hiv awareness research paper in the philippines

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The State of the HIV Epidemic in the Philippines: Progress and Challenges in 2023

Louie mar a. gangcuangco.

1 Hawaii Center for AIDS, John A Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI 96813, USA

Patrick C. Eustaquio

2 Love Yourself, Inc., Mandaluyong 1552, Metro Manila, Philippines; hp.flesruoyevol@kcirtap

In the past decade, the Philippines has gained notoriety as the country with the fastest-growing human immunodeficiency virus (HIV) epidemic in the Western Pacific region. While the overall trends of HIV incidence and acquired immunodeficiency syndrome (AIDS)-related deaths are declining globally, an increase in new cases was reported to the HIV/AIDS and ART Registry of the Philippines. From 2012 to 2023, there was a 411% increase in daily incidence. Late presentation in care remains a concern, with 29% of new confirmed HIV cases in January 2023 having clinical manifestations of advanced HIV disease at the time of diagnosis. Men having sex with men (MSM) are disproportionately affected. Various steps have been taken to address the HIV epidemic in the country. The Philippine HIV and AIDS Policy Act of 2018 (Republic Act 11166) expanded access to HIV testing and treatment. HIV testing now allows for the screening of minors 15–17 years old without parental consent. Community-based organizations have been instrumental in expanding HIV screening to include self-testing and community-based screening. The Philippines moved from centralized HIV diagnosis confirmation by Western blot to a decentralized rapid HIV diagnostic algorithm (rHIVda). Dolutegravir-based antiretroviral therapy is now the first line. Pre-exposure prophylaxis in the form of emtricitabine–tenofovir disoproxil fumarate has been rolled out. The number of treatment hubs and primary HIV care facilities continues to increase. Despite these efforts, barriers to ending the HIV epidemic remain, including continued stigma, limited harm reduction services for people who inject drugs, sociocultural factors, and political deterrents. HIV RNA quantification and drug resistance testing are not routinely performed due to associated costs. The high burden of tuberculosis and hepatitis B virus co-infection complicate HIV management. CRF_01AE is now the predominant subtype, which has been associated with poorer clinical outcomes and faster CD4 T-cell decline. The HIV epidemic in the Philippines requires a multisectoral approach and calls for sustained political commitment, community involvement, and continued collaboration among various stakeholders. In this article, we outline the current progress and challenges in curbing the HIV epidemic in the Philippines.

1. Introduction

In the past decade, the Philippines has gained notoriety as the country with the fastest-growing human immunodeficiency virus (HIV) epidemic in the Western Pacific region [ 1 ]. The first recorded cases of HIV in the Philippines were in 1985 among two then-labeled “ hospitality women ” from the cities of Angeles and Olongapo in Central Luzon [ 2 ]. Prior to 2010, the HIV epidemic was described to be “low and slow”, with about four newly diagnosed cases reported every month and a national prevalence of less than 0.1% [ 3 ]. Several factors implicated for the initial indolent rise in cases include the archipelagic geography of the Philippines, high rates of male circumcision, lower proportion of people who injecting drugs, and the culture of sexual conservatism [ 3 ].

While the overall trend of HIV incidence and AIDS-related deaths are declining globally [ 4 ], an increase in new cases was reported to the HIV/AIDS and ART Registry of the Philippines (HARP) in the recent decade ( Figure 1 ). In 2012, there were only approximately nine new HIV cases every day. In 2023, however, there have been 46 cases reported daily [ 5 ], a stunning 411% increase in daily incidence in 10 years. Late presentation in care remains a concern, with 29% of new confirmed HIV cases in January 2023 having clinical manifestations of advanced HIV disease at the time of diagnosis [ 5 ].

Estimated annual new HIV infections among individuals 15 years old and above from 2000–2021 globally and in the Philippines, based on UNAIDS estimates.

As of January 2023, there were 110,736 HIV cases reported in the Philippines [ 5 ]. Although this number seems low considering that the country has over 109 million people [ 6 ], the pervasive stigma, sociopolitical conditions, and barriers to healthcare services are fueling the epidemic in marginalized populations. The number of people living with HIV (PLHIV) is projected to increase by 200% from 158,400 in 2022 to 364,000 by 2030 [ 7 ]. Despite these challenges, there were advances in the rollout of newer antiretroviral agents, access to pre-exposure prophylaxis, and healthcare legislations that positively impact HIV treatment and prevention. In this narrative review, we outline the current progress and challenges in curbing the HIV epidemic in the Philippines.

2. Populations Disproportionately Impacted by HIV

Populations disproportionately affected by HIV include key populations, comprising 92% of the new infections in 2022, and vulnerable populations [ 7 ]. Key populations include males having sex with males (MSM), transgender women, sex workers, trafficked women and girls, and people who inject drugs (PWID) [ 7 ]. Vulnerable populations include migrant workers, people with disabilities, people in enclosed spaces, and female partners of key populations [ 7 ].

2.1. Men Having Sex with Men

Sexual transmission remains to be the predominant mode of HIV acquisition in the Philippines, primarily among MSM [ 5 ]. One of the earliest HIV prevalence studies among MSM was conducted in 2010. HIV testing performed outside the entertainment areas/gay bars of Manila found that, among 406 MSM screened using rapid HIV antibody test kits, 48 tested positive (11.8% [95% confidence interval: 8.7% to 15.0%]). Forty participants consented to a Western blot confirmatory test, with 39 participants testing positive for HIV-1 and one patient testing positive for both HIV-1 and HIV-2 [ 8 ]. Data from the Philippine Department of Health (DOH) in January 2023 showed that approximately 70% of all HIV cases were among males who have sex with other males, and 17% were among males who have sex with both males and females [ 5 ].

