Public Health Policy versus Individual Patient Rights: Addressing the Philippine HIV Epidemic

According to the Department of Health (DOH) National Epidemiology Center (NEC) AIDS Registry, one Filipino is newly diagnosed with human immunodeficiency virus (HIV) infection every hour.

I was chatting face to face with Dr. Ted Herbosa and Dr. Narciso Tapia last week, and a sort of debate on how we should address the growing HIV epidemic lead me to re-thinking my perception of the problem, and to explore the different possible strategies to address the problem. One view is that of a public health policymaker, where the welfare of the public is of foremost concern.  In an epidemic, what needs to be done to control an infection is identification of cases and contact tracing.  In the Philippines, we have a number of HIV advocates whose priority is the protection of individual patient rights to privacy and confidentiality, lobbying for laws to improve counselling and testing, HIV risk reduction and stigma reduction and improvement of access to health service delivery and support.  Do these hinder control and elimination of the HIV infection in our country?

Previously described as “low and slow”, the HIV epidemic in the Philippines has now been described as “fast and furious” - and we need to do something about it!

Question 1. What public health policies do we currently have to address the HIV Epidemic in the Philippines?  In the Philippines we have the AIDS law, formally known as the Republic Act 8504, The Philippine AIDS Prevention and Control Act of 1998.

On HIV testing, the AIDS law requires that the patient to be tested for HIV give informed consent, and that this is voluntary and cannot lawfully be mandatory.  In simple terms, nobody can be forced to undergo HIV testing.

“SEC. 15. Consent as a Requisite for HIV Testing – No compulsory HIV testing shall be allowed. However, the State shall encourage voluntary testing for individuals with a high risk for contracting HIV; Provided, That written informed consent must first be obtained. Such consent shall be obtained from the person concerned if he/she is of legal age or from the parents or legal guardian in the case of a minor or a mentally incapacitated individual.”

Medical practitioners and healthcare professionals are bound to maintain confidentiality on the identity and status of persons with HIV.  This therefore prohibits the healthcare professional from disclosing to anyone (even the patient’s sexual partner) the HIV status of the patient.

“SEC. 30. Medical Confidentiality - All health professionals, medical instructors, workers, employers, recruitment agencies, insurance companies, data encoders, and other custodians of any medical record, file, data, or test results are directed to strictly observe confidentiality in the handling of all medical information, particularly the identity and status of persons with HIV.

Although healthcare professionals themselves cannot disclose the HIV status of their HIV-positive patient, the law encourages contact tracing, provided it is the patient who decides to disclose to his/her partner:

“Section 29.  Contact Tracing.  HIV/AIDS contact tracing and all other related health intelligence activities may be pursued by the Department of Health: Provided, That these do not run counter to the general purpose of this Act.”

Section 34 of Republic Act 8504 on Disclosure to Sexual Partners reads:

“Any person with HIV is obliged to disclose his/her HIV status and health condition to his/her spouse or sexual partner at the earliest opportune time.”

The DOH issued  Administrative Order 2009-0016 on Policies and Guidelines on Prevention of Mother to Child Transmission (PMTCT) of Human Immunodeficiency Virus (HIV).  Under Article VI Section 4 of this administrative order on Components of PMTCT on HIV Counseling and Testing, it reads:

“all partners of women infected with HIV shall be offered HIV counselling and testing.”

Question 2: How does one get HIV in the first place?

1. First, through unprotected penetrative sexual intercourse: commercial sex workers with low rates of condom use; increasing rates of casual sex among young adolescents (e.g. call center agents)

2. Transfusion of HIV-infected blood through IV drug use or blood transfusion:  The incidence of HIV infection through needle sharing in 2010 was relatively fewer in comparison to some Asian countries. A cited reason for this is the small population of people who inject drugs (PWID) in the country (Farr & Wilson, 2010), but recently an explosive rise in HIV was noted among injection drug users in Cebu.

3. From HIV-infected mother to her unborn child.  Anti-retroviral prophylaxis is a mainstay for preventing mother to child transmission.  However, there may be merits for Plan B+ also known as test-and-treat regardless of CD4 count and WHO stage of HIV infection.

