Philippines

A young man wearing a striped red T-shirt and faded blue jeans enters a popular bar in downtown Quezon City, the Philippines. He starts speaking to the owner and is soon joined by several other young men. It’s 10 p.m. and the group blends in seamlessly with the other bar customers. The young men are not here to relax, though. They are peer educators and health workers employed by Quezon City’s health department.

“You just get used to it,” said Mai. “The night is to us what the day is for others. It’s the job.”

Outside, a street lamp casts an orange glow on a city ambulance that purrs softly, parked and waiting unobtrusively for clients. The group of men has come to conduct HIV counselling and testing with bar patrons and staff, who are mostly gay men or other men who have sex with men. On this steamy night they test around 50 people.

With nearly 3 million residents, Quezon City is the Philippines’ most populous urban centre and has made stopping a burgeoning AIDS epidemic a top priority.

“Quezon City is unrelenting in its effort to pursue and sustain its programme of zero new HIV infections, zero discrimination and zero AIDS-related deaths. We remain committed to providing preventive interventions, treatment, care and counselling to ensure our people receive a better quality of life,” said Mayor Herbert Bautista.

UNAIDS has encouraged cities to accelerate their AIDS response by front-loading investments and reaching critical HIV prevention and treatment targets. In the Philippines, Quezon City is leading the push to implement the UNAIDS Fast-Track Strategy in urban areas.

On 4 December, Quezon City hosted a meeting with representatives from cities in the Metro Manila area on how to end the AIDS epidemic by 2030. Participants adopted the Fast-Track approach.

UNAIDS estimates there were 6400 new HIV infections nationwide and 36 000 people living with HIV in the country in 2014. HIV prevalence among men who have sex with men was 3.3% in 2013, compared to 1.68% in 2011. Among the general population aged 15–49, the estimated HIV prevalence was lower than 0.1% in 2014.

Quezon City: a trailblazer in the country’s HIV response

While a network of facilities catering to the health needs of sex workers has existed since the 1990s in the Philippines, in 2012 Quezon City became the first city in the country to open a clinic providing services for men who have sex with men and transgender people.

Klinika Bernardo, popularly known as the Sundown Clinic, is located along a busy highway. It operates from 3 p.m. until 11 p.m., allowing a maximum number of clients to visit.

“We cater to men who have sex with men from all over the Philippines,” said Leonel John Ruiz, head physician at Klinika Bernardo. “Only 40% of our clients are from Quezon City.”

From the start, demand for services at the Sundown Clinic was high. Almost 250 HIV tests and pre- and post-test counselling services were conducted in its first two months of operation and 18 people tested HIV-positive. By the end of 2014, the clinic had conducted more than 2500 tests, of which a little more than 200 were HIV-positive. The first Sundown Clinic was so successful that the city opened a second one earlier this year.

The Sundown Clinic: a safe space for men who have sex with men and transgender people

While same-sex sexual relations are legal in the Philippines, such relationships are viewed negatively by many people and there is a high degree of stigma and discrimination towards gay men and other men who have sex with men. Fear of being outed and ostracized prevent many men who have sex with men from accessing traditional health services. Studies by city health officials show that two thirds of men who have sex with men in Quezon City have never had an HIV test.

With its row of potted plants and bright green decor, Klinika Bernardo exudes a cheerful atmosphere. It has 10 staff members, with four peer educators, who include men who have sex with men and a transgender woman. Clients can choose the educator who best suits their needs. Instead of documenting and calling clients by their name, the clinic maintains their anonymity by giving each person a number.

Staff are skilled at reassuring jittery clients.

“This is my first HIV test. I do not know what to expect,” said one young man while filling out registration forms. “I tried to read up on HIV so I would have some background information, but it took me awhile to gather the courage to come here. My partner came here with me, too, after hearing about it from our friend. We’re taking the test together.”

The young man found the staff supportive and skilled at easing his fears.

People who test HIV-positive receive counselling on antiretroviral medicines and are accompanied by staff through their initial months of HIV treatment, which is free in the Philippines.

Quezon City’s HIV programme becomes a model for other cities

Quezon City operates the Sundown clinics and has significantly increased investments in its HIV programmes in the past few years. And the city's efforts to scale up HIV testing are getting results. The number of gay men and other men who have sex with men being tested almost quadrupled between 2011 and 2014.

