DUTERTE:  Kasi kung sana na medyo 50 million lang tayo, ma-manage natin ‘yung pagkain. Enough for all, tapos may trabaho. Kasi kung 50 million lang… Pero kaya naman alam ko. Sumunod nalang… Hindi ako nagpapatawa, sumunod nalang kayo sa programa ng gobyerno.

May pills libre. ‘Wag ‘yang condom kasi hindi masarap ‘yang condom. [laughter] Hindi, totoo. Hindi ako nagpapatawa. Harap nga ng ating Republika eh.

Nagdala ako talaga, ito. Kainin mo ‘to. ‘Wag mong balatan. [laughter] Kinuha ko doon sa kotse. Kainin mo. ‘Yan ang condom. [laughter]

Fake na, fake pa ang news. Fake lahat.  Ako, I’m just telling you that is why Biology. Alam ko ayaw ninyo ng condom so either magpa-injection kayo good for six months. So walang limit ‘yung ka-l****** mo diyan. Bahala ka kung ano. [laughter] …

[From welcome speech to OFW amnesty availees from kuwait 13 Feb 2018]

i’m shocked, distressed, and seriously exasperated to find that the president has joined the church (imagine!) in the campaign against condoms — even if they come from different places:  the president from a place where patriarchy and the pleasure principle rule, the CBCP from a place where all sex (and thoughts of sex) outside of monogamous marriage is a SIN and all contraception EVIL.

totoo naman, condoms can be a hassle in lovemaking, both for men and women, pero puwedeng pag-trip-an.  BESIDES, condoms are essential in preventing unwanted pregnancies especially in an already over-populated uber-impoverished third world country.  IN ADDITION, condoms are essential in preventing the spread of sexually-transmitted diseases, especially the deadly HIV/AIDS that continues to stalk the gay male community that merrily indulges in anal sex exclusively with men, plus the wide spectrum of the bisexual community — men having sex mostly with men and rarely with women, men having sex with men and women with the same frequency, and men on the other end of the spectrum, known-heterosexual family men who dabble in occasional male-to-male sex.

imposible namang hindi alam ng presidente na parami nang parami ang reported HIV cases dito sa pinas.  buwan-buwan halos ay may update ang UN at ang DOH on the latest numbers — davao city mismo under mayor sara is a test area of rapid HIV-AIDS detection.

read aljazeera‘s  Philippines: HIV cases up 3,147 percent in 10 years

… in terms of percentage increase, the UN said in August 2017 the country has the fastest growing HIV epidemic in the Asia-Pacific region in recent years … the Philippines has become one of eight countries that account “for more than 90 percent of new HIV infections” in the region…

but there is also this:

With a population of more than 100 million, the number of HIV cases in the Philippines remains low.

ano ba yung low.  ilan ba yung low.

according to the HIV and AIDS Registry of the Philippines (HARP) report the number (cumulative) of confirmed HIV cases countrywide from january 1984 to  january 2018 was 51,049 (from 50,725 in december 2017).  the number of deaths: 2,466.  read manila bulletin‘s PH has 1,021 new HIV cases recorded in January 2018.  read DOH’s 2017 update here.  and read inquirer‘s Number of deaths Due to HIV in Asia.

i bet the figures are higher.  easily twice, maybe thrice, those numbers, but unreported.  read Dying of shame and AIDS in the Philippines (2016).  read Philippines: Discrimination Against Workers with HIV (2018).

i am mighty scared for the gay community.  a number of my gay friends  back in UP the basement in the late sixties (i was a fag hag) died of AIDS, so this is personal.

read the borgen project‘s Addressing the Problem of HIV in the Philippines (sept2017).  elsewhere in the asia-pacific region, people have become more educated about HIV transmission and its dangers.

[…] the lack of access to information about HIV has been a substantial problem in the country. Two out of every three infections were in males between 15 to 24 who did not have adequate awareness about the dangers and pathways of transmission of the virus. In fact, many gay men, a group in particular risk of contracting HIV, only get tested eight years after their first sexual encounter.

this bears repeating:  the lack of access to information about HIV has been a substantial problem in the country. Two out of every three infections were in males between 15 to 24 who did not have adequate awareness about the dangers and pathways of transmission of the virus.

