L~~.,.
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GLOSSARY OF TERMS USED IN THIS REPORT
AIDS BRL BSS
Acute Immunodeficiency Syndrome Bureau of Research and Laboratories Behavioural sentinel surveillance Department of Health Field Epidemiology Training Program Freelance Female Sex Workers Human Immunodeficiency Virus HIV Serologic Surveillance Injecting Drug Users Men Who Have Sex with Men National HIV Sentinel Surveillance System Program for Appropriate technology for health
DOH FETP FLSW HIV HSS IDU MSM NHSSS PATH
POEA
Philippine Overseas Employment Administration
RFSW RITM SHC STI USAID WHO YAFS
Registered Female Sex Workers Research Institute for Tropical Medicine Social Hygiene Clinic Sexually Transmitted Infections US Agency for International Development World Health Organization Young Adult Fertility Survey
Consensus Report on STI, HIV and AIDS Epidemiology: Philippines
EXECUTIVE SUMMARY A workshop was held in the Philippines in May 2000 to review the HIV/AIDS situation by establishing the trend of Sexually Transmitted Infections (STI) and Human Immunodeficiency Virusl Acute Immunodeficiency syndrome (HIV/AIDS) infection, reaching a consensus on the status of STls and HIV/AIDS infection and formulating appropriate recommendations. The major sources of information were the passive and active surveillance systems of the Department of Health, behavioural monitoring surveys (BMS) carried out by the Program for Appropriate Technology for Health (PATH), special STI surveys, data from the blood transfusion, and data from the Bureau of Research and Laboratories (BRL). A total of 1325 HIV infections were reported between January 1984 and December 1999. Of these, 441 developed AIDS and 203 have died. The number of reported HIV infections has slowly been rising. Prior to 1990, fewer than 50 were ported each year. Since 1993, the annual number of reported cases was at least 100. Most of the the HIV infections reported up to December 1999 were in males, with a male to female ratio of 3:2, and the majority (68%) were in the 1939 age group. Most cases (80%) had acquired HIV through sexual intercourse. Some 309 (24%) said that they were overseas contract workers and another 194 (15%) that they are were sex workers. The Philippine National Red Cross estimated that, in 1999, they received and tested about 500 000 bags of blood. Of these, 54 were found to be positive when screened, but only one was confirmed as HIV seropositive. In the past 7 years, since active HIV serological surveillance (HSS) has been established, infection rates among high-risk groups (female sex workers, injecting drug users, men who have sex with men) have remained at low levels «1%). The number of HIV infections in 2000 was estimated, based on HSS and other serological data, as well as available data on the estimated populations of risk groups. In the worst case scenario, using a prevalence rate for each subgroup that is biased towards the upper limit, there could be about 10 000 HIV cases. From 1993 to 1998, the number of STI cases (syphilis and gonorrhoea) reported annually averaged about 35 500. HSS data showed a syphilis prevalence rate of 1%-5% among high-risk groups
2
Special STI prevalence studies have been carried out since 1991 and it has been noted that STI prevalence rates seem to be increasing among both high- and low-risk groups (antenatal women). Data from specific studies have provided overall estimates of STI. Among sex workers, the average prevalence rate for gonorrhoea is estimated at 5%; for chlamydiosis, 35%; for syphilis 3.5%; and for trichomoniasis, 9%. Most of the behavioural studies carried out in connection with HIV/AIDS have focused on risks from sexual transmission and limited data on injecting drug use. These surveys, although conducted by different groups, produced similar findings: a high knowledge of ways to prevent HIV transmission was not translated into an increased proportion of risk groups who consistently and correctly used condoms, nor a decrease in the proportion of IDUs sharing injecting equipment. Behavioural surveillance and special STI prevalence studies have shown that there is potential for rapid transmission of HIV/AIDS, because of unsafe sex practices and high STI rates. The situation could change in the next few years. Rapid HIV transmission could occur if efforts to improve sexual practices among the subpopulations at risk are not strengthened and STI transmission rates are not reduced. For a better assessment of the situation, HIV surveillance needs to be continually improved. Other vulnerable groups, such as returning overseas contract workers, should be monitored. The surveillance system should consider including analysis of data from other information systems, such as blood donor screening and HIV screening of applicants for overseas work, to complement its surveillance data. A plan should be drawn up to establish a national STI surveillance system. Universal STI reporting should be integrated into this system, together with syndromic sentinel reporting. STI prevalence studies could be conducted every five years. Behavioural studies have provided useful information, but more indepth qualitative studies on sexual behaviour, sexuality and gender should be carried out to further assess the HIV transmission pattern in the Philippines and guide IEC intervention activities. More attention should be given to FLSWs, who have more sex partners per week than other groups, as well as higher STI rates and poor access to social hygiene clinics (SHCs). The Philippines needs a simple and appropriate method to project the HIV/AIDS epidemic.