“In the three years that we have been operating, the perspective has definitely changed,” says Mr Ruiz. “Before, we would have a hard time inviting people for testing. Now, most of our clients are walk-ins. People are personally and actively seeking information.”

Quezon City won the prestigious Galing Pook Award for outstanding local governance in 2014 for its pioneering HIV clinics. Several other local city governments are starting to adapt the Quezon City model and establish their own clinics.

While the Sundown Clinic staff are proud of their achievements, they are looking forward to closing shop one day.

“I pray before sleeping,” says Adel, the only female peer educator at Klinika Bernardo. “I pray that there would come a day when there will be no one in need of our services. That’s what I am working for.” 

Five countries across Asia have embraced the Protect the Goal campaign. An innovative partnership between UNAIDS, the Asian Football Confederation (AFC) and the Asian Development Bank (ADB) is promoting a multicountry football-based HIV prevention programme in the region.

Cambodia, Malaysia, Myanmar, Philippines and Thailand have all committed to carrying out activities with the aim of helping to address HIV transmission among young people.

Myanmar kicked off its campaign in April with a football match at the national stadium featuring national stars Kyaw Ko Ko and Than Than Htwe from the Myanmar men’s and women’s national teams. Supported by the Myanmar National League and the Myanmar Football Federation, the match was played in front of thousands of fans. Through additional activities focusing on young people in schools, football clubs and other venues, the campaign will promote the importance of voluntary HIV testing and the elimination of stigma and discrimination towards people living with HIV.

The UNAIDS–AFC–ADB initiative will be implemented by the Myanmar National League and Football United, a flagship programme of the School of Public Health and Community Medicine at the University of New South Wales, Australia.

Cambodia has also initiated activities within the campaign. In March 2014, stars of the Phnom Penh Crown Football Club came out to support the Protect the Goal campaign and entertain fans in an event supported by the SALT Academy, the Football Federation of Cambodia and the Ministry of Education, Youth and Sport.

Malaysia, Thailand and Philippines are all set to roll out key activities in the near future, with Malaysia officially launching its campaign on 16 May.

The UNAIDS–AFC–ADB initiative is part of the Protect the Goal campaign efforts to roll out activities and messages on HIV prevention in the lead up to the 2014 FIFA World Cup in Brazil, where there will be an event profiling the global campaign in Salvador, Bahia, on 9 June 2014.

The United Nations Secretary Generals’ Special Envoy on AIDS in Asia and the Pacific Prasada Rao visited the Philippines at the end of August to advocate for a scaled up response to HIV in the country.

After more than 20 years of low rates of new HIV infections, the Philippines is now seeing an increase in the number of new HIV infections among key populations at high risk in certain geographical sites. For example, the HIV prevalence among people who use drugs in Cebu—one of the most populated areas in the country—went form 0.6% to 53% between 2009-2011. Similarly, the HIV prevalence among men who have sex with men in 2011 was as high as 6% in Quezon City and 5% in Cebu—the HIV prevalence among the general population in the country was less than 0.1%. According to the Philippines Department of Health, there has been a 523% increase in new cases compared to 2008.

Speaking at the Executive Committee Meeting of the Philippine National AIDS Council (PNAC) Mr Rao urged increased leadership and rapid action to stem the spread of the epidemic. He also noted that policies, plans, antiretroviral treatment and HIV prevention technologies are all available and within reach to ensure progress on reversing current trends. 

During a meeting with Socio-economic Planning Secretary Arsenio Balisacan, who also heads the government’s National Economic and Development Authority, Mr Rao emphasized the need for greater government investment on HIV, noting that current prevention investments of US$ 8 million - US$ 10 million per year fall short of the estimated need of at least US$ 40 million per year.

Secretary Balisacan agreed that investing now in HIV prevention will lead to savings in HIV treatment costs in the future and shared that both he and the President of the Philippines, Benigno C. Aquino III, have requested the Health Secretary to present a ‘prevention strategy’ for the Health agenda, including the issue of HIV.

The new study, Vulnerabilities of Migrant Women: from Asia to the Arab Statessays that Asian women migrating to Arab countries often face circumstances which leave them highly vulnerable to factors leading to HIV infection.