LACK OF INFORMATION.  kasalanan iyan nino?  ng DOH?  ng DEPED?  ng simbahan?  all of the above, i tend to think.  so why isn’t the gay community rising to the occasion, as ACT UP did in america in the mid-1980s when gay men and bisexuals were dying like flies.  thinking boy abunda and vice ganda, gay TV personalities, public figures who could make a real difference in the campaign to inform about HIV, and to counter the president’s immature anti-condom rhetoric.

the virus is spreading, guys, girls, gays!  we have been warned.  we are being warned, again and again.  matakot sa HIV / AIDS.  for now, for starters, alamin niyo man lamang what it is all about, and why you should be very afraid not just of becoming infected but also of infecting your wives / girlfriends / significant others.  unless in a seriously monogamous relationship, the condom is a sexually active person’s best friend.

read a primer: HIV in the Philippines / Window of Opportunity or Predictable Failures (dec2015) by dr. godofredo u. stuart jr., internal medicine specialist who for 14 years was with a baltimore clinic providing HIV/AIDS treatment to a patient population of mostly gay men and IV drug users, staffed by nurses and mostly gay and lesbian volunteers who provided unbelievably compassionate care.

… The Gay and Bisexual Community

A report recently published that about 85% of HIV cases in the Philippines were identified in gays (men having sex with men). Men having sex with men (MSM) is the predominant mode of transmission in the Philippines.

It comes as no surprise. In the Philippine sexual revolution of the past two decades, change has been most visible in the homosexual community—the ubiquitous presence of gays in the commerce of radio and television, with a masa acceptance that helped open the closet doors for many, with increased public visibility especially among the BCD and creating the seeming increase in the number of gays.

An estimate has been made that a minimum 10% of the population is gay. This number pales to the common street guesstimate that 4-5 of 10 Filipinos are gay or bisexual. The numbers are too high or too low, depending on where you live or who is polled. The ubiquitous presence of gays on radio and TV, likely contribute to the skewing of estimates.

According to a 2002 Young Adult Fertility and Sexuality Survey, 11% of sexually active Pinoys between the ages of 15 and 24 have had sex with someone of the same sex.

CNN is said to have listed the Philippines as one of Asia’s top travel spot for gays, “full of gorgeous gay-friendly beaches and welcoming gay bars.” The country has even been ranked as one of the most gay-friendly in the world, and the most gay-friendly in Asia.

Grapevine stories tells of bathhouse-type venues with a merry-go-round of dozens of different partners, one bragging of over 100 different contacts in one year. Hidden in the MSM (men having sex with men) numbers are an estimated 30-40% who are bisexuals, unaware of their serologic status, with the potential to infect their female partners: prostitutes, wives, and girlfriends.

FSW (Female Sex Workers)
The first wave of HIV infections was identified in FSW around the US military bases. The exodus of the American military helped stem the early rise of HIV cases. However, the red-light commerce is a booming enterprise. Despite the FSW seeming low contribution to the total HIV numbers, they continue to be a very vulnerable population, with anatomical risks and often compromised positions in condom negotiations.

OFWs
The Trade Union Congress of the Philippines warned the number of OFWs testing positive for HIV may reach over 4,000 this year. One report on new cases estimate more than 30% to be among homosexual and bisexual OFWs. The OFWs now comprise some 14 percent of the 24,936 cases in the Philippine HIV and AIDS Registry as of April 2015.

Other High Risk Venues
There are other niches of risk populations: intravenous drug users in an unmanageable population of shabu addicts, sex tourism and child prostitution, call centers that have been flagged as red-hot zones, and of course, a small population who gets infected through heterosexual or bisexual transmission. These are separate risk populations that need separate programs of outreach, surveillance, and education.

HIV/AIDS AND SEX EDUCATION
In any efforts of HIV/AIDS prevention and treatment, education is forefront and paramount. Every pulpit of concern urgently clamors for more effective education. The past is littered with failed efforts on education. Although there have been a Health Department campaigns and media blitzes for HIV and AIDS awareness, misconceptions and ignorance on cause, prevention and risk practices are still widespread.

