World AIDS Day: Communities make the difference!

In a few hours, we will be celebrating WORLD AIDS DAY. World AIDS Day, designated on 1 December every year since 1988, is an international day dedicated to raising awareness of the AIDS pandemic caused by the spread of HIV infection and mourning those who have died of the disease. As of July 2019, there have been 69,512 total reported cases in the Philippines since 1984 with 3,514 reported AIDS-related deaths. More than a third of new cases occur among our youth ages 15-24 years old, mostly among those males having sex with males. Transmission can occur in three ways: (1) thru unprotected penetrative sexual intercourse with an infected individual; (2) thru injection of infected blood and (3) from an infected mother to her unborn child during pregnancy, during labor and delivery and thru breastfeeding. Body fluids that can transmit HIV include seminal fluid, vaginal fluid, blood, and breastmilk. Preventing HIV transmission includes ABCDE: A - abstinence, wait for your one true love B - be mutually faithful C - check your HIV status. If reactive, correct and consistent condom use D - don't do drugs and don't drink alcohol E - educate yourself and others for early detection Knowing all these about HIV prevention, we need to raise HIV awareness because there is no cure for HIV. However, with medications, we can manage HIV infection just like any other disease, to allow the PLHIV to live normal productive lives free of stigma and discrimination. It is time for everyone to be involved.
We invite everyone to be involved.
HIV/AIDS is not THEIR problem.
It is everyone's problem.


Families cannot do it alone.
Healthcare workers can not do it alone. Local government units can not do it alone.

World AIDS Day Cebu 2019 is an inclusive event. Everybody is invited to join #WADCebu2019. If everyone in the community as gathered here today, including government agencies, hospitals, medical and civil societies, academic institutions, researchers and students, organizations, religious groups, business and industries, and other agencies, cared enough to do their part to show support and work together in raising the issues and finding solutions to address the Philippine HIV Epidemic, then maybe, just maybe our communites will make the difference. This is our call to action, that every child can be protected against the threat of HIV infection.

Join us tonight (Nov 30, 2019) at 9:00 pm on #HealthXPH as we discuss how communities make the difference for World AIDS Day.

T1. How can you help raise HIV awareness?
T2. How can we reduce stigma and discrimination against people living with HIV?
T3. What message can you give to families and friends affected by HIV, especially those who lost loved ones to AIDS?

First of all, DO NO HARM!

It was during the Public Health Forum 2019 when I answered the question "what is your biggest regret in medical school?" with "I was not able to document my experiences in medical school..."

So here I am taking each available moment to write about things that seem important to me.  Stories that keep me awake at night and stories that motivate me to wake up in the morning and keep trudging through tedious and challenging work.

Today was such a day.

I was originally expected to attend the ALARM course of POGS.  However, today was the HIV ENDGAME - when the Philippine Infectious Disease Society for Obstetrics and Gynecology (PIDSOG) finalizes its position statement on the interventions for the prevention of mother to child transmission of HIV infection.  There are three known modes of HIV transmission.  These include unprotected penetrative sexual intercourse, transfusion of infected blood and from an infected mother to her child.

Of these three, perinatal transmission of HIV infection is easiest to address.  There is poor uptake of condom use among males who have sex with males and freelance sex workers.  Drug rehabilitation, needle exchange and even washing of needles have proven ineffective among injecting drug users.  However, pregnancy is a condition where women generally seek consult with a physician, hopefully an obstetrician.  Prenatal check up is an opportunistic event where we can get pregnant women tested for HIV, linked to care and initiated on anti-retroviral therapy with adherence.  During pregnancy, a mother can transmit the virus to her child (1) during pregnancy, (2) during labor and delivery and (3) during breastfeeding.  Therefore, the known interventions include (1) initiation of anti-retroviral drug therapy as early as possible during pregnancy to reduce the viral load (2) to deliver these patients via elective cesarean delivery as many multi-center trials show that cesarean delivery reduce vertical transmission in untreated patients by as much as 30% and (3) avoidance of breastfeeding, especially in high risk patients who have not started anti-retroviral therapy with viral load >1,000 copies, may prevent transmission of the virus to the neonate.

