Farr and Wilson Journal of the International AIDS Society 2010, 13:16

http://www.jiasociety.org/content/13/1/16

REVIEW Open Access

An HIV epidemic is ready to emerge in the

Review

Philippines
Anna C Farr and David P Wilson*

Abstract
Background: The state of the HIV epidemic in the Philippines has been described as "low and slow", which is in stark
contrast to many other countries in the region. A review of the conditions for HIV spread in the Philippines is necessary.
Methods: We evaluated the current epidemiology, trends in behaviour and public health response in the Philippines
to identify factors that could account for the current HIV epidemic, as well as to review conditions that may be of
concern for facilitating an emerging epidemic.
Results: The past control of HIV in the Philippines cannot be attributed to any single factor, nor is it necessarily a result
of the actions of the Filipino government or other stakeholders. Likely reasons for the epidemic's slow development
include: the country's geography is complicated; injecting drug use is relatively uncommon; a culture of sexual
conservatism exists; sex workers tend to have few clients; anal sex is relatively uncommon; and circumcision rates are
relatively high.
In contrast, there are numerous factors suggesting that HIV is increasing and ready to emerge at high rates, including:
the lowest documented rates of condom use in Asia; increasing casual sexual activity; returning overseas Filipino
workers from high-prevalence settings; widespread misconceptions about HIV/AIDS; and high needle-sharing rates
among injecting drug users.
There was a three-fold increase in the rate of HIV diagnoses in the Philippines between 2003 and 2008, and this has
continued over the past year. HIV diagnoses rates have noticeably increased among men, particularly among
bisexual and homosexual men (114% and 214% respective increases over 2003-2008). The average age of diagnosis
has also significantly decreased, from approximately 36 to 29 years.
Conclusions: Young adults, men who have sex with men, commercial sex workers, injecting drug users, overseas
Filipino workers, and the sexual partners of people in these groups are particularly vulnerable to HIV infection. There is
no guarantee that a large HIV epidemic will be avoided in the near future. Indeed, an expanding HIV epidemic is likely
to be only a matter of time as the components for such an epidemic are already present in the Philippines.