I have written opinions on the failure of the education: The Comic Failure of Language in Sex Education and the Predictable Failure of HIV Education in the Philippines. Education will continue to fail if it continues to kowtow to the dictates of a church who insists on a language of sex education expunged of vernacular sex words which it has decided are vulgar or bastos, with no place in the setting of decent conversation and education. Many do not recognize the colonial roots and church’s influence on language cleansing in sex education and the prudishness in conversation when it pertains to sex—many convinced of its vulgarity. Others who see it as it is can only shrug and say: The Church won’t allow it. . . Hindi papayag ang simbahan. . . Napakalakas nang simbahan.

The religious constraints placed on education has been comic. In an earlier sterilized effort of the Philippine National AIDS Council on HIV education (HIV and AIDS 101 and Republic Act 8504 Basics), there was not a single mention of the word “condom” in its ABCDE of AIDS prevention.

Thankfully, that might be a thing of the past. Activism against the establishment has won small battles. Education efforts have turned a new leaf. Clinics have sprouted with secular teaching modules. The condom has finally become part of the language of HIV education and prevention, replete with demo models of penises.

Even with the exclusion of the church, the great task for educators will be the translation of education and information into a comprehensible regional vernacular; Taglish or regional dialects, and when needed, infused with ample doses of Swardspeak.

Sex and HIV/AIDS education is a continuum and should be sensitive and appropriate to the varied audiences being addressed. For the young, sex education should be a departure from the stale and sterile birds-and-bees type of teaching. For the general public, education should focus on prevention and risk behaviors, unexpurgated and stripped of “hiya” or “bastos”, with emphasis on safe sex practices, condom use, anal sex, and the importance of knowing one’s HIV status, that HIV infected patients might feel well for many years, until their immune system declines significantly enough to cause symptoms or opportunistic infections. For the masa, the CDE, it should be in a language that they understand, without the preponderance of English words that causes “nosebleeds.” For MSM and bisexuals, education should be brutally frank, delivered in their vernacular, Taglish, or swardspeak, focusing on their sexual risk practices and anal sex; and for bisexuals, the added risks for their female partners (girl friends, wives, or prostitutes). For FSW education, efforts should focus on their higher risks, safe sex practices focusing on both vaginal and anal sex, condom and lubricant use, For those who test negative, they should be aware that there is a window of a month, from contact to seroconversion. For those who tests positive, the importance of safe sex practices, to learn of the disease process, its usual decade long course, symptomatology, treatment options and how treatment extends lives and decreases the risk of transmitting infection to their partners. For those already infected and on treatment, education should focus on treatment compliance, prognosis, monitoring for opportunistic infections.

The setting for sex and HIV education matters, not just in language and messengers, but also in abilities and sensitivities. Many physicians are uncomfortable dealing with HIV patients, lacking in knowledge and the time to keep current in information, the sensitivity to want to address certain patient populations, and the ability to advise on the taboo subjects of risky sexual practices related to HIV infection. Likewise, patients easily sense this inability and discomfort and reflexly distance themselves and withdraw into silence and denials. In a country where 85% of HIV infections are in MSM, clinics staffed by dedicated and well-trained gays and lesbians can provide much needed atmosphere of trust, sensitivity, and nonjudgmental compassion.

CONDOMS
Condoms play a crucial and central role in the prevention of HIV and other sexually transmitted diseases. Male and female condoms effectively reduce the transmission of HIV, besides reducing other sexually transmitted diseases. In HIV epidemic settings, condom use has been found to significantly reduce rates of HIV, with an estimate that condom use might have prevented about 50 million new HIV cases since the HIV epidemic. Education should include its storage and proper use, how to minimize condom failures, the use of double condoms and water based lubricants especially for anal sex.

Despite the 2010 Catholic Church historic shift on its ban on condoms—that condom use can be morally justified, that it is acceptable to use a prophylactic when the sole intention is “to reduce the risk of infection” from AIDS, a first step to a more humane sexuality—the local church hierarchy continues to refuse to grant its blessing to condom use in the setting of HIV prevention.

But with condoms the bigger problem is not the church, but rather, the cultural aversion to it, and to some degree, the stigma associated with its use. Education and easier availability can help in the effort to make the condom commonplace. “Better alive, with condom use; rather than sick or dead, without.”

