel them," she stressed. "There is such a thing as caregiver pain and you need to let it out."

Even men, she stressed, "need to have a good cry." She encouraged male caregivers to ignore society's dictates that big boys do not cry.

Hayhurst says that too often, caregivers bury their feelings of anger, frustration, despair and helplessness, which often lead to burnout in caring for people with HIV/AIDS. "There's something in the (Filipino) culture where it's almost impossible to work out the "I" because there's always the "we," she says.

The workshop, the second in a series funded by the Ford Foundation, was meant to provide AIDS caregivers with a venue to "look inside themselves," says Dr. Jose Narciso Melchor Sescon, executive director of the Remedios AIDS Foundation.

"Filipino caregivers tend to be superman and superwoman. When they help out, it's all out, even at the expense of self," says Sescon.

"Yet they need to know that the real essence of caregiving is caring for one's self first. It's learning to deal with your own set of feelings before helping others, otherwise it can lead to more harm than good. They also need to learn that there are limits to caregiving."

The value of a workshop for caregivers cannot be underestimated, especially in a country where the family is main social support system. Compared to other Asian countries like Burma, Thailand and Cambodia, the Philippines still has a low prevalence of HIV/AIDS at seven adults per 10,000 according to the United Nations Development Programme. But experts have warned of a "major epidemic" in the future.

Aside from high-risk exposure among Filipinos ages 15 to 24, there are other factors that could trigger an epidemic such as cultural and religious barriers that deter open discussion of risk behaviour as well as the promotion of condoms and safer sex.

Hayhurst, who runs a 100-bed hospice in Sydney, Australia and has been a consultant on palliative care for HIV/AIDS patients at the San Lazaro Hospital here, has identified some cultural issues that hinder Filipino caregivers and patients from dealing squarely with the issue of HIV/AIDS.

"The main issue is the terrible shame and stigma that they live with. It's incredibly sad and causes huge suffering," says Hayhurst. "I have to say this with respect, but there's something in the culture and within the value system where my shame becomes your shame. If I do anything which brings me disgrace, it affects the entire family."

'Hiya', the Filipino word for shame, often results in "one big collusion of silence," adds Hayhurst. "The silence around what's happening is so disempowering and only compounds the suffering."

This culture of shame and silence is "deeply entrenched," says Hayhurst and needs to be addressed. "We need to liberate people from the shame. The patients are already deeply shamed on their own, to add an entire family's shame on top of that is terrible."

In its "redeemed state," however, Hayhurst says that the close-knit family structure in the Philippines can offer an entire support system for a person living with HIV/AIDS. "The potential of the family is beautiful to tap. The sure knowledge that someone will be there is just something that we don't have in the West."

Sescon agrees that there are still "cultural sensitivities" in the Philippines that need to be addressed, not just in the case of HIV/AIDS patients but also their families, caregivers and the entire society as well.

"When we encourage families to talk to psychiatrists, some would say 'but we're not crazy)," says Sescon. "So we have to course the counselling through social workers."

He says that even caregivers need to have "respite" from situations of caring for their relatives with HIV/AIDS, but this is just not readily available to them because of limited resources in taking care of their kin.

Caregivers need to be part of the whole equation when dealing with the issue of HIV/AIDS but they are not considered a priority because most of the attention usually goes to the people with HIV/AIDS themselves, he adds.

"Unlike South Africa or Myanmar, the Philippines is a low-prevalence, low-priority area," says Sescon. "Funding agencies just don't see they opportunity to set up structures when it's still manageable, before the epidemic sets in."