Review The Philippines is one of the exceptional countries that

Southeast Asia is experiencing numerous and diverse has not faced a large HIV epidemic. It is important to
HIV epidemics that are evolving at varying rates, in dif- understand the reasons for the disparate nature of HIV in
ferent population groups, and in different geographical this country in order to ascertain whether lessons can be
areas. Approximately 5 to 10 million people are living learnt for effective control in other settings and to ensure
with HIV in Asia, with prevalence estimates of well over that a large HIV epidemic does not emerge in the Philip-
1% among adults in numerous countries [1]. Yet there are pines. The first recorded case of HIV infection in the
some settings in which HIV prevalence has remained rel- Philippines was in 1984 [2-10]. Since then, the country
atively very low. has maintained an HIV prevalence of less than 0.1%, even
among populations at high risk [3,5,7,9], with a cumula-
* Correspondence: [email protected] tive total number of HIV diagnoses of just over 3300 [11].
1National Centre in HIV Epidemiology and Clinical Research, University of New In this paper, we attempt to evaluate the current epidemi-
South Wales, Sydney, Australia
Full list of author information is available at the end of the article
ology and public health response to identify factors which
© 2010 Farr and Wilson; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Com-
BioMed Central mons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduc-
tion in any medium, provided the original work is properly cited.
Farr and Wilson Journal of the International AIDS Society 2010, 13:16 Page 2 of 8
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could account for the "low and slow" development of the levels may not necessarily be a reflection of low average
HIV epidemic in the Philippines, as well as to review rates of partner change across a population.
behavioural and epidemiological conditions that may be There has also been the establishment of social hygiene
of concern for facilitating an emerging epidemic. clinics to allow for regular examination and sexually
The geography of the Philippines may be one of the first transmitted infection (STI) treatment for establishment-
reasons for the slow spread of HIV. The Philippines is an based female sex workers [5,15,22]. The prevalence of
archipelago of more than 7000 islands and islets; its com- ulcerating STIs, which are believed to facilitate HIV
plicated geography and separateness from mainland Asia transmission [24,25], is relatively low [13]. There is also a
could aid in shielding it from the larger regional epidemic low occurrence of penile-anal sex in the Philippines [13]
[5,9,12,13]. and a high rate of circumcision, ~93% [9,26], which is
Additionally, the initial core group of people usually known to reduce the risk of males acquiring HIV in het-
affected with HIV in Asian epidemics is not present to a erosexual intercourse [27-29].
large extent in the Philippines. Most HIV epidemics in Some countries, such as Vietnam, Indonesia and Papua
southeast Asian settings initially establish among inject- New Guinea, have shown that a delayed HIV epidemic is
ing drug users (IDUs) [14]. However, there are very low possible [6,30]. While HIV prevalence has remained "low
numbers of IDUs in the Philippines compared with most and slow" [5,6,31], the presence of many conditions for a
other southeast Asian countries [5,9,13,15]. At present, large, increasing and generalized HIV epidemic are in
there are only an estimated 10,000 IDUs in the Philip- place in the Philippines. These include: a low rate of con-
pines [13] (out of its population of ~90 million people; dom use; unsafe injecting practices among IDUs; large
that is, 0.01%). In comparison, neighbouring Thailand, migration rates; increasing trends in extramarital and
China and Indonesia have estimated IDU populations premarital sex; a lack of education and common miscon-
sizes (and population proportions) of 160,000 (0.38%), ceptions about HIV/AIDS; and cultural factors that
1,800,000 (0.25%) and 219,000 (0.14%), respectively [16]. inhibit public discussion of issues of a sexual nature [10].
There also exists a culture of relative sexual conserva- We will now expound these factors.