Consensus Report on STI, HIVand AIDS Epidemiology: Philippines
,
I. INTRODUCTION
1.
PHILIPPINE COUNTRY PROFILE
The Philippines is an archipelago of 7100 islands, with a territorial coastline extending to 13 411 kilometres. The country is divided into 16 regions and organized into 78 provinces, 82 cities, 1525 municipalities, and 41 940 barangays. The estimated population for 2000 is 76.3 million, with an annual growth rate of 2.3% and a male to female ratio of 101: 100. About 56% of the population live in urban areas. The reproductive age group (15-49 years) comprises about 51 % of the population. In 1997, The Philippine Overseas Employment Administration (POEA) reported about 756 000 overseas contract workers, the majority (74%) of whom were land-based. However, it is estimated that there may actually be more than six million overseas contract workers (Asia and Pacific Migration Journal, 1998). The estimated number of sex workers in the Philippines is about 500 000 - 2 000 000 (International Labor Organization Survey, 1998). In 1998, it was estimated that about 0.5% of the rural adult population and about 1% of the urban adult population may be involved in sex work (Ofreneo and Ofreneo 1998), giving an estimate of around 400 000 - 500 000 sex workers. There are limited data on injecting drug users (IDU) in the Philippines and available data show a wide range of figures. For example, the Trends-MBL survey showed that 5% of males injected drugs while the Young Adult Fertility Survey II (YAFS II) reported 2% for males and slightly less than 2% for females. The HIV sentinel surveillance system actually discontinued monitoring IDU as a sentinel, except in Cebu City, because none of the other sentinel sites were able to come up with the required sample size (100 per site).
4
Consensus Report on STI, HIV and AIDS Epidemiology: Philippines
2.
HIV/AIDS SURVEILLANCE HISTORY AND STI REPORTING
The first AIDS case in the Philippines was recorded in 1984, with the death of a foreign national from pneumonia. In 1987, to track the epidemic, the Department of Health started a passive form of surveillance called the HIV/AIDS registry. Accredited hospitals, clinics, laboratories and blood banks for HIV screening submit monthly reports to the Department of Health. These are identified by codes, which are anonymously linked. Only those cases that are confirmed by the Research Institute for Tropical Medicine (RITM) Bureau of Research and Laboratories (BRL) are included in the report. In 1993, the National HIV Sentinel Surveillance System (NHSSS) was established, with funding support from the United States Agency for International Development (USAID), and technical assistance from the World Health Organization (WHO). Active surveillance comprises HIV serological surveillance (HSS) and behavioural sentinel surveillance (BSS). Surveillance activities are implemented by selected local government units (LGUs), with supervision by the Field Epidemiology Training Program (FETP) of the Department of Health Starting in two cities, the HSS gradually expanded to cover 10 cities in the Philippines (Angeles, Baguio, Cagayan de Oro, Cebu, Davao, General Santos, Iloilo, Pasay, Quezon, and Zamboanga). The sentinel surveillance started in six high-risk groups, reduced to four in 1997: registered female sex workers (RFSW), freelance female sex workers (FLSW), men who have sex with men (MSM), and injecting drug users (lDUs). Since 1995, new recruits of the Armed Forces of the-Philippines (AFP), have been monitored as a surrogate for the general population. Blood is collected and tested for HIV (confirmed by WB) and syphilis (confirmed by TPHA). Following the modified Lot Quality Assurance Sampling (LQAS) technique, 300 samples per group per site are needed to detect HIV prevalence of >1%. LQAS presupposes that HIV prevalence is >1% if at least one out of 300 is positive for HIV. If no one tests positive, it does not mean that HIV prevalence is 0%, but that it is <1%, too low to be detected by the sample size.