Question 3: Why is there stigma and discrimination among people living with HIV?

The risk factors for acquiring HIV infection stem from high risk behaviors that are still considered taboo, such as promiscuity, casual sex or having multiple sexual partners increase the risk for acquiring HIV.  Males who have sex with males have an increased risk of HIV transmission.  Commercial sex work involves having sexual intercourse with individuals of unknown HIV status, most with low condom use. Illegal drug use is a crime punishable by law, hence re-use of needles possibly infected with HIV predispose IV drug users in acquiring the infection.

Question 4: What would be the implications of allowing HIV-positive patients confidentiality of their status which prohibits effective contact tracing?

Are there enforceable policies that can  require HIV-positive patients to change their behavior to reduce risk of transmitting the HIV infection? Counsellors and medical practitioners need to appeal to their sense of justice and benevolence.  Not allowing doctors to trace the contacts of their HIV-positive patients prevents them from advising these contacts to get tested and treated.

For instance, pregnancy is an evidence of unprotected penetrative sexual intercourse.  Many of these patients referred to us have not disclosed to the father of their child that they are HIV-positive.  The harm posed to the possibly HIV-negative sexual partner is evident since a woman can only get pregnant through unprotected penetrative sexual intercourse.  However, they fear that in disclosing to their partners, they would be thrown out on the streets with nobody to support them throughout their pregnancy.

• One such patient kept asking “kung iwanan niya ako, pano kami kakain? Saan kami titira ng mga anak ko? Saan ako kukuha ng pang-gastos ng CS ko? Paano ako bibili ng gatas ng anak ko? Anong trabaho ang pwede ko gawin eh hindi naman ako nakatapos ng pag-aaral…” (if he leaves me, how will we eat? Where will we live? Where will we get budget for my caesarean delivery? How will I buy milk formula for my baby? What work can I find when I did not finish school?)

• One HIV patient admitted that she was liberated when it came to sex, and that’s how she got infected. We were trying to convince her to disclose her HIV status to her current partner so that he could be tested as well.  She answered “bakit, sila ba naawa sa akin nung hinawahan nila ako ng HIV?” (why, did they have pity on me when they infected me with HIV?)

Non-disclosure of HIV-positive status puts people at risk for getting HIV infection.  You prevent the natural ability of the public to protect itself from acquiring the HIV infection.

Question 5: What about moves to provide needle exchange programs, condom use and pre-exposure prophylaxis?

The common view about these interventions are that these are band-aide therapies, with the risk of reinforcing high risk behaviors like IV drug use and sexual intercourse among patients already positive with HIV instead of addressing the root cause of the problem, which is drug addiction and high risk sexual behaviors.

Needle Exchange Program.  The NEP, properly understood and operated, does not contradict the goal of treatment. Research has shown that NEPs, aside from being preventive to HIV transmission, is also an effective conduit to treatment programs and other health services (Geffray, Schiray, Fabre, & Guilhem, 2002).

Pre-exposure Prophylaxis.  Just like diabetics say “I can eat cake and icecream, anyway there’s medicine to reduce my blood sugar…”  Pre-exposure prophylaxis does not address risk reduction, but allows HIV-positive patients to continue having risky sexual behaviors, after all, “there is medication for my partner anyway…”

Privilege should come with responsibility.  If HIV advocates demand that they be protected by law and afforded privacy and confidentiality regarding their status so that they can continue to be productive and self-sufficient working citizens, then they should be required to at least 1) get appropriate treatment that they need, 2) inform their own contacts to get those people tested and treated as well.

What needs to be done?  Support should be provided for these patients to be able to openly disclose their status 1) to their sexual partners on whom they are fully dependent financially, emotionally and spiritually and 2) to drug addicts to be rehabilitated to prevent addictive IV drug use which predisposes to HIV transmission from use of infected needles and syringes 3) increase awareness and acceptance of HIV counselling and testing, especially among high risk groups.