tism in the Philippines [9,17]. There are limited data
available on sexual partner acquisition in the Philippines, Condom use
and detailed behavioural sentinel surveillance data are The Philippines has the lowest documented rates of con-
not widely released [18]. The only reference to sexual dom use in Asia [2,32], at 20-30% among groups at high-
partner rates of which we are aware is from a previous est risk of HIV (including sex workers) [4,5,8,17,21,33,34].
Philippines National AIDS Council Report, which indi- This is concerning since the vast majority of HIV trans-
cates that the majority of the male population has only mission in the Philippines is through sexual contact
one sexual partner at any time and relatively low partner- [10,13,17,32]. A survey published in 2003 found that 63%
ship breakup rates [19]. Although the validity of this of male respondents said that they had never used a con-
statement should be questioned until solid data have dom [2]. Condom use among any extramarital partners is
been evaluated, this suggests that sexual conservatism also rare [8].
exists in the Philippines relative to neighbouring coun- There are various factors that may contribute to low
tries. condom use in the Philippines. A common perception is
The limited reporting available from behavioural sur- that condoms are only for birth control and not for pro-
veillance conducted a number of years ago suggests that tection against HIV and other STIs [8]. This perception is
Filipinos tend to have fewer sexual partners than their reinforced by the view that condoms are discouraged by
counterparts in countries with higher HIV/AIDS rates the Roman Catholic Church. Government family plan-
[20]. For example, sex workers in the Philippines tend to ning programmes have policies against supplying con-
have fewer clients, an average of between two and four doms to unmarried people [4,35].
per week compared with ~15 in many other settings The cost of condoms is also relatively high [18]. The
[5,13,15,21,22]. Although this does not indicate levels of majority of the supply of condoms is from international
sexual activity in the general population, it is indicative of aid agencies (e.g., USAID) [8,35]. Many female sex work-
less sexual mixing outside regular partnerships. ers assert that "knowing" their client was reason enough
However, fewer sexual partners is not necessarily a to not use a condom [8]. Filipino women also tend to
clear indicator of a smaller epidemic as reflected in believe that the decision to use a condom is up to the man
China's expanding HIV epidemic despite reported sexual [8]. Men tend to feel the need to maintain their
partner acquisition rates being similarly low [23]. One machismo image to the extent that they refuse to practice
could expect different sexual behaviour across different safe sex [36]. Culturally-sensitive but influential promo-
social strata and thus an HIV epidemic sustained at low tion of condoms appears to be an obvious gap in the Phil-
ippines HIV/AIDS response.
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Casual sex infected with HIV are seafarers and domestic helpers.
There is anecdotal evidence among numerous media OFWs may be a bridge population for the spread of HIV
sources and organizational reports that casual sexual and other STIs [32,43,44]. This population will undoubt-
activity, particularly among the male population aged 15- edly be important in any HIV epidemic in the Philippines.
25, has been increasing. A study from over a decade ago
estimated that 55% of young men have engaged in pre- HIV/AIDS education and social factors
marital sex compared with 23% of young women [4]. Even though awareness of the disease is high [5], miscon-
While most premarital sex in the Philippines is with the ceptions of HIV/AIDS are widespread among health
person who becomes a future spouse, men are more likely workers, as well as in the general population [2]. For
to have at least one additional partner compared with example, a survey of 1200 males found that many respon-
women [2,4,8]. Most casual sexual encounters are unpro- dents believed that antibiotics, prayer and keeping fit
tected [21,37,38]. would protect against HIV/AIDS [32]. Many young peo-
However, all of this evidence is based on relatively old ple also believe that HIV/AIDS can be prevented or