Consensus Report on STI, HIV and AIDS Epidemiology:Philippines
5
Behavioural sentinel surveillance (BSS) was added to complement the HSS in 1997. Before this, very few surveys dealt with the social BSS is carried out and behavioural aspects of STIIHIV/AIDS. regularly on an annual basis, consistently monitoring the same groups as those included in the HSS. In addition, deep-sea fishermen in General Santos City are monitored. The surveys are carried out by local research institutions at all sites except those in Baguio and Cagayan de Oro, where they are conducted by city surveillance teams. One hundred and twenty respondents per group per site are interviewed during each round. Surveys are performed by direct interview, using a standard questionnaire. Most of the behavioural studies done in connection with HIV/AIDS have focused on risks from sexual transmission and limited data on injecting drug use. For the last four decades, sexually transmitted infections (STls) have been classified as notifiable diseases. However, regular reporting comes only from social hygiene clinics (SHC), which serve mainly as screening clinics for female sex workers. Since 1991, efforts have been made to determine specific STls through prevalence studies of high-risk groups and antenatal women. The Research Institute for Tropical Medicine started to conduct drug resistance or antimicrobial susceptibility studies in 1997. In 1993, experts, using EPIMODEL, projected that there would be about 100 000 HIV infections in the Philippines by 2000. In 1996, when surveillance data and other STIIHIV/AIDS studies showed that this did not seem likely, the Department of Health and WHO adjusted that estimate to about 38 000 HIV/AIDS infections by 2000.
6
Consensus Report on STI, HIV and AIDS Epidemiology: Philippines
The objective of this workshop is to review the HIV/AIDS situation in the Philippines by analysis of available data, establish the status of the trend of the STI/HIV/AIDS epidemic, reach a consensus about the status, and formulate appropriate recommendations. The major sources of information were the passive and active surveillance systems of the Department of Health (DOH), behavioural monitoring surveys (BMS) done by the Program for Appropriate Technology for Health (PATH), the Men's Study on Sexuality and AIDS (MENSSA) done by De La Salle University for Family Health International, special STI surveys, Red Cross data, and data from the Bureau of Research and Laboratory (BRL).
III. RESULTS 1. HIV/AIDS EPIDEMIOLOGY
a.
HIVIAIDS passive surveillance (HIVIAIDS registry)
From January 1981. to December 1999, there were 1,325 reported HIV positive cases:igure 1). Of these, 441 developed AIDS and 203 have already d\ 1. The number of reported cases has slowly been rising. Prior to '-990, less than 50 cases were reported each year. Since 1993, m\ 3 than a hundred cases are reported each year. Most of the cases were male with a male to female ratio of 3:2. Majority (68%) of cases were in the 19-39 years age group when initially reported. Only 2% were children aged 12 years and below. Female cases tended to be younger than male cases (Figure 2).
Consensus Report on STI, HIV and AIDS Epidemiology: Philippines
7
Figure 1: HIV Seropositives * by Year of Report January 1984 - December 199.9 (N=1,325)
Number
200.------------.-------------------------------,
ill Asymptomatic "AIDS
150 f - - - - - - - - - - ' 100
50
o Lliiiiiiiili_ _• Total Asymptomatic AIDS Died 2
0 2 2
10 6 4 4
29 19 11 11
38 25 13 12
35 20 15 11
39 31 8 6
68 49 19 17
79 66 13 9
69 100 119 50 64 63 19 36 56 11 11 17
117 156 65 105 52 51 22 28
117 94 23 11
190 149 41 14
157 79 78 17
• includes asymptomatic and symptomatic (AlDS) whether living or dead
Figure 2: HIV Seropositives by Age and Gender January 1984 - December 1999 (N=1,325) Age group (years)
Male
Female
.-~--~-~~-~--~----~-,
< 13 13-1 B
19-29
> Unknown 300 250 200 150 100 50 0 50 100 150 200 250 300
No. of Cases
8
Consensus Report on BTl, HIV and AIDS Epidemiology: Philippines
Most (80%) cases had acquired HIV through sexual intercourse. Of those, 72% had become infected through heterosexual contact, 21% through homosexual contact and 6% through bisexual contacts. Bloodbome transmission (transfusion, needle prick injuries, or injecting drug use) was reported in 2% of the cases. Nineteen cases of perinatal transmission were reported, accounting for 1% of cases. In 17% of cases, no probable mode of transmission was reported (Figure 3). Figure 3: Reported modes of transmission HIV cases (N=132S*) Jan 1994 - Dec 1999 Made of Transmission
o
10
20
30 Percent
40
50
60
* 219 cases had no reported mode of transmission
Some 309 (24%) said that they are overseas contract workers and another 194 (15%) said that they are sex workers. The AIDS Registry questionnaire does not include information on history of travel abroad.
b.