We consider that public health looks at the bigger picture, that many women living with HIV might not have access to the care that she needs.  However, considering that women living with HIV are strongly advised to deliver in a facility capable of dispensing anti-retroviral drugs, referral to centers capable of doing emergency or elective cesarean section and providing alternative infant feeding modes would not be too difficult.

It is difficult to bend and compromise to policies when evidence shows that there is harm if we do nothing.  As clinicians, first of all, DO NO HARM.  We also need to remember that once we compromise, we would be changing the way other policies will be directed.

• If we allow vaginal delivery to be the standard of care for women living with HIV, health insurance might not consider HIV infection as an indication for cesarean delivery.  This will make it harder for us to facilitate delivery of these HIV-exposed neonates.
• If we allow breastfeeding to be the standard of care for all women living with HIV, it goes against the teaching that breastmilk is one of the body fluids that can transmit HIV, so why would we give something to our children that would not be 100% risk-free?  Consider the milk code and the mother-baby friendly hospital and "breastmilk is still best for babies" - there is always an exception to the rule.  Let HIV infection be that exception, so that we can find ways for the newborn to survive the first one to two years of life without spending the rest living with HIV.

In the end, patients always have a choice.  Physicians need to respect patients' autonomy, for them to decide for their own health.  Who are we to dictate how they want to deliver and how they intend to feed their baby? After all, it would be the mother who will ultimately take care of her child, whether infected with HIV or not.

Building Partnerships for Health

What keeps me busy these days is connecting, organizing, and collaborating.  It's not easy to be a people person.  You have to cultivate your patience, tolerance and the skill to make people comfortable.  It's a habit you develop and improve everyday you meet new people.  #HealthXPH has taught me how to be kind to strangers and how to connect with people who are different from you.  Based on the connectivist theory, you learn in the digital age not just within the individual but within and across networks.  Connectivism sees knowledge as a network and learning as a process of pattern recognition.  Every Saturday, we learn how to be gracious and as the participants how their week was, and to introduce yourself and be conscious of one another's mental health.  Through this process, we build communities.

This process of building communities online has taught me how to effectively build communities offline.  You see, I am a government employee and working in a patient-congested tertiary government hospital with a lot of maternal deaths motivated me to organize periodic meetings with stakeholders from referring institutions like provincial and city hospitals.  Initially, we presented our needs and solicited suggestions for improvement and how the stakeholders could help us improve our health service delivery.  From there we proceeded to lay down our cards to become accountable for our performance, where each hospital presented their own accomplishment reports and best practices.  No blaming, no name-calling, but with constructive criticism to help each other improve to reduce maternal mortality.  We all agreed that the apex hospital cannot do it alone, we each should contribute to achieving the same goal of reducing maternal mortality.  Here was a prime example of building partnerships toward one common goal: to reduce maternal mortality.

Last May 2018, the Association of Medical Colleges of the Philippines (APMC) urged each medical school to develop its own HIV program.  This spurred a move to coordinate with HIV coordinators of each medical school to link them to the HIV treatment hubs and social hygiene clinics as well as community-based organizations, to unify the efforts for HIV advocacy campaigns.  This lead to the development of the informal group called #TEACHCebu which stands for "Targeting Enhanced Awareness and Control of HIV in Cebu".

We were able to organize an HIV Forum with free HIV counseling and testing for medical students for each of the six (6) medical schools in Cebu.   By December 1, 2018, we will be launching "KAAMBAG (meaning partnership): together we TEACH..." an HIV Congress for Healthcare Professionals on December 1, 2018 at the Cebu Doctors' University auditorium.  We hope that this is the first of many successful unified efforts to increase HIV awareness among service providers to reduce stigma and discrimination against people living with HIV.

These are just some personal experiences in building partnerships to achieve health-related goals. 

Share experiences of building partnerships and collaborating with other groups for health-related goals.  What are the benefits and challenges of working together toward one health-related goal? What is the role of social media in building partnerships for health?

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.