data. There is a great need for behavioural surveillance treated by a concoction of drinks, douching with deter-
data to be collected and reported systematically and regu- gents, interrupting coitus and washing the penis [5]. The
larly in order to monitor risk activities, particularly Young Adult Fertility Survey found that a large propor-
around casual sex, associated with transmission. tion (60%) of young people believed that there was now a
cure for HIV/AIDS and, as such, they could become more
Injecting drug users complacent [45].
The most recent estimates of the size of the IDU popula- Women in the Philippines are not largely empowered to
tion in the Philippines suggests that the number is rela- protect themselves and negotiate for safe sex due to cul-
tively low [39]. However, serosurveillance of IDUs has tural, physiological and socio-economic factors. An esti-
only been available at one site, in Cebu City, and no data mated 43% of women have admitted to being forced into
exist for other cities. It is possible that the actual number sex, and 15% believed that they were obligated to have sex
of IDUs is considerably greater than previously thought. with their partners [5].
A 2004 report by the Philippines National AIDS Coun- Condom use is also low among the population of men
cil estimated that only 48% of IDUs reported using sterile who have sex with men (MSM) [5,6]. Unprotected penile-
injecting equipment the last time they injected, and most anal sex is a highly efficient mode of HIV transmission
IDUs reported that they regularly share injecting equip- [46-51]. Discrimination, harassment and intolerance of
ment [6]. A 2008 report published by the Joint United homosexuality, particularly male homosexuality, have
Nations Programme on HIV/AIDS (UNAIDS) indicated resulted in MSM becoming a "hidden" population group,
that the prevalence of sharing injecting equipment is still even though 20% of reported HIV cases involve male-to-
very high, with 29% of IDUs self-reporting use of an male transmission [5]. With intolerance still high, it is dif-
unsterile needle/syringe the last time they injected [39]. ficult to provide MSM with HIV/AIDS information, edu-
Sharing HIV-contaminated injecting equipment is an cation and treatment.
efficient mode of HIV transmission [40,41]. Given the
experience of neighbouring countries, IDUs could be an The current epidemiological state of HIV in the Philippines
important population group for the spread of HIV in the In this section, we present HIV/AIDS surveillance data in
Philippines if the size of the IDU population increases. the Philippines and analytical findings based on monthly
diagnoses reported from March 2003 to June 2008 [11].
Overseas Filipino workers There is a steady increase in the cumulative number of
There are approximately 7.5 million Filipinos working in HIV notifications in the Philippines (Figure 1).
170 countries around the world, with more than 2000 However, the trends in HIV notifications differ between
workers departing from the country daily [32,42]. By par- the genders. The cumulative number of HIV notifications
ticipating in casual unprotected sex or other risky behav- among females has been increasing at a steady rate (p <
iour while overseas in higher prevalence settings, 0.0001), suggesting that incidence is approximately con-
overseas Filipino workers (OFWs) become a substantial stant and at an endemic equilibrium. In contrast, the
source of new HIV cases in the Philippines upon their trend among males is not constant, incidence levels are
return home. substantially greater than in females, and the rate of new
Of all the HIV/AIDS cases reported in the Philippines, notifications is increasing (evidenced by the curvature
OFWs account for ~30-35% of all cases (this level has away from linear). This suggests that there may be an
remained relatively steady over the past decade) [5,13,32]. emerging HIV epidemic among Filipino MSM.
Heterosexual sex is the dominant mode of transmission The emergence of an increasing HIV epidemic in the
for OFWs, and the main occupations of OFWs who are Philippines is evident from trends in monthly reported
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Bisexual contact refers to men who have had sex with