HIV Sentinel Surveillance System
In the past seven years, results showed that infection rates even among high risk groups remained at low levels. The highest aggregate prevalence rate (10 sentinel sites) was 0.19% among RFSWs in 1998 (see Table 1). Figure 4 shows the HIV prevalence among RFWs from 1996.
Consensus Report on STI, HIVand AIDS Epidemiology: Philippines
9
Table 1: Number of HIV (+) Cases detected during HIV Serologic Surveillance All Sentinel Sites, 1993-2000 Round Quezon RFSW FLSW MSM RFSW FLSW MSM 1 93 1/305 01100 0/309 0/310 0/109 0/302 0/223 2 Apr/94 11302 Oil 01 0/316 0/303 0/109 01192 01162 0/300 0/103 01145 3 Sep/4 11303 0/101 01198 0/309 01175 0/216 01224 0/317 01110 0/39 0/299 0/62 2/311 0/210 0/245 01122 4 Mar/95 0/339 01161 11134 0/306 01121 01103 0/142 1/313 0/104 0/19 2/321 0/103 0/316 0/200 0/239 0/173 5 Sep/95 0/311 0/258 0/83 0/332 01184 01128 01188 0/311 01121 0/69 2/339 0/58 2/307 0/223 11257 01180 0/307 0/100 0/250 0/86 6 Mar/96 0/300 0/209 0/79 0/306 01192 0/133 01122 0/320 01114 0/31 2/300 0/98 0/298 0/257 0/260 01168 0/302 0/229 0/245 01110 0/437 01129 0/301 01104 2/3069 (0.07) 011610 0/243 01122 7 Sep/96 11293 01124 Oil 04 0/302 0/203 01165 11168 0/319 01171 0/64 4/300 0/65 11295 0/240 0/248 01151 0/421 0/231 01220 01139 01330 01221 0/292 01216 5/3020 (0.17) 011761 0/333 11168 8 Mar/97 1/300 0/106 0/56 0/348 0/227 11168 0/131 0/301 0/273 01118 1/300 0/95 0/301 01238 0/277 01146 0/298 0/295 2/305 01112 0/299 0/271 0/299 0/237 4/3028 (0.13) 0/2000 11342 (J/131 9 Mar/98 0/300 01120 01186 0/327 0/302 0/332 01175 11303 0/301 2/300 11269 0/302 0/300 11232 01169 10 Mar/99 0/300 01127 0/41 0/300 0/300 0/300 01184 0/300 0/300 0/300 0/300 0/300 0/279 0/302 0/300 11300 0/137 11300 0/300 0/300 0/271 0/300 0/300 2/3002 (0.07) 0/2314 0/341 01184 11 FeblMar 00 11300 0/215 0/184 1/300 0/300 0/300 0/127 0/300 0/300 1/300 1/300 0/300 11273 0/300 0/300 0/300 0/246 0/300 0/300 1/300 0/300 0/300 0/300 4/3000 (.13) 2/2834 0/484 0/127
Cebu
IDU RFSW FLSW MSM Angeles RFSW FLSW RFSW Pasay FLSW RFSW lloilo FLSW Cagayan RFSW de Oro FLSW General RFSW Santos FLSW Baguio RFSW FLSW Zamboanga RFSW FLSW Total RFSW (prev. rate) FLSW MSM Davao
11307 0/307 0/300 0/300 0/301 0/300 5/2672 (0.19) 112368 0/518 01175
IDU
11615 (0.16) 0/209 0/611 0/223
11905 (0.11 ) 0/313 0/653 01162
3/1784 (0.17) 0/789 0/453 0/224
311834 (0.16) 0/862 11256 01142
5/2414 (0.21 ) 011210 0/280 0/188
10
Consensus Report on STI, HIV and AIDS Epidemiology: Philippines
Figure 4. HIV Prevalence among RFSW, 1996-2000 Sentinel Surveillance System 0.2 0.18 0.16 0.14 0.12 0.1 0.08 0.06 0.04 0.02
.; ,/
/'
/'\
.A
\
\
J;
\
¥
/'
\ V
/ ,/
o 1996
• 1997
• 1998
• 1999
• 2000
RFSW
2/3069
4/3028
5/2672
2/3002
4/3000
Consensus Report on STI, HIVand AIDS Epidemiology: Philippines
11
Nine out of 10 sentinel sites have detected HIV (+) cases as shown in Table 2
Table 2. Sentinel Groups with HIV Positives by Site and Round March 1993 - March 1999 Sentinel Site Quezon City Cebu City Davao City
••••••
1993 RFSW
1994a RFSW
1994b RFSW
1995a MSM
1995b
1996a MSTD
1996b RFSW
1997
199B
1999
~6~~ RFSW
RFSW RFSW RFSW R::: RFSW RFSW RFSW RFSW RFSW RFSW
i..... ••••'
,'....