ANAL SEX
Although its practice is frequently assumed to be confined to the gay male population, anal intercourse appears to be more popular than possibly expected among heterosexual couples under 45, according to a Center for Disease Control and Prevention (CDC) report.

The report, titled “Sexual Behavior, Sexual Attraction and Sexual Identity in the United States,” which reportedly polled thousands of people between the ages of 15 and 44 from 2006 through 2008, found that 44 percent of straight men and 36 percent of straight women admitted to having had anal sex at least once in their lives. In another poll, 40% of women 20-24 years of age had experienced receptive anal intercourse.

Condom use during heterosexual anal intercourse is lower than condom used during anal sex among MSM. This is compounded by the belief that while 96 percent of teen girls believe they can get HIV from vaginal intercourse, 20% did not think they can get it through anal intercourse.

Having a smaller anus and rectum, women are also at greater risks for anal fissures, and at greater risks for anal trauma than MSM.

Despite the increasing popularity of male-female anal intercourse, probably pornography-boosted, anal sex continues to be a tabooed subject in the physician’s Q&A of usual concerns, or at best, invariably skimmed over. When it comes to female anal sexuality: “Doctors don’t ask, patients don’t tell, and educators gloss over.” And for women in anal receptive intercourse, this spells risk for HIV, and also, anal cancer. (8)

TESTING
Fear, denial, stigma and discrimination keep many away from the usual clinic setting of testing. There are many who would not want their test results disclosed in a clinic.

In a TV ad for HIV/AIDS awareness trying to draw out the public to submit for HIV testing, Dr. Garin’s crowned her invocation with “Ang DOH ang bahala sa inyo!” The DOH will take responsibility for you — a typical “bahala na” political promise you hear from politicians.

In a country where the masa population venerates their celebrities and embraces as “truth” every delivered message on shampoos, soap, and noodles, celebrities and icons of the gay community can greatly help in delivering the urgency for testing of populations at risk, together with messages of awareness, prevention, safe sex practices.

STIGMA
After more than three decades, the stigma associated with HIV/AIDS has not abated. In a country that is 80 percent Catholic, the church’s uncompromising position (a queer position for an institution likewise stigmatized for its homosexual population and plagued by a flood of sexual molestation charges)
against gays and their sexual practices contributes no small amount to the stigma and shame people with HIV feel.

But while the church rants and raves against homosexuals, the Philippines is also considered one of the most gay-tolerant and gay-friendly of countries, offshoot of the LGTB liberation and revolution of the past two decades, and the present ubiquity of of gays and cross-dressers on radio and television.

Despite the seeming gay-tolerance or gay-friendliness, discrimination against LGBTs is well and alive in its many forms: sexual, physical or verbal violence, discrimination in school, workplace, and many public venues, and even in health care settings.

For the LGBT who tests HIV positive, the stigma is inordinately increased with the infection linked to risk behaviors, deviant sex practices, irresponsibility, drug use, prostitution, promiscuity, together with the myths and misinformation of contagiousness.

Rather than suffer stigma and discrimination, many choose to withdraw into isolation without the benefits of treatment, resigning themselves to the certainty of progressive illness.

A home testing kit, which has become available in many countries, allows people access to testing in the privacy of home. Those who test positive might have to contend with denial, depression, hopelessness, and suicidal ideations. Fast access to support and counseling should be available, as well as 24-hour hot lines manned by trained counselors.

MENTAL HEALTH
In the Philippines, where mental health is a neglected field of health care, PLHIV will likely suffer absence of psychological support. Most HIV-infected patients will suffer through a psychological spectrum of stigma, discrimination, social isolation, depression, hopelessness, helplessness, and suicidal ideations. In many studies, suicide rates among HIV-infected patients are consistently higher than in the general population. HIV care should address the suicide risk in PLHIV and provide mental health screening and access to counseling and pharmacological treatment.

TREATMENT
There is now considerable science, replete with guidelines and protocols in the treatment of HIV disease and AIDS. While HIV is treatable with regimens available to rein it into chronicity, the cost will be prohibitive to many in this country.