Asian women migrating to the Arab states often do so under unsafe conditions, are targets of sexual exploitation and violence and are highly vulnerable to factors that lead to HIV infection, according to a study launched today, produced in collaboration by UNDP, UNAIDS, CARAM Asia, IOM,UNIFEM, and Caritas Migrant Centre in Lebanon.

HIV Vulnerabilities of Migrant Women: from Asia to the Arab States examines the health, social and economic toll that migrant women often face, particularly those who are low-skilled. In the current global economic crisis, with rising unemployment, their situation can become precarious as they tend to be in a weak bargaining position and are more likely to accept poor conditions to secure or keep a job.

Migration itself is not a risk factor for HIV infection, but it is the conditions under which people migrate, and the working and living conditions they find themselves in that make them highly vulnerable to HIV.

Based on some 600 interviews in four Asian countries and three Arab states (Bahrain, Lebanon and United Arab Emirates), the study reveals that migrant women, many of whom become domestic workers, often lack legal coverage, suffer duress and sexual exploitation in the workplace, and have limited or no access to health and social services.

The Arab States are the primary destination for many migrant workers from Asia, including the four countries which are the focus of research; Bangladesh, Pakistan, the Philippines and Sri Lanka.

The movement of women and money between the countries studied is considerable. The report estimates that 70-80 percent of migrants from Sri Lanka and the Philippines to the Arab States are female. Between 1991 and 2007, 60 percent of women migrants from Bangladesh left to find employment in these countries and remittances from Filipinos working in the Arab States in 2007 amounted to US$ 2.17 billion. In Bangladesh, migrant workers sent back close to US$ 637 million from the UAE. Current remittances by migrant workers from Sri Lanka amount to US$ 3 billion.

HIV Vulnerabilities of Migrant Women: from Asia to the Arab States charts a way forward. According to the report, host countries and countries of origin share equal responsibility to provide protective policies and programmes for women who seek a better life away from home. Recommendations include:

• Migrants who have a medical condition that does not impair their ability to work, such as living with HIV, should not be denied the right to work
• Health insurance schemes for migrant workers should cover all aspects of health, including HIV
• Hiring agents and employer blacklists need to be created, monitored and shared
• Embassy and consular staff in host countries should be trained on the special needs and vulnerabilities of migrant women
• Existing labour laws should be changed/reformed to cover migrant workers in the domestic sector

Michel Sidibe, UNAIDS Deputy Executive Director,
highlights the important role of parliamentarians
at the opening ceremonies of the First Global
Parliamentary Meeting on AIDS .
Photo credit: UNAIDS

The First Global Parliamentary Meeting on AIDS was opened on Wednesday 28 November in Manila by Mr Manny Villar, President of the Senate of the Philippines.

Around 200 participants from around the world are attending the three-day meeting which has been organized by the Inter-Parliamentary Union in cooperation with the Senate of the Philippines and in close collaboration with the United Nations Development Programme and the Secretariat of the Joint United Nations Programme on HIV/AIDS (UNAIDS).

It is the first time that Parliaments from all over the world have been convened to jointly discuss the part they have to play in responding to the AIDS epidemic. The main aim of the event is to enhance the commitment and collaboration of Parliaments worldwide as crucial stakeholders in the AIDS response.

During his opening address, UNAIDS Deputy Executive Director, Michel Sidibe highlighted the important role parliamentarians have to play in the global response to the epidemic, “As Parliamentarians you are opinion-leaders and decision-makers. What you say matters. You can encourage informed debate. You can address prejudice and misconceptions. You can lead by example,” he said.

Michel Anders B. Johnsson, Secretary General of
the Inter-Parliamentary Union, presents “The
Handbook on Taking Action”.
Photo credit: UNAIDS

The meeting is being held ahead of World AIDS Day (1 December) under the main theme of ‘Leadership’. In addition, five sub-themes will be discussed in plenary sessions or panel discussions; stigma and discrimination; affordability of drugs; vulnerable groups; legalization and criminalization issues; and budgeting.

A range of keynote speakers have been invited to contribute to the sessions including Dr Nafis Sadik, UN Secretary-General’s Special Envoy on AIDS for Asia and the Pacific, Mr Marcel van Soest, Executive Director of the World AIDS Campaign and Justice Michael Kirby, from the High Court of Australia.