both men and women. It cannot be determined whether
the initial actual transmission event was male-to-male
sexual contact or transmission from an infected woman.
It is more likely that the transmission was via male-to-
male sexual contact due to biologically higher transmis-
sion rates, but the bisexual category accurately reflects a
degree of uncertainty in the route of exposure.
The dominant mode of HIV transmission in the Philip-
pines is sexual (~92%). But the largest increases in the
rate of new HIV notifications are due to homosexual and
bisexual contact, and not heterosexual contact (Figure 3).
Over the period, 2003-2008, there was an increase in the
Figure 1 Cumulative number of HIV diagnoses in the Philippines
monthly number of diagnoses, from 328 for homosexual
by month from March 2003 to June 2008. Year on figure indicates
data at the start of the year. contact and 92 for bisexual contact to 704 and 289,
respectively; that is, respective increases of 114% and
214%. Therefore, there appears to be an increasing epi-
HIV diagnoses (Figure 2). In mid-2003, there were 10 to
demic of HIV among men who have sex with men. The
15 monthly HIV notifications and there are currently 30
increase among bisexual men also has important conse-
to 50 notifications per month; that is, a three-fold
quences for the spread of HIV to the general heterosexual
increase over five years. The trend has increased even
population. However, data on testing rates would help to
further from 528 notifications in 2008 to 835 in 2009 (a
elucidate the extent to which these diagnoses rates are
58.1% increase in one year) [52]. This suggests that the
reflective of underlying incidence.
epidemic could be approaching a large expansion phase.
It should be noted that some of the rise in HIV diagno-
However, the divergence in HIV diagnosis rates
ses could be attributable to an increase in testing rates.
between men and women could also reflect possible dif-
This is evident by the decreasing proportion of all HIV
ferences in testing rates. There are no data to suggest dif-
cases that are detected with AIDS disease: ~33% of diag-
ferences in testing rates, and the Philippine AIDS
noses in 2003 were in AIDS stage disease and this has
Prevention and Control Act of 1998 encourages HIV test-
decreased to ~24%. However, the disproportionate trend
ing of all individuals at high risk of contracting HIV, with
in diagnoses between genders and between different
informed consent [53]. But this alternate explanation for
routes of exposure strongly suggests that the trends in
the epidemic trends cannot be ruled out until reliable
diagnoses reflect actual trends in population incidence.
testing data are available.
But since a substantial proportion of infections is
Diagnoses of HIV in the Philippines are notified
detected in late-stage disease, it is likely that the majority
according to various categories of likely route of expo-
of all HIV cases are currently undiagnosed in the Philip-
sure. These include: heterosexual contact; male homosex-
pines [5].
ual contact; bisexual contact; blood transfusion; injecting
The cumulative number of AIDS deaths is increasing
drug use; needle prick injury; or perinatal exposure.
approximately constantly (p < 0.0001), suggesting that
AIDS death rates are relatively constant (Figure 4). It
could be expected that there will be a delay of a number
of years before the rise in HIV diagnoses translates to a
rise in AIDS-related deaths.
AIDS is now a reversible HIV-related condition due to
combination antiretroviral therapy (ART). The number
of people receiving ART in the Philippines has been
increasing since 2004, with a rate of approximately 10% of
diagnosed cases receiving treatment in 2006, and ART
coverage has now increased to approximately 30%
[10,54]. But this is still considerably less than desirable
levels. Universal treatment access for HIV-infected peo-
ple is becoming a reality in some of the poorest countries
of the world. Since HIV is relatively contained in the Phil-
Figure 2 Cumulative number of HIV diagnoses in the Philippines ippines, there is the opportunity to substantially scale up
by month to June 2008, by gender. treatment access before the number of HIV cases
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Figure 3 The cumulative number of HIV diagnoses in the Philippines by month to June 2008, by route of exposure.