A dollar estimate in 2014 puts the cost of HIV treatment in the U.S. at about $30,000 to $36,000 per year, with an estimated lifetime cost of $ 400,000 to $500,000, with the cost of treatment increasing as a patient gets sicker.

In the Philippines, 60% or P300 milion of the DOH’s National HIV/STI Prevention Program budget of P500 million for 2015 is allotted for treatment. With 10,200 patients with HIV under the DOH’s care, that divides into about P30,000 per patient (about $650) per year. With this budgetary constraints, I cannot imagine a DOH that can deliver quality care and treatment for PLHIV.

This concern is further underscored by Tricia Aquino’s article: HIV Cases Reported 1984 – 2015 / PNoy gov’t’s inadequate program to combat HIV/AIDS hit amid worsening epidemic which reviews the many facets of the HIV problems and the daunting and ominous task for the DOH in combating the HIV problem.

There are about 10,200 PLHIV on retroviral therapy provided by the government every three months through 22 treatment hubs, drugs not commercially available locally, some forced to access them abroad “during times of shortages” which have occurred thrice, February and May 2014 and June 2015. Treatment compliance is most important, discontinuances and more than occasional missed doses provide the setting for viral resistance, with treatment likely to fail sooner than later. This is compounded by the fact that less effective regimens continue to be used “simply because it was what the government could afford”—again, certain to contribute to the nightmare of viral resistance and consequent treatment failures.

In a disease that requires daily compliance and uninterrupted treatment of expensive regimens, outcomes and prognosis will likely be determined by economic realities: Only the rich can afford and truly benefit from highly aggressive and expensive multidrug antiretroviral therapy, the prevention and management of opportunistic infections, pre- and post-exposure prophylaxis, and state-of-art clinical follow up and laboratory testing. The poor will be consigned to what the government, constrained by budget and unpredictable shortages, can dole out.

And, where pray tell are the 15,000 PLHIV who are not on record as receiving antiretroviral therapy? Perhaps, some could afford anonymity to privately access clinical evaluations and treatment. For the rest, it’s a matter of time (five to ten years) and numbers (decreasing cell counts) before HIV disease becomes AIDS with its consequent opportunistic infections. And, to keep the numbers keepers in trepidation, how many of them continue to be sexually active?

Many will eventually come home to roost, to severely burden a health care system already unable to provide for the treatment concerns and needs of present day PLHIV. But while quality care will be unaffordable to many, nurses and health care assistants can be trained to provide an alternative to expensive hospitalizations through home care for the management for many of the disabling opportunistic infections, hospice care and end care.

Predictable Failures and Windows of Opportunities
In the 2012 WHO report on leading causes of death in the world, AIDS ranked 6th with 1.5 million deaths. In the same year there were 300 reported AIDS deaths in the Philippines. In a 2014 World Health Ranking of the top twenty causes of deaths in the Philippines, coronary heart disease ranked number 1 with 87,881 deaths and peptic ulcer disease ranked 20 with 6,234 deaths or 1.20% of total deaths.

In that context, HIV in the Philippines is far from becoming the epidemic it has become in other countries —and perhaps, that presents another window of opportunity. However, religious, political and social realities in the Philippines threaten to hinder a real comprehensive effort against HIV/AIDS disease. Treatment will suffer the economic realities of a third world country, the unavailability and unaffordability of standard aggressive and life-extending therapies for many. Mental health issues should be addressed with non-judgmental compassion. Education and prevention efforts will continue to be forefront and should urgently focus on the high risk populations and their high risk behaviors, outreach the population of HIV-diagnosed who have chosen to withdraw into anonymity.

HIV/AIDS is a disease of the younger populations, where death, once unfamiliar, has become common place. Education, condom use, and safe sex practices can drastically stem the rise of the HIV infected. And between infection and death, education and treatment will provide hope for a life lived much longer and with greater fulfillment than what was once not possible in the early years of the HIV epidemic.

Sadly, many in civil society will continue to wear blinders, comforted by the notion that they are far removed from the dangers of a scourge that they believe afflict only high risk populations, and confident and hopeful, for now, that government, despite the failures of the past, can stem the rising tide of the HIV threat.

*