2.2. Persons Who Inject Drugs

HIV transmission through the sharing of infected needles remains relatively low in the Philippines. It was reported to be highest in 2010, accounting for 9% of all new HIV cases that year [ 9 ]. In the same year, an outbreak of HIV and hepatitis C virus (HCV) occurred in Cebu City, where over 50% of PWID were found to have HIV, and 93% were infected with HCV [ 10 ]. HIV transmission through infected needles has decreased since 2011 and constitutes ~1% of all newly reported cases in the past few years [ 9 ]. However, due to the recent sociopolitical climate, particularly during former president Rodrigo Duterte’s “ war on drugs” [ 11 ], it is likely that data among PWID and among those who use illicit drugs remain underreported for fear of legal ramifications. The last biobehavioral surveillance data among PWID were reported in 2015.

Needle and syringe programs (NSPs) provide access to sterile needles and syringes and facilitate their safe disposal. NSPs have been shown to effectively reduce HIV transmission [ 12 ]. However, the implementation of NSPs remain difficult in the Philippines given that the Comprehensive Dangerous Drugs Act of 2002 (Republic Act [RA] 9165) considers any unauthorized possession of drug paraphernalia as prima facie evidence of self-administration of dangerous drugs [ 13 ]. Violation could lead to a maximum of 4 years imprisonment and a minimum monetary penalty of PHP 10,000 (~USD 182) [ 13 ], which is higher than the upper bound of the average monthly minimum wage in 2022 [ 14 ]. Political pressure and the Dangerous Drugs Act of 2022 continue to make NSPs inaccessible, deterring effective community-based comprehensive HIV prevention services among PWID. The Big Cities Project (BCP) in Cebu funded by the World Bank and the Asian Development Bank aimed to reduce HIV transmission by reducing risk behaviors among PWID. However, the sterile needle distribution aspect of this project was halted within 5 months of implementation due to political pressure [ 15 , 16 ]. Mental health and substance use disorders need to be addressed as part of a comprehensive response to the HIV epidemic in the Philippines.

2.3. Transgender Populations

In the HIV surveillance systems of the Philippines, transgender women were previously included under MSM until 2018 when the HARP and the Integrated HIV Behavioral and Serologic Surveillance (IHBSS) disaggregated data based on gender identity. Of the total reported new HIV cases in January 2023, 3% were transgender women [ 5 ]. Unique concerns among transgender populations in the Philippines include differences in HIV knowledge, need for safe sex communication, and disparate access to healthcare services [ 17 ]. One study among trans men and trans women ( N = 525) in Metro Manila showed that as many as 82% declined HIV testing and counseling services [ 18 ]. Amid the gaps in healthcare access, a community-led health service delivery model providing integrated HIV and gender-affirming care showed promise in providing essential health services to transgender people [ 19 ].

2.4. Other Vulnerable Groups

There are other populations in the Philippines vulnerable to HIV. These include migrant workers, people who exchange sex, people trafficked for sex, and people in enclosed spaces.

Despite efforts to abolish policies that discriminate against PLHIV, several countries continue to mandate HIV antibody testing prior to migration or employment [ 20 ]. Historically, overseas Filipino workers (OFWs) have comprised a significant proportion of HIV cases, likely because of increased case detection from the pre-departure HIV testing imposed by their prospective employers abroad. In a 2006 publication, it was reported that, of 2410 HIV seropositive cases in the Philippines, 821 (34%) were OFWs [ 21 ]. As HIV testing entry requirements are eased by countries globally and the epidemic affects other key populations, there has been a decline in the proportion of OFWs diagnosed to have HIV. In January 2023, OFWs comprised only 5% ( N = 76) of newly diagnosed cases in the Philippines [ 5 ]. In a serological study of over 69,000 OFWs screened for HIV antibody, only one (0.001%) tested positive [ 22 ]. OFWs remain vulnerable to HIV due to the intersectionality of sociocultural factors, stigma, working conditions abroad, and barriers to healthcare access [ 23 ].

Data from the Young Adult Fertility and Sexual Health (YAFSH) study showed that 1% of Filipino men and 0.03% of women aged 15 to 24 years paid for sex in 2021, while 1% of men and 0.1% of women received payment for sex [ 24 ]. High-risk behaviors were also reported in this survey, with only 13% of male youth using condoms every time they paid for sex in the past 12 months [ 24 ]. Vulnerable populations are more likely to engage in transactional sex. For instance, female sex workers previously constituted majority of the HIV cases during the early part of the epidemic [ 25 ]. Moreover, around 38% of MSM and transgender women surveyed in the IHBSS 2018 reported receiving payment in exchange for sex in the past year [ 26 ]. Additionally, sex work has been reported outside of urban areas, as demonstrated by the “ call boys ” in rural fish ports [ 27 ]. Although commercial sex work is illegal in the Philippines, transactional sex encompasses “nonmarital, noncommercial sexual relationships motivated by the implicit assumption that sex will be exchanged for material benefit or status” [ 28 ]. Alcohol, drugs, monetary gifts, and housing have also been implicated as drivers of transactional sex [ 29 ]. Young people who engage in transactional sex have increased risk of alcohol and substance use, as well as of HIV and sexually transmitted infections [ 28 , 29 ].

According to human rights groups, the Philippines is a major sex trafficking hub in Southeast Asia. Underage Filipinos as young as 14 years old have been reported to trade sex while working in entertainment bars, spas, or illegal brothels [ 30 ]. The minors, compared to the older workers, were more likely to have been told to have sex without a condom by their managers [ 30 ]. Some risk factors for sex trafficking that have been identified include a history of childhood abuse, gender inequality, and poverty [ 31 ].