Angeles City Pasay City Iloilo City
~~~~ RFSW FLSW RFSW
I; • • • '.....
Gen. Santos City
lii~!-UiO
RFSW
RFSW
RFSW
Zamboanga
1::;'111·111 •.•
c.
Data from blood transfusion
The Philippine National Red Cross has estimated that, in 1999, about 500 000 bags of blood were received by their office and tested for HIV, syphilis, malaria and hepatitis B in 1999. Of these, 54 were found to be positive when screened, but only one was confirmed as HIV-seropositive.
EPIDEMIOLOGY OF OTHER STI IN THE PHILIPPINES From 1993 to 1999, the number of STI cases reported annually averaged about 35 500, with a range of 30360 51 287. The STls reported were syphilis and gonorrhoea, but not all of the SHCs screened for syphilis, and the system underreported, underdiagnosed, and misdiagnosed cases.
12
Consensus Report on STI, HIV and AIDS Epidemiology: Philippines
Syphilis surveillance, incorporated into HSS in 1993, showed a rate of <1% to 5% among vulnerable groups. The highest rates were among FLSWS, followed by MSMs. Rates among MSMs, however, showed a decreasing trend. Rates among RFSWs were the lowest. Many ad hoc STI prevalence studies have been conducted since 1991. Comparison between studies is not always possible, but it has been noted that STI rates seem to be increasing. Among FSWs, from 1998 to 1999 the chlamydiosis infection rate varied from 27% (Cebu, n=241) to 36% (Angeles, n=351), and the gonorrhoea rate varied from 2.6% (Cebu, n=348) to 25% (Angeles, n=351). Syphilis seropositivity was below 3% in 1998 (Davao, Baguio, and Cebu) but was found to be 12% in Angeles in 1999. A study among high-risk groups in Angeles City at the end of 1999 showed the following rates for selected STls:
Table 3. Prevalence of STI among selected subpopulations December 1999
Sexually transmitted Infection Chlam dia Gonorrhea S hilis
RFSW N = 200 35% 15% 4% 5% 56%
FLSW N = 151 37% 38% 24% 8% 71%
MSM N = 100 12% 1% 2% 1%
Clients N = 100 16% 5% 5% 1%
Trichomonas Bacterial Va inosis
The study also revealed that 80% of were asymptomatic.
laboratory confirmed cases
A high level of STI has also been found among low-risk groups. In 1998, chlamydial infections were found in 18% of antenatal women in Manila (n=800), 11.7% in 8aguio (n=308), 9.6% in Cebu (n=343), and 7.5% in Davao (n=349). Gonorrhoea rates ranged between 0.4% among pregnant women in Manila (n=400) and 1.6% among non pregnant women (n=200). Syphilis rates ranged between 0% in antenatal women in Baguio (n=308) and 0.6 % in Cebu (n=344). Trichomoniasis infections were detected in 1 % in Baguio (n=308) and 4% in Davao (n=348).