One of the highlights of the meeting will be the launch of a handbook for Parliamentarians entitled, ‘Taking action against HIV’. The handbook will serve as both a call to action for parliamentary leadership and a reference book that parliamentarians and their staff may consult for information and guidance on specific issues in relation to the AIDS response.

Photo credit: J.Carual-PCPO

“AIDS is not a passing storm but a long-run threat to development and national security in Asia,” UNAIDS reported at the ‘Special Session on HIV/AIDS’, held as part of the 12 th Association of South East Asian Nations (ASEAN) Summit on Saturday 13 January.

The special report from UNAIDS Executive Director Dr Peter Piot on the state of AIDS epidemics globally, in the ASEAN region, and the challenges faced by countries was considered by the Heads of State from 10 ASEAN countries at their extraordinary session on AIDS. This is the first time an external body has been invited to brief the Heads of State Summit on AIDS.

Asia has the second largest number of people living with HIV in the world and its share of the global epidemic is increasing. According to latest estimates, the ASEAN region – which includes Brunei Darussalam, Cambodia, Indonesia, Lao PDR, Malaysia, Myanmar, Philippines, Singapore, Thailand, Viet Nam -shows the most severe epidemics within Asia. In 2006, there were an estimated 1.6 million people living with HIV in the ASEAN region and in some countries up to 1.5% of all adults are living with HIV.

“We are still in the early phases of the epidemic in Asia and must redouble and sustain efforts, not let our guard down,” the UNAIDS report said. “The most worrying fact for the ASEAN countries is that AIDS affects the most productive sections of ASEAN populations, i.e. the workforce which is the powerhouse of economic development of the region,” the report noted.

Underlining AIDS as ‘one of the make-or-break challenges of our time’, the UNAIDS report outlined the threat AIDS poses in the region to the achievement nearly all the Millennium Development Goals. However UNAIDS stressed there are opportunities to put in place a long term response to the epidemic.

The meaningful involvement of community based and civil society organizations – especially people living with HIV – into national AIDS responses must also be a priority. The importance of personal leadership from the Heads of State on AIDS was underlined. “The threat of AIDS will not pass in a year or five years. [UNAIDS] and the world look to you for your continued leadership on AIDS,” the report stated.

The report outlined how a number of countries in the region have made significant progress in ensuring that the most vulnerable communities, including young people, sex workers and their clients, men who have sex with men and injecting drug users, are getting priority in national AIDS responses. In the short-term, increase in scale and size of such programmes focused to reach people most at risk in the region is urgently needed. At the same time programmes need to take into consideration the drivers of epidemics within countries such as gender inequality, homophobia and HIV-related stigma.

The 2007 ASEAN Special Session on AIDS was held in response to the resolution passed at the 7th ASEAN Summit held in Brunei Darussalam in November 2001 where the ASEAN Heads of State and Government agreed to convene the “Special Session on HIV and AIDS” in conjunction with the 12th ASEAN Summit in 2007, to signal ASEAN’s commitment in combating AIDS and to give impetus to regional responses in taking urgent action.

Representing UNAIDS Executive Director Dr Peter Piot, UNAIDS Deputy Executive Director Deborah Landey attended the ASEAN Summit and observed the Special Session.

Following the Special Session, the ASEAN Heads of State are due to adopt a Declaration on AIDS, affirming their commitment to prioritize, lead and strengthen national AIDS programmes ensuring policies and programmes respond to the people most at risk and most in need within the region. “[This Declaration] will form part of the permanent history and lexicon of ASEAN,” said ASEAN Spokesperson, Philippine Ambassador to Malaysia Victoriano Lecaros.

As part of the Special Session, the Secretary-General of ASEAN, Mr Ong Keng Yong delivered his own report to the Heads of State in Cebu. In his report, the ASEAN Secretary-General observed that “commitment of the leadership and political will are key in addressing challenges posed by the spread of HIV and AIDS”. Secretary-General Ong reported to the ASEAN Leaders on progress made since 2001. Mr Ong also outlined key points of action over 2006-10 through an operational work plan for ASEAN’s third regional programme on HIV and AIDS.

“Future ASEAN responses would involve multi-sector initiatives, and closer partnerships with the private sector, civil society, and people living with HIV,” he said. He highlighted the main elements in the Declaration on AIDS, drawing attention to the “commitment on integration of HIV with development priorities to reduce both the impact of development on HIV transmission, and the impact of the HIV epidemic on development, consistent with ASEAN’s commitments to the Millennium Development Goals and the 2006 UN General Assembly decision”.