Multiple social vulnerabilities prior to incarceration, the prison environment, and management practices in these facilities have magnified HIV vulnerability among prisoners in the Philippines [ 32 ]. This is a particularly urgent issue as the recent “war on drugs” was associated with the 511% congestion rate in prisons and jails in the Philippines, fueling the twin epidemic of HIV and HCV [ 33 , 34 ].

3. The “ABCs” of HIV Prevention

HIV prevention efforts have traditionally focused on the ABCs: abstinence, being faithful, and condom use [ 35 ]. Among MSM, several reasons for not using condoms were trust in one’s sexual partner, diminished pleasure, and unavailability of condoms [ 8 ]. Among heterosexuals, condoms were perceived primarily as a birth control measure rather than as protection against HIV and sexually transmitted infections [ 36 ]. Other barriers identified were the stigma associated with purchasing a condom, as it is associated with premarital sex or infidelity [ 36 ]. Behavioral and cultural challenges to these interventions call for more robust prevention strategies, including pharmacological interventions (pre-exposure prophylaxis, PrEP), increased HIV testing, and treatment as prevention. The seventh AIDS Medium Term Plan (2023–2028), serving as the country’s blueprint to address the HIV epidemic, aims to expand access to combination prevention services and to address social, gender inequities, and stigma [ 7 ].

Stigma is an attribute causing people to be perceived as less or shamed, and it can be (1) enacted through experiencing discrimination, (2) felt through vulnerability toward discrimination, or (3) internalized through self-validation of negative societal experiences [ 37 ]. Stigma is enacted through various forms of discrimination, including victimization, violence, and macro- and microaggressions, by different perpetrators, including by the general public, employers, healthcare workers, or even oneself, friends, and family [ 38 , 39 ]. Stigma and discrimination are associated with poor quality of life and poor physical and mental health outcomes [ 40 , 41 , 42 , 43 ], which affect engagement in HIV-related services [ 44 , 45 ]. In the Philippine PLHIV Stigma Index 2019, about one in five reported stigma and discrimination within the past year, mostly from being gossiped by friends and/or family [ 46 ]. There were reports of HIV status disclosure without consent, particularly among coworkers [ 46 ]. Around one in three reported that their HIV status negatively affected their self-efficacy, most commonly in losing desire to have children [ 46 ]. There were also reports of feelings of worthlessness, shame, guilt, and self-exclusion [ 46 ].

Populations disproportionately affected by HIV experience multiple sources of stigma, from their serostatus, race and/or ethnicity, sex assigned at birth, sexual orientation, gender identity and/or expression (SOGIE), drug-injecting behavior, sex work, religious beliefs, language, culture, and social class [ 37 , 39 , 47 ]. MSM living with HIV in Manila described perceptions of being immoral and fatalistic, which often perpetuate internalized shame and hopelessness [ 37 ].

Stigma may be present even within groups of sexual and gender minorities; in particular, transgender women in the Philippines report discomfort in accessing HIV services in facilities focused on MSM [ 48 ]. People who use drugs are often targets of stigma perpetuated by the current sociopolitical climate [ 42 ]. The burden of multiple sources of stigma and their deep underpinning in larger social, political, and cultural contexts of inequity and power warrant a lens of intersectionality on studying health disparities based on stigma [ 49 ]. Being mindful of the intersecting social determinants of health is crucial in tackling health issues, particularly among populations with overlapping behaviors that put them at higher risk of HIV, such as key populations engaging in sexualized drug use (e.g., “chemsex” among MSM) and key populations engaging in sex work or transactional sex.

5. HIV Counseling and Testing

The World Health Organization (WHO) recommends that, in countries with less than 5% HIV prevalence, HIV testing should be offered to (a) individuals who present in clinical settings with manifestations and conditions suggestive of HIV primary or coinfection, such as tuberculosis and sexually transmitted infections, (b) children and infants who are symptomatic or exposed to HIV, (c) key populations and their partners, and (d) all pregnant individuals [ 50 ]. In the Philippines, HIV testing remains focused among the aforementioned key populations. Barriers to HIV testing among Filipinos included HIV-related stigma, misconceptions about the virus, fear of testing HIV-positive, and financial instability [ 51 ]. Particularly among MSM, barriers to HIV screening included perception of not needing the test due to the absence of symptoms, feeling morally superior, belonging to a higher socioeconomic class, inaccessibility of the testing facility, uncertainty of treatment side-effects, and fear of HIV-related healthcare expenses [ 52 ].

Historically, the Philippine AIDS Prevention and Control Act of 1998 (RA 8504) required pre-test and post-test counseling by a certified HIV counselor, amid their limited number, and required parental consent for HIV testing among individuals less than 18 years old, despite their level of risk for HIV [ 53 ]. In 2018, RA 8504 was revised into the Philippine HIV and AIDS Policy Act of 2018 (RA 11166). This law expanded HIV testing to include provider-initiated counseling and testing, allowing licensed social workers and health service providers to provide HIV testing services [ 54 ]. Furthermore, RA 11166 allows HIV testing among individuals 15–17 years old without parental consent [ 54 ].

Community-based organizations (CBOs) have played a key role in improving access to HIV prevention services in the Philippines. CBOs were at the forefront of research, advocacy, and policy work that expanded HIV testing from the traditional facility-based screening to now include community-based screening and HIV self-testing [ 55 , 56 ]. Monumental to the introduction of HIV self-testing in the country were HIV self-testing demonstration projects held in the Western Visayas region and in Metro Manila [ 57 , 58 ]. In the former, multiple CBO project sites reached many first-time testers among MSM and trans women [ 57 ]. In the latter, participants reported high acceptability for HIV self-testing [ 58 ]. In both projects, about 8–9% tested positive for HIV antibody, and more than half were linked to further testing and treatment [ 57 , 58 ]. These projects were conducted successfully despite the stringent quarantine protocols during the COVID-19 pandemic. It was estimated that there was a 61% decrease in the number of HIV tests performed and a 37% decrease in HIV diagnosis in 2020 nationally, attributed largely to the quarantine restrictions imposed during the COVID-19 pandemic [ 59 ], further highlighting the importance of improving the accessibility of HIV testing services in the community.

Given the success of community-led HIV testing projects, HIV self-testing was included in the national HIV testing guidelines in 2022 [ 56 ]. However, challenges remain in the rollout of HIV self-testing. Most of the HIV self-testing kits in the Philippines are blood-based tests, despite the acceptability of oral-based tests [ 60 ]. Moreover, there are unauthorized online sellers of HIV test kits [ 61 ]. Regulations must be strengthened to ensure the quality of HIV test kits purchased online. Furthermore, support systems must be in place to facilitate linkage to care, making medical and psychosocial support accessible for persons who test positive at home.

In addition to HIV self-testing, social network and index testing (partner notification) were recently included as HIV testing approaches [ 56 ]. While benefits outweigh the risk, index testing is associated with experiences of intimate partner violence [ 62 , 63 ]. In the Philippines, where intimate partner violence among cisgender women is prevalent [ 64 ] and national legislative protections for sexual and gender minorities are lacking [ 65 ], it is imperative for the country to improve violence prevention and push forward legislations that will protect the rights and wellbeing of key and vulnerable populations regardless of HIV status.

In 2019, the Philippines started to transition from the use of the Western blot test for HIV confirmation to the rapid HIV diagnostic algorithm (rHIVda), which involves the use of three rapid diagnostic test kits to confirm HIV diagnosis ( Figure 2 ) [ 66 , 67 ]. This approach decentralized confirmation of HIV diagnosis from a couple of reference laboratories in Metro Manila to the 38 certified rHIVda confirmatory laboratories around the country as of September 2022 [ 68 ]. RHIVda significantly decreased waiting time for HIV confirmation and facilitated linkage to care from weeks to days [ 68 ]. As there are limited algorithms approved in the Philippines [ 69 ], stock issues in rapid diagnostic test kits present a potential challenge. Nonetheless, the continuous validation of kits and consideration of new technologies provide flexibility to this challenge [ 67 , 69 ].

Traditional versus rapid HIV diagnostic algorithm in the Philippines. Abbreviations: rHIVda: rapid HIV diagnostic algorithm; IA: immunoassay.

6. HIV Pre-Exposure Prophylaxis (PrEP)

PrEP is the use of combination antiretrovirals for HIV prevention indicated for people who are HIV-seronegative at substantial risk for HIV [ 50 , 70 ]. Depending on a person’s risk behavior, PrEP may be taken daily or “on demand”/event-driven. Event-driven PrEP, otherwise known as “2–1–1”, is currently recommended by the WHO to prevent sexual acquisition of HIV by cisgender men and trans and gender diverse people assigned male at birth who are not taking hormones that are estradiol-based [ 70 ]. In this regimen, a person takes two pills of emtricitabine/tenofovir 2–24 hours before potential exposure, one pill 24 hours after the first dose, and one pill 24 hours after the second dose [ 70 , 71 ].

A landmark pilot implementation project that paved the way to the approval of PrEP in the Philippines was the community-led program called Project PrEPPY. In this 2 year pilot implementation, there were no reported new HIV infections, no increase in condomless anal intercourse, and no significant increase in STI incidence from baseline among MSM and transgender women who used PrEP [ 72 ].

Emtricitabine–tenofovir disoproxil fumarate (TDF) was the first approved PrEP medication [ 73 ]. Chronic use of TDF has been associated with mild kidney-related adverse events [ 74 ] and decreased bone mineral density [ 75 ]. A newer prodrug of tenofovir (tenofovir alafenamide) was shown to have less impact on the kidney and bone mineral density [ 76 ], but was associated in some studies with weight gain and lipid disorders [ 77 , 78 ].

In 2021, the WHO recommended dapivirine vaginal rings (DPV-VR) as a new choice for HIV prevention for women at substantial risk of HIV infection [ 79 ]. DPV-VR is a bendable silicone ring inserted into the vagina that slowly releases the antiretroviral dapivirine, replaced every 28 days [ 79 ]. In 2022, long-acting cabotegravir, which is administered intramuscularly 4 weeks apart for the first two injections and then every 8 weeks thereafter, was recommended by the WHO as an additional prevention choice for people at substantial risk of HIV infection [ 80 ]. However, only oral emtricitabine–TDF is currently available in the Philippines and is not covered by the national health insurance. Donor-funded emtricitabine–TDF is limited, and the out-of-pocket cost is about USD 30–65 for a 30-tablet bottle. It must be noted that the minimum wage in the National Capital Region is about PHP 500 (~USD 9.20) per day (minimum wage is lower in other regions of the Philippines) [ 14 ], limiting the accessibility of PrEP, especially among people living in poverty.

7. HIV Post-Exposure Prophylaxis (PEP)

Persons without HIV who may have been recently exposed to HIV may take post-exposure prophylaxis (PEP) as soon as possible within 72 hours of high-risk exposure to prevent HIV acquisition [ 81 ]. PEP implementation in the Philippines remains limited to healthcare-related exposure, in both clinical and community-based settings [ 55 , 82 ]. The Philippine Health Sector HIV Strategic Plan 2020–2022 aimed to expand PEP to non-healthcare-related exposures [ 83 ].

8. HIV Treatment and Care Delivery

8.1. access to hiv services.

As of January 2023, there were about 180 treatment hubs and primary HIV care facilities in the Philippines [ 5 ]. ART is dispensed only through these designated facilities and is not available from commercial pharmacies, which may pose as a challenge for PLHIV living in rural areas trying to access ART [ 1 , 84 ]. While the national HIV program provides ART for free to PLHIV, other fees for medical care, such as consultation fees and laboratory tests, may be covered by the national health insurance, Philippine Health Insurance Corporation (PhilHealth), through their Outpatient HIV/AIDS Treatment (OHAT) Package. The OHAT package provides an annual reimbursement of PHP 30,000 (~USD 544), which is paid to the treatment facility where the PLHIV is enrolled [ 85 ]. In 2022, it was estimated that one in three PLHIV was not enrolled in OHAT [ 7 ].

The OHAT package provides financial support to PLHIV and covers the biomedical aspect of the HIV care cascade. However, other components essential to strengthen HIV management, such as peer support and counseling, psychosocial support, and ancillary services for shelter and violence response/prevention are mostly out of pocket, if not covered by external funding, particularly from donor organizations, or by the national program through domestic funding.

Although domestic funding comprises 94% of HIV spending from government sources, through the national HIV program and PhilHealth, with 6% coming from external sources, these only constitute 40% of the financial requirement to reach the 95–95–95 UNAIDS target (see Section 9 ), leaving a 60% funding gap [ 7 ]. The country’s transition toward universal healthcare (UHC), since the passage of the UHC Law (RA 11223) [ 86 ], goes hand in hand with RA 11166 in providing sustainable mechanisms to address these financial gaps. Moreover, the Mandanas Ruling by the Supreme Court would potentially increase the share of local government units from national taxes, which could also contribute to address these gaps if HIV and healthcare services are prioritized at the local level [ 7 ].

8.2. Antiretroviral Therapy (ART)

Although studies to cure HIV through various novel techniques are ongoing, such as bone marrow transplant and gene therapy [ 87 , 88 ], there remains no commercially available cure for PLHIV. Plasma HIV RNA suppression is achieved through regular ART. Early in the infection, HIV establishes latency in various cellular and tissue reservoir sites, including the central nervous system, gut lymphoid tissue, and resting memory CD4 T cells [ 89 ]. ART controls active viral replication in the plasma but does not completely eradicate viruses in these reservoir sites. Once ART is stopped, viral load rebounds [ 90 ].

For several years, the only available one pill once a day ART regimen in the Philippines has been lamivudine/TDF/efavirenz (LTE). Although efavirenz is a potent non-nucleoside reverse transcriptase inhibitor, it is known to cause neuropsychiatric symptoms, such as vivid dreams, severe depression, or suicidal ideation, which have been reported in up to 50% of patients [ 91 ]. In July 2019, the WHO issued a statement that the integrase strand transfer inhibitor (INSTI) dolutegravir is the preferred first-line and second-line treatment option for all populations [ 92 ]. This was based on multiple studies showing that dolutegravir is more effective in achieving virological suppression, is better tolerated, and is more cost-effective than alternative drugs [ 92 ]. Furthermore, dolutegravir displays potent in vitro activity and a lower barrier for genetic resistance development [ 93 ].

In 2020, the Philippines started prescribing TDF/lamivudine/dolutegravir (TLD) single-formulation tablets. The Philippine government prioritized the use of TLD among newly diagnosed PLHIV and among patients with severe side-effects from the current efavirenz-based regimen [ 94 ]. Significant progress has transpired with the inclusion of TLD in the Philippine National Formulary in 2021 [ 95 ], enabling government procurement. The Philippine HIV treatment guidelines were also revised in 2022 [ 96 ], officially recommending dolutegravir-based ART as the first-line regimen for PLHIV.

The long-acting injectable combination of cabotegravir/rilpivirine has been approved by the US FDA for use in adult PLHIV who are virologically suppressed on a stable ART regimen [ 97 ]. Cabotegravir/rilpivirine is administered by a healthcare provider as an intramuscular (gluteal) injection every 2 months [ 98 ] and replaces the need for daily oral ART. This medication is currently not available in the Philippines.

8.3. Tuberculosis and Hepatitis B Co-Infection

The treatment of PLHIV with tuberculosis (TB) co-infection remains a challenge in a country with one of the highest TB/HIV burdens in Asia [ 99 ]. Rifampicin, one of the key medications for long-term tuberculosis treatment, reduces dolutegravir exposure, requiring an additional dose of dolutegravir to be administered 12 hours after the standard daily dose [ 100 ]. However, the single-formulation dolutegravir 50 mg tablet remains difficult to access in the Philippines. This limits the use of TLD, particularly among the estimated 12,000 individuals with TB/HIV co-infection [ 101 ]. Moreover, PLHIV who have treatment failure with efavirenz are further disadvantaged, as they are likely taking protease inhibitors which have serious drug–drug interactions with rifampicin [ 102 ].

Another challenge in the ART management among PLHIV in the Philippines is the high burden of hepatitis B virus (HBV) in the country, with an estimated Hepatitis B surface antigen (HBsAg) seroprevalence of 16.7% in the general population [ 103 ]. Prevalence data on HBV/HIV co-infection in the Philippines remain limited, but one study reported that, among PLHIV ( N = 302), 13.3% ( n = 40) were co-infected with HBV [ 104 ]. The use of certain ART in the setting of HIV/HBV co-infection (such as TDF and lamivudine) requires careful monitoring, since chronic HBV may increase the risk of hepatotoxicity from ART and abrupt discontinuation of ART with anti-HBV activity may lead to HBV reactivation and fulminant hepatitis [ 105 , 106 ].

8.4. Treatment as Prevention

VL suppression is not only essential in decreasing morbidity and mortality among PLHIV, but also a key measure to prevent HIV transmission in the community. In recent years, the public health message “ undetectable = untransmittable (U=U)” has gained significant traction to fight stigma and promote ART adherence. PLHIV who achieve and maintain an undetectable viral load by regularly taking ART as prescribed will not sexually transmit HIV to others [ 107 ]. This concept of U=U is underpinned by “treatment as prevention”, where achieving viral load suppression through ART is used as a prevention strategy at the population level [ 108 ]. Communicating U=U was associated with improved overall sexual and mental health, medication adherence, and viral load suppression [ 109 ]. Moreover, it is a huge step in de-stigmatization, particularly among people who face multiple intersecting stigma [ 108 , 110 ].

8.5. Maternal–Child Transmission

A total of 724 women in the Philippines were diagnosed to have HIV during their pregnancy between January 2011 to January 2023 [ 5 ]. The DOH started to recommend triple screening among pregnant women for HIV, syphilis, and HBV in 2016 [ 111 ]. This is aligned with the global movement for the triple elimination of HIV, syphilis, and HBV. Only 15% of pregnant women are receiving ART for the prevention of mother-to-child transmission (MTCT) [ 112 ]. Although newer recommendations on antiretroviral prophylaxis among HIV-exposed infants were provided in the recently revised HIV treatment guidelines [ 96 ], the last DOH guidelines on prevention of MTCT was published in 2009 [ 113 ]. Updating these guidelines is crucial to ensure continuity of standard of care across all the components of the MTCT cascade.

9. Viral Load Monitoring, Genotyping, and Resistance Testing

The Joint United Nations Program on HIV/AIDS (UNAIDS) set a global target of 95–95–95 by 2030: 95% know their HIV status, 95% are on ART, and 95% have achieved viral load suppression [ 114 ]. As of September 2022, the Philippines has achieved 63–65–97 [ 7 ]. It should be noted, however, that the 97% viral suppression rate was based only among 20% of PLHIV on ART who were tested for plasma HIV RNA [ 7 ]. A study on the care cascade of 3137 MSM diagnosed to have HIV in a community-based clinic in Manila showed a 98% viral suppression rate among 84% of PLHIV on ART who were tested for viral load [ 115 ]. In another surveillance study, an HIV clinic in a tertiary hospital found 95% viral suppression among the 48.2% of PLHIV on ART who had viral load testing [ 116 ].

HIV RNA viral load testing is unfortunately not routinely performed in the country due to the associated costs and limited availability [ 116 ]. An administrative order was issued by the DOH in 2022 to facilitate the integration of HIV and TB services. This collaborative approach to the prevention and control of TB and HIV aims to increase the access to polymerase chain reaction (PCR) machines for HIV viral load and TB diagnosis [ 117 ].

Where resources are available, baseline HIV drug resistance testing is recommended to guide the selection of the initial ART regimen [ 118 ]. HIV genotype testing is also helpful to facilitate the switching of medications in the event of treatment failure. However, low- and middle-income countries face challenges in accessing HIV drug resistance testing. In 2013, deep sequencing analysis to assess drug-resistance mutations (DRMs) among PLHIV in the Philippines showed that only two from the 110 evaluable individuals with major HIV variants were highly resistant to non-nucleoside reverse transcriptase inhibitors (NNRTI: efavirenz and nevirapine). However, minority drug-resistant HIV variants were detected: highly resistant to nevirapine (89/110), rilpivirine (5/110), and efavirenz (49/110) [ 119 ]. A study published in 2017 among a relatively small sample of treatment-naïve PLHIV in the Philippines ( N = 95) showed transmitted drug resistance (TDR) in six patients (6.3%) [ 120 ]. In a more recent publication of PLHIV ( N = 513) on ART, 10.3% experienced treatment failure after 1 year [ 121 ]. Among those who failed treatment ( n = 53), 90.6% had DRMs. The study found unexpectedly high rates of NRTI, NNRTI, and K65R tenofovir resistance, as well as multiclass resistance [ 121 ]. These data emphasize the need for continued efforts to increase viral load and drug resistance testing in the Philippines.

10. Changing Molecular Epidemiology of HIV

The increase in HIV cases in the Philippines is multifactorial and cannot only be attributed to various healthcare, socioeconomic, and political factors. The changing molecular epidemiology of the virus may also be fueling transmission. During the early part of the epidemic, subtype B was the prevailing HIV-1 subtype in the country. However, multiple studies in the past decade have shown that CRF_01AE is now the predominant subtype, constituting over 70% of strains among newly diagnosed PLHIV [ 122 , 123 ]. CRF_01AE appears to be a more aggressive subtype, reported in various cohorts to cause more rapid CD4 T-cell decline and faster HIV/AIDS progression [ 121 , 124 , 125 ]. The poorer outcomes associated with this predominant HIV subtype circulating in the Philippines should be an impetus for various stakeholders to further ramp up HIV testing, treatment, and care delivery in the country.

11. Conclusions

There has been significant progress in HIV treatment and prevention in the Philippines. The Philippine HIV and AIDS Policy Act of 2018 expanded access to HIV services in the country [ 54 ]. HIV testing now includes community-based screening and self-testing [ 56 ] and allows for the screening of minors 15–17 years old without parental consent [ 54 ]. Newer antiretrovirals have been procured, and dolutegravir-based ART is now first line, consistent with the WHO recommendations [ 92 ]. PrEP has been rolled out [ 72 ]. The number of treatment hubs and primary HIV care facilities continues to increase. However, barriers including stigma, limited harm reduction services for PWID, and sociocultural and political deterrents remain. HIV RNA viral load testing and drug resistance testing are not routinely performed due to associated costs and limited resources. The high burden of TB and HBV co-infection complicates HIV management [ 102 , 104 ]. PrEP and PEP need to be expanded to further reach populations at risk. The HIV epidemic in the Philippines requires a multisectoral approach and calls for sustained political commitment, community involvement, and continued collaboration among various stakeholders.

Funding Statement

This review article received no external funding.

Author Contributions

L.M.A.G. and P.C.E. contributed equally to this article. All authors have read and agreed to the published version of the manuscript.

Conflicts of Interest

The authors declare no conflict of interest. The views and opinions expressed in this article do not reflect the views and opinions of the authors’ affiliations.

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Open Access

Peer-reviewed

Research Article

Determinants of HIV testing among Filipino women: Results from the 2013 Philippine National Demographic and Health Survey

Roles Conceptualization, Formal analysis, Methodology, Writing – original draft

* E-mail: [email protected]

Affiliations Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom, Center for Research and Innovation, School of Medicine and Public Health, Ateneo de Manila University, Pasig City, Philippines

Roles Conceptualization, Methodology, Supervision, Writing – review & editing

Affiliations Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana

• Veincent Christian F. Pepito, 

• Published: May 12, 2020
• https://doi.org/10.1371/journal.pone.0232620
• Peer Review
• Reader Comments

26 Jan 2021: Pepito VCF, Newton S (2021) Correction: Determinants of HIV testing among Filipino women: Results from the 2013 Philippine National Demographic and Health Survey. PLOS ONE 16(1): e0246013. https://doi.org/10.1371/journal.pone.0246013 View correction

The prevalence of having ever tested for HIV in the Philippines is very low and is far from the 90% target of the Philippine Department of Health (DOH) and UNAIDS, thus the need to identify the factors associated with ever testing for HIV among Filipino women.

We analysed the 2013 Philippine National Demographic and Health Survey (NDHS). The NDHS is a nationally representative survey which utilized a two-stage stratified design to sample Filipino women aged 15–49. We considered the following exposures in our study: socio-demographic characteristics of respondent and her partner (i.e., age of respondent, age of partner, wealth index, etc.), sexual practices and contraception (i.e., age at first intercourse, condom use, etc.), media access, tobacco use, HIV knowledge, tolerance to domestic violence, and women’s empowerment. The outcome variable is HIV testing. We used logistic regression for survey data to study the said associations.

Out of 16,155 respondents, only 372 (2.4%) have ever tested for HIV. After adjusting for confounders, having tertiary education (adjusted odds ratio (aOR) = 2.15; 95% Confidence Interval (CI): 1.15–4.04), living with partner (aOR = 1.72; 95% CI: 1.19–2.48), tobacco use (aOR = 1.87; 95% CI: 1.13–3.11); belonging to the middle class (aOR = 2.72; 95% CI: 1.30–5.67), richer (aOR = 3.00; 95% CI: 1.37–5.68), and richest (aOR = 4.14; 95% CI: 1.80–5.91) populations, having weekly television access (aOR = 1.75; 95% CI: 1.04–2.94) or internet access (aOR = 2.01; 95% CI: 1.35–3.00), living in a rural area (aOR = 1.87; 95% CI: 1.34–2.61); and being a Muslim (aOR = 2.30; 95% CI: 1.15–4.57) were associated with ever testing for HIV.

Conclusions

The low percentage of respondents who test for HIV is a call to further strengthen efforts to promote HIV testing among Filipino women. Information on its determinants can be used to guide the crafting and implementation of interventions to promote HIV testing to meet DOH and UNAIDS targets.

Citation: Pepito VCF, Newton S (2020) Determinants of HIV testing among Filipino women: Results from the 2013 Philippine National Demographic and Health Survey. PLoS ONE 15(5): e0232620. https://doi.org/10.1371/journal.pone.0232620

Editor: Joel Msafiri Francis, University of the Witwatersrand, SOUTH AFRICA

Received: January 31, 2020; Accepted: April 17, 2020; Published: May 12, 2020

Copyright: © 2020 Pepito, Newton. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data for the 2013 Philippine National Demographic and Health Survey Individual Recode are available from the Demographic and Health Surveys Program Website ( https://www.dhsprogram.com/data/available-datasets.cfm )

Funding: The authors have not received specific funding to conduct the analysis; however, they have received financial support from the Ateneo de Manila University School of Medicine and Public Health and the PLOS Publication Fee Assistance Office for the publication fee of the manuscript. These funding agencies did not have a role in the analysis, writing of the manuscript, as well as decision to publish.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Despite the worldwide decrease in the incidence of Human Immunodeficiency Virus (HIV) infections [ 1 , 2 ], the Philippines is currently experiencing a rapid increase in the number of HIV cases [ 2 – 5 ]. For the first seven months of 2019, around 35 new cases of HIV are diagnosed in the country every day. From 1984 to July 2019, there have been 69,512 HIV cases that have been diagnosed in the Philippines; 4,339 (6.7%) of whom are women [ 6 ]. However, HIV statistics in the Philippines are perceived to be underestimates due to Filipinos’ low knowledge and/or stigma associated with HIV testing [ 3 – 5 , 7 , 8 ]. It is estimated that around one-third of all Filipinos who have HIV do not know their true HIV status, despite HIV testing being free in many facilities throughout the country [ 3 ]. From the 2013 Philippine National Demographic and Health Survey (NDHS), only 2.3% of all the female respondents have reported that they have ever tested for HIV [ 9 ].

HIV testing is considered to be among the cornerstones of most HIV prevention and control strategies [ 10 – 12 ]. At the individual level, HIV testing, together with counselling, is an avenue where people can be educated about risky behaviors associated with the disease [ 13 ]. For those who have the disease, HIV testing is the first step into the continuum of care where they can be managed accordingly which will hopefully stop disease progression and transmission [ 12 , 14 ]. From a public health perspective, the greater the number of individuals who will undergo HIV testing, the more accurate the statistics will be for the disease. This will lead to better allocation of resources for public health interventions that will help curb the HIV epidemic [ 3 , 12 ]. For women, HIV testing has an added benefit of possibly preventing mother-to-child transmission of HIV. It is for this reason, together with the increasing numbers of pregnant women diagnosed with HIV and children born with HIV from 2011–16, that the Philippine Department of Health (DOH) has strongly encouraged pregnant women in the Philippines to undergo HIV testing. In relation to this, the DOH has decreed that by 2022, the proportion of people living with HIV (PLWH) who knows their status should be 90% [ 3 ]. This is in-line with the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target, which stipulates that by 2020, “90% of all PLWH will know their true status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy, and 90% of all people receiving antiretroviral therapy will have viral suppression” [ 15 ].

Given the importance of HIV testing among women, studies identifying its determinants have been carried out before. These determinants can be classified into socio-demographic determinants (e.g., age, educational attainment, address, religion, marital status, socio-economic status, employment, media exposure, and number of children) or HIV-related determinants (e.g., sexual behaviors, knowledge on HIV, perceptions on HIV testing, consumption of intoxicants, and having talked to mother or female guardian about HIV) [ 16 – 21 ]. Other determinants of HIV testing include having a dysfunctional relationship with their spouse/partner, tolerance of domestic violence, experiencing stigma, media exposure, number of lifetime sexual partners, having talked to mother/female guardian regarding HIV testing, ever pregnant, and exposure to public health interventions regarding HIV [ 16 , 17 , 22 ]. Two reviews emphasized that there are a host of social, institutional- and policy-level factors, often not considered in most observational studies, which may also act as barriers or enablers of HIV testing [ 23 , 24 ]. However, despite the numerous studies cited on HIV testing among women worldwide, and despite the HIV epidemic in the Philippines, there were no studies focusing on HIV testing among Filipino women in published literature. This is ostensibly due to the low proportion of cases of women with HIV in the country [ 6 ]. This implies that women could have been left behind in the response to the HIV epidemic in the country.

In order to address this gap and in order to craft interventions to encourage Filipino women to undergo testing, this analysis aims to identify the determinants of HIV testing among Filipino women. The results of this study could serve as the first step in the implementation of interventions to promote HIV testing among Filipino women to help meet DOH and UNAIDS targets.

Study design, setting, and participants

This study is a secondary analysis of the 2013 Philippine NDHS women’s individual recode data. The survey used a stratified two-stage sampling design with the 2010 Philippine Census of Population and Housing as sampling frame. The first stage sampling involved a systematic selection of 800 sample enumeration areas all over the country, distributed by urban/rural regions, to ensure representativeness. In the second stage, 20 housing units were randomly selected from each enumeration area using systematic sampling. All households in the sampled units were interviewed. From each household, women aged 15–49 were interviewed. The interviews were carried out all throughout the Philippines from August to October 2013. Other details of the sampling method for the 2013 Philippine NDHS can be found in its report [ 9 ].

Data collection and study variables

The 2013 Philippine NDHS utilized a paper-based, pre-tested interview schedule to collect data on a wide range of socio-demographic, economic, knowledge on some health issues, health practices, fertility and childbirth, immunization of children, health insurance, domestic violence, women’s empowerment, and other variables from a nationally-representative sample. A copy of the interview schedule can be seen on the final report of the 2013 Philippine NDHS [ 9 ].

Despite the multitude of variables collected in the study, only variables that are deemed to influence HIV testing were included in the analysis. The exposure variables for this study were: Age; educational attainment; civil status; condom use; consistent condom use; condom access; use of any traditional contraception method; tobacco consumption; age of husband/partner; educational attainment of partner; HIV knowledge, wealth index; address; tolerance to domestic-based gender violence; women’s empowerment score; number of children; religion, reading newspapers; weekly access to television, radio, newspapers, and internet; age of first sexual intercourse, and knowledge of condom source. The outcome variable for this study is HIV testing. A description of how the variables were operationally defined, as well as how they were coded are described in an Appendix ( S1 Appendix ).

To minimize observer bias, data collectors for the 2013 Philippine NDHS underwent a two-week training in administering the data collection tool. Furthermore, systematic random sampling was used to ensure representativeness. Moreover, data collectors visited the respondents at home repeatedly to ensure that the randomly selected respondents were interviewed, instead of replacing them with whoever is convenient, thus minimizing selection bias. To minimize encoding errors, encoders underwent training in using the data entry program created specifically for this NDHS [ 9 ].

Data management

Once permission was obtained from the NDHS data curators, the Individual Recode dataset of the 2013 Philippine NDHS was downloaded from the DHS website [ 25 ]. After this, the dataset was cleaned. In cleaning the dataset, new variables were generated from each variable that were included in the analysis. These new variables were cleaned and analysed to preserve the original data as much as possible. Inconsistent responses were considered as “no data” as the original responses of the respondents could no longer be obtained.

Some variables (e.g., employment status, marital status, etc.) were recoