The Philippines is facing the fastest growing HIV epidemic in the western Pacific, with a 174% increase in HIV incidence between 2010 and 2017. There were 1047 new cases in August, 2018, alone.1 Although national HIV prevalence remains below 0·1%, men having sex with men are disproportionately affected, accounting for 84% of all new infections. UNAIDS estimates that only 67% of people living with HIV know their status, 55% have CD4 count lower than 200 cells/μL at the time of diagnosis, 32% are on antiretroviral therapy (ART), and 82% remain on ART 12 months after treatment initiation.
In this Correspondence, six interventions are outlined to curb the epidemic. First, stigma should be reduced through education. Promotion of sexual health is challenging in a country where HIV infection is equated to sin and immorality. Sexual health and gender-sensitivity education must be integrated in school curriculums and should be delivered by trained teachers in an age-appropriate and culturally-sensitive manner.
Second, awareness among health-care providers should be increased. Medical and nursing curriculums should emphasise the importance of early HIV detection and that HIV infection is a chronic manageable disease.2 Mandatory rotations at HIV clinics for medical and nursing students will reinforce manpower in these sites, improve medical knowledge, and foster increased understanding of the sociocultural challenges faced by people living with HIV.
Third, pre-exposure prophylaxis (PrEP) should be distributed on a national scale. PrEP (emtricitabine-tenofovir disoproxil fumarate) is highly effective in preventing HIV transmission,3 but its availability in the Philippines is limited to Manila and it should be made accessible nationwide as part of comprehensive HIV prevention programmes.
Fourth, integrase inhibitors should be used as first-line ART. Lamivudine-tenofovir-efavirenz (LTE) is the only fixed-dose combination ART in the Philippines. Neuropsychiatric symptoms are common with efavirenz, which affects life quality and treatment adherence.4 A new coformulated tablet of tenofovir-lamivudine-dolutegravir (TLD) is now available in several low-income countries, which is approximately 10–15% cheaper than current efavirenz formulations. TLD has a lower proportion of treatment failure and provided better clinical outcomes than efavirenz-based regimens.5
Fifth, primary care physicians should be empowered to provide HIV care. The Philippines is composed of more than 7000 islands, which can be a barrier to health-care delivery. ART is dispensed only through 95 HIV treatment hubs, which are unevenly distributed. In the National Capital Region, 25 hubs oversee the care of more than 23 000 people living with HIV (about 920 patients per hub). In Region 4A, there are only six treatment hubs for 8000 people living with HIV (approximately 1300 patients per hub).1 Hubs are located in major cities and problems arise for people living with HIV in rural areas or islands where no hubs exist. The rapid increase in HIV prevalence is overwhelming the health-care system, prolonging wait times, and decreasing doctor–patient visit time. This poses a potential risk for patients of falling out of care.
The Philippine Department of Health should strongly consider decentralising HIV management to allow primary care physicians to prescribe and dispense ART in their general practice. This can be achieved by creating an HIV training program consisting of a standardised HIV treatment module, rotation in treatment hubs, and a certifying exam.
Finally, substance abuse should be addressed and mental health promoted. Injecting drug users account for 4% of the cases of HIV infection in the Philippines.1 HIV incidence among injecting drug users has sharply increased but needle exchange programmes are illegal in the country. In Cebu City, 50% of injecting drug users are infected with HIV and 93% are coinfected with hepatitis C virus.6 The Philippine Government should reconsider the implementation of needle exchange programmes or provide alternative evidence-based interventions to help people struggling with addiction.
The HIV crisis in the Philippines is an emergency. Youth education, empowerment of health-care providers, national access to PrEP and integrase inhibitors, and harm reduction are urgently needed.
Published by The Lancet