In an unusual partnership with provincial authorities, a group of gay activists calling themselves the ‘Butterfly Brigade’ are leading an innovative community awareness campaign on sexual health and HIV prevention in the Philippines. Their work combines wide-reaching public education with social marketing of condoms and care for people living with HIV.

Health education class is mandatory for massage parlour workers in Kalibo.

The Brigade was founded five years ago by a small group seeking to share knowledge within their own community. Since this time their efforts have blossomed into a network of 164 volunteers, mostly gay men, who run classes in 17 municipalities throughout Aklan province—in high schools and colleges, and within health programmes for women and men involved in sex work.

The Aklan province contains many booming resort areas where the campaign is making a critical difference. By day, the idyllic beaches are full of sunbathers, children frolicking in the water and tourists taking scuba diving lessons. By night, much of the province is a party zone, as local and foreign travellers sway to the music of reggae bands or drink beer in waterfront bars.

“Almost anyone could be at risk of acquiring HIV or another sexually transmitted infection,” said Municipal Health Officer Dr Adrian Salaver. “We can educate people about HIV prevention to try to help reduce those risks.”

HIV prevalence in the Philippines is estimated to be less than 0.1 per cent, one of the lowest rates in the region. But few people have been tested, and experts suspect the real numbers of people living with HIV to be higher. Widespread sex work, inconsistent condom use, early sexual initiation and multiple partnerships could trigger a more serious epidemic, as has occurred in other countries.

Aklan health officials recognize that the Butterfly Brigade’s frank approach to sexuality and strong prevention messages are part of an effective response to this threat. They started working with the initial core group in 2001 with support from the United Nations.

Members were trained to teach other gay men about the ways HIV is spread and how to protect themselves. As the trainers’ expertise increased, they developed their own curriculum and innovative techniques. They became known in their towns as health advocates and were asked to work with wider audiences.

One group that has benefited are the women who work in Aklan’s massage parlours and similar entertainment venues. Following awareness raising drives, employees are now required to have a health certificate indicating they have been tested for sexually transmitted infections (STIs) and have attended a class on disease prevention and condom use.

Photo: Albert Ilarina teaches sex workers to use condoms and avoid infection.

Albert Ilarina, chairperson of the Butterfly Brigade, teaches these classes at the Social Hygiene Clinic run by the Women’s Health and Safe Motherhood Project in Kalibo’s hospital.

Twenty-year old Grace has participated in some of Albert’s classes. Grace works in a massage parlour to support her small son and daughter. She earns 200 pesos (about $4) a day, but can make more if she leaves with a client and negotiates a price for other “services”. She explains how the Butterfly Brigade classes have underlined how important it is to try to negotiate condom use with clients. “Sometimes I use condoms, but about three of every five customers don’t want to use them,” she says. “I have had gonorrhoea but I never knew about HIV before. Now I am scared. I want to buy condoms and start using them every time.”

Benefits from the Butterfly Brigade’s initiative are evident throughout the province. The Aklan health system now offers a “full package” of HIV-related services, including condom promotion, voluntary testing and counselling, and care. Last year the United Nations provided antiretroviral drugs for 14 people living with HIV; the Global Fund to Fight AIDS, Tuberculosis and Malaria now supports their treatment.

“The Butterfly Brigade is fun to be a part of and we do help,” says Butterfly co-founder Nono Bantigue, a municipal counsellor in Balete and chair of the town’s Committee on Women’s and Children’s Welfare.

The programme also provides HIV awareness training to police officers and merchants, as well as to boatmen and tricycle drivers.  Brigade members have also persuaded Boracay officials to let them install a condom vending machine in an area known as a pickup spot.

“Local governments, the provincial health office and the local business sector have all recognized our work,” reports Bantigue. With support from the United Nations, municipal mayors and provincial health officials from all over the country have visited Aklan with a view to replicate its peer education network.

“The Butterfly Brigade are helping raise awareness and break down stigma – which is key to getting ahead of the epidemic in the Philippines,” said UNAIDS Country Coordinator for the Philippines, Dr. Marlyn Filio-Borromeo.