increases out of control. Treatment should be universal Treatment not only sustains life among HIV-infected
for HIV-positive pregnant women for preventing mother people, but by reducing their viral loads, it reduces infec-
to child transmission (PMTCT) [55]. However, PMTCT tiousness. At the population level, this would likely pre-
is relatively uncommon in the Philippines. vent considerable numbers of secondary transmissions of
One of the reasons for such low rates of ART is that HIV [57-59].
funding for such care and treatment of HIV-infected per- The average age at HIV diagnosis in the Philippines was
sons makes up a mere 1.6% of the Philippines HIV/AIDS ~35-36 years prior to 2005, but recently, the average age
budget [56]. While expenditure on treatment and care is at diagnosis has been decreasing (p = 0.0067) (Figure 5). It
currently low, the Philippine National AIDS Council's 4th is now ~29 years of age. Although it is possible that
AIDS Medium Term Plan and its country report for the increased testing rates mean infections are detected ear-
period, January 2006 to December 2007, to the United lier, the extent of decrease in ages cannot be attributable
Nations General Assembly Special Sessions (UNGASS) to changes in testing rates.
states that it will endeavour to improve access to treat-
ment, care and support to HIV-infected persons [13,21].

Figure 4 Cumulative number of AIDS deaths by month from Figure 5 Trend in the average age at HIV diagnosis for three-
March 2003 to June 2008. monthly notifications in the Philippines.
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The trend in decreased age at diagnosis is likely to ments are also broad and do not outline targeted strate-
reflect a decrease in age at infection. Younger age groups gies with specific goals.
tend to have greater sexual activity. The fact that the aver- Other programmes have also been established for mon-
age age is decreasing is a strong indicator that HIV inci- itoring the spread, understanding key epidemic drivers
dence could increase substantially in the future in the and planning the control of HIV in the Philippines. There
Philippines. This trend is also in contrast to most other are currently four types of surveillance systems in place in
settings where epidemics are being controlled [60]. How- the Philippines:
ever, younger age is not necessarily indicative of greater 1. The HIV/AIDS Registry was established in 1987
sexual activity among all population groups, particularly and is a passive surveillance system. It continuously
among men who have sex with men, as suggested from records Western Blot-confirmed HIV cases reported
other settings [61]. As men who have sex with men are by hospitals, laboratories, blood banks and clinics
the population group greatest affected with HIV in the that are accredited by the Department of Health.
Philippines, the decreasing age at diagnoses may not nec- 2. The HIV Sentinel Surveillance System (HSSS) was
essarily suggest a future increase in HIV. established in 1993 with a grant from the USAgency
for International Development (USAID). It monitors
Conclusions 10 key cities: Baguio City, Angeles City, Iloilo City,
The Filipino government and other stakeholders have Zamboanga City, Pasay City, Quezon City, Cebu City,
responded to the HIV/AIDS threat in the Philippines in a Cagayan de Oro City, Davao City and General Santos
number of ways in order to circumvent a large HIV epi- City. It pays particular attention to establishment-
demic from arising. The Philippine National AIDS Coun- based female sex workers, freelance female sex work-
cil (PNAC) was created in 1992 to act as an advisory body ers, MSM and IDUs [3,6,32].
to the President for the development of policy for the 3. Behavioral Sentinel Surveillance was added at the
control of AIDS. The PNAC consists of members from 10 HSSS sites in 1997 and is a systematic and repeated
the government, public, civil society, private sector and cross-sectional survey of behaviour related to the
non-governmental organizations (NGOs), and is the cen- transmission of HIV and other STIs [3,32,62]. Its
tral advisory, planning and policy-making body for the major purpose is to detect trends among vulnerable
comprehensive and integrated HIV/AIDS prevention and populations and groups at high risk whose behav-
control programme [5]. But its small budget has limited ioural change would have the greatest impact on the
its ability to instigate implementation of large interven- HIV epidemic.
tion and education campaigns. 4. The Sentinel STI Etiologic Surveillance System was
The official response of the Philippines Government to set up in December 2001, but made operational in
the HIV threat was to enact the Philippine AIDS Preven- 2003. It monitors STI trends that could guide pro-
tion and Control Act of 1998 (Republic Act No. 8504) gramme interventions to prevent the transmission of
[53]. This Act was enacted by Congress after a long pro- HIV.
cess of deliberation and advocacy by the PNAC and other These surveillance systems have been monitoring the
stakeholders [19]. The Act called for: a comprehensive progress of HIV in the Philippines and have provided
nationwide HIV/AIDS educational and information cam- valuable data to inform appropriate response measures.
paign; full protection of the human rights of known and The PNAC's 4th AIDS Medium Term Plan for 2005 to
suspected HIV-infected persons; promotion of safe and 2010 is one of the plans that utilized data from the sur-
universal precautions in practices and procedures that veillance systems [5,21]. This plan aligns with the Philip-
carry risks of HIV transmission; the eradication of condi- pines AIDS Prevention and Control Act, with the aims of
tions that aggravate spread of HIV infection; and recogni- scaling up and improving the quality of preventive inter-
tion of the important role that affected individuals could ventions and the quality of treatment, care and support
have in promoting information and messages about HIV/ services for people infected with and affected by HIV/
AIDS. The Act also states that local governments are to AIDS. It also aims to integrate stigma reduction measures
provide community-based HIV/AIDS prevention, control in the preventive treatment, care and support services
and care services. and in the design of management systems.
While the Act is a step in the right direction, it is far The current state of HIV in the Philippines is not attrib-
from effective due to a lack of monetary commitment utable to any one factor. While the Philippines response is
from the government, relying heavily on NGOs for fund- associated with effectively controlled levels of HIV, there
ing for HIV/AIDS education and prevention pro- is no guarantee that a large HIV epidemic will be avoided
grammes, and the current government's seemingly in the near future. Indeed, an expanding HIV epidemic is
unwilling attitude to promote wide condom use for fear likely to be only a matter of time as the components for
of angering the Roman Catholic Church [35]. Its state- such an epidemic are already present in the Philippines.
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ACF conducted the extensive literature search, collated available data, pro- 20. WHO: HIV and Behavioural Surveillance in the Philippines. Manila
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National Centre in HIV Epidemiology and Clinical Research, University of New 23. Parish WL, Laumann EO, Cohen MS, Pan S, Zheng H, Hoffman I, Wang T,
South Wales, Sydney, Australia Ng KH: Population-based study of chlamydial infection in China: a
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Received: 14 September 2009 Accepted: 22 April 2010
24. Fleming DT, Wasserheit JN: From epidemiological synergy to public
Published: 22 April 2010
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Ltd.terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. health policy and practice: the contribution of other sexually
transmitted diseases to sexual transmission of HIV infection. Sex
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