Con.sensus Report on STI, HIV and AIDS Epidemiology: Philippines
13
Condom use rates with non-regular customers have been gradually increasing among female sex workers In 1999, there was a significant (p<.01) decline (from 77 to 53%) in the proportion of injecting drug users who shared injecting equipment. However, among those who shared injecting equipment, there was a decrease from 50% to 25% in the proportion of those who cleaned their equipment with bleach prior to use (N.B. cleaning with bleach is the method recommended). Behavioural Monitoring Surveys (BMS) was done by communitybased NGOs to provide information to partner NGOs for program direction and to increase the capacity of the NGOs to understand and conduct quantitative monitoring. In 1998, the BMS interviewed the following groups: sex workers, customers and potential customers of sex workers, and MSM. Thirty separate surveys were conducted by 30 NGOs in 7 cities (Angeles, Cebu, Davao, General Santos, Iloilo, Quezon City, and Zamboanga.) Results showed that fewer than 2/3 of the respondents were aware of their inability to identify a person with HIV/AIDS by their appearance but there was a high proportion of respondents who perceived themselves to be at risk of STD from unprotected sex. Most sex workers (79%) said they used a condom with a customer while only 59% of men said they used a condom with a sex worker. Less than half (47%) of sex workers reported customers who refused to use a condom. The Behavioural Sciences Department of De La Salle University was commissioned by Family Health International to assess the level of HIV/AIDS risk behaviour among the male general population. This was called MENSSA of Men's Study on Sexuality and AIDS. Face to face interview was done with 3615 men in the cities of Quezon, Cebu and Davao. The ages of the respondents ranged from 15-44. About half said that they were married but most (95%) of the men in the youngest age group (15-24) were single. The mean age at first marriage was 25 years (range 20-26) while the coital debut was 19 (range 17-19). There was no money involved in 9 out of 10 respondents where coital debut was concerned. Most «82%) of sexually active men had sexual experience in the last 12 months and 80% of them
16
Consensus Report on STI, HIV and AIDS Epidemiology: Philippines
practiced vaginal sex. Almost 87% reported having only one partner while the rest had 2 or more sex partners. Almost all (96%) said they did not pay their partners. Very few reported homosexual and Of those who reported homosexual bisexual relationships. relationships, very few practiced anal sex (insertive or receptive). Almost all of them, however heard about AIDS (99%) of HIV (88%). Majority (86%) said they were willing to take care of a relative with HIV/AIDS. Most knew that being faithful was protective (94%), as well as using syringes only once (89%). About 76% knew that using condoms was protective even though only 4% admitted consistently using condoms of vaginal sex, and even fewer used condoms during Remarkably, only 45% said that abstinence was anal sex. protective. Overall, the MENSSA seemed to show that the Filipino males on average don't have high risk sexual behaviours that those who practice risk behaviour are put at a greater danger beccause they do not protect themselves.
4. ESTIMATES AND PROJECTION a. Estimates of HIV infections
An estimation of current HIV infections in 2000 was made, based on HSS and other serologic data, as well as available data on estimated population of risk groups. Table 4 shows that there could be about 10,000 HIV cases (prevalence rate used for each subgroup was upper limit). b. Estimates of other STls
If we assume that the 15-49- year-Old population of the Philippines (40,000,000) has the same STI prevalence as the infection rate among women attending antenatal clinics (Table 5) there would be a minimum of 4,000,000 Chlamydia cases (10% PCR); 240,000 gonorrhea cases (0.6%, culture); and 520,000 syphilis cases (1.3%, RPR+ TPHA) per year.
Consensus Report on STI, HIV and AIDS Epidemiology: Philippines
17
Table 4: Estimated number of current HIV infections in the Philippines, 2000 GROUP SEXWORKERS IDUs ESTIMATED POPULATION 500,000 ESTIMATED PREVALENCE RATE 1% ESTIMATED NUMBER OF HIV CASES 5,000
400,000 40,000,000
1% .01%
4,000 4,000 13000
15-49 YEAR OLD TOTAL
Table 5: Estimated STI Rates among Sex workers and women attending antenatal clinics, 1999 STI GONORRHEA CHLAMYDIA SYPHILIS TRICHOMONAS INFECTION RATE AMONG SEX WORKERS % 15.0 INFECTION RATE AMONG Low RISK GROUP % 0.6*
35.0 4.0 5.0
10.0 1.3* 2.5
Rates or means of rates from surveys;
* 1998, 1999
IV. CONCLUSIONS AND RECOMMENDATIONS There is no evidence of a rapid increase in HIV transmission in the Philippines. Infection rates remain low and the epidemic spread is slow. Possible factors for the slow transmission were identified: 1. The sexual network is not extensive with a few sexual partners for sex workers. 2. The male population (clients of female sex workers) has low exposure to sex workers or even if they have multiple sex partners, it is more likely a case of "serial monogamy" wherein they have one partner at a time. 3. Majority of the general male population have only one sex partner. 4. There are few males who engage in anal sex. 5. There is low prevalence of ulcerative STls. 6. There is a smalilDU population. 7. Almost all males are circumcised. 8. Geography of the Philippines.
18
Consensw; Report on STI, HIV and AIDS Epidemiology: Philippines
The idea has also been ventured that the country's accelerated response has contributed to the slow transmission' rate. The STI programme has been going on for the past 50 years, and the HIV awareness campaign was started in the early 1990s. The response has also included formalization of organized multi sectoral action; increased recognition of the vital importance of local resources; active engagement of individuals and organizations; obtaining knowledge of the epidemic through surveillance; and a concerted intervention effort. The situation could change in the next few years if efforts to improve best sexual practices of the subpopulations at risk are not strengthened and STI transmission rates are not reduced. To make a better assessment of the situation, HIV surveillance needs to be continually improved. Other vulnerable groups, such as retuming overseas contract workers and deep-sea fishermen, should be monitored in selected sentinel sites to complement surveillance data. The surveillance system should also consider including analysis of data from other information systems, such as blood donor screening and HIV screening of applicants for overseas work. A plan should be drawn up to establish a national STI surveillance system. Universal STI reporting should be integrated into this system, together with syndromic sentinel reporting. STI prevalence studies could be conducted every five years. Behavioural studies have provided useful information but more indepth qualitative studies on sexual behaviour, sexuality and gender should be carried out to further assess the HIV transmission pattem. A reasonable estimate for HIV infections in the Philippines in 2000 is about 10 000 cases. There have been concems that the estimate should be higher, considering the limitations of the surveillance system, but this is not supported by available data. In the context of low HIV prevalence, it has been concluded that projections cannot be made for HIV infections.
Consensus Report on STI, HIV and AIDS Epidemiology: Philippines
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ANNEXES CONSENSUS WORKSHOP May 10, 2000
Observers: 1. Gilles Poumerol Regional Adviser STI, HIV/AIDS, WHO Westem Pacific Regional Office Public Health Consultant, USAID Country Programme Advisor, UNAIDS Technical Advisor, European Union Executive Director, PATH Foundation Resident Advisor, FHI Co- chair, PNACI Asst. Secretary of Human Resource Development, DILG Project Coordinator, JICA First Secretary, AUSAID President, AIDS Society of the Philippines Technical Advisor, World Health Organization
2. Cora Manaloto 3. Mari Ortega 4. Janeka Roos 5. Carmina Aquino 6. Teodora Wi 7. Asec. Austere Panadero -
8. Yoshinori Tereasaki 9. Helen Moody 10. Ofelia Monson 11. Thuy Nguyen
Participants: 1. Ma. Consorcia Quizon 2. 3. 4. 5. Loreto Roquero, Jr. Ofelia Saniel Maridel Bo~a Michael Tan Resident Advisor, NHSSS/FETP, DOH Director III, NASPCP, DOH Faculty, UP-CPH Faculty, UP-CPH Executive Director, HAIN
20
Consensus Report on STI, HIV and AIDS Epidemiology: Philippines
5. Dorothy Agdamag 6. Edgar Mejia
7. Gloria Tan 8. Tess Estrella 9. Sandra Tempongko
10. Ma. Concepcion Roces 11. Manuel M. Dayrit 12. Mary Ann Lansang 13. Carlos Calica 14. Teresita Esguerra 15. Toti Uysingco 16. Florence Tadiar 17. Ricky Hernandez 18. Maybelle Gorospe POEA/OWWA
-
Head, SACCL Programme Coordinator for Asian Red Cross and Red Crescent AIDS Task Force Secretary Representative, National Voluntary Blood Program, BRL Representative, National Voluntary Blood Program, BRL Regional Expert, Control of HIV/AIDS/STD Partnership Project in Asian Region Director III, FETP-HIS, DOH Vice President, UNILAB CEU,UP President, PSVI Social Hygiene Physician, SHC Angeles City Executive Director, Tri-Dev President, Women's Health Care Foundation Overall Convenor NCR Chapter, Phil. Social Science Association Representative,
SECRETARIAT: 1. Liza Castro 2. Ma. Anna Liza Carillo 3. Noel Palaypayon Medical Specialist II ASPCP/DOH Sentinel Nurse, NHSSS/FETP, DOH Sentinel Nurse, NHSSS/FETP, DOH
Consensus Report on STI, HIV and AIDS Epidemiology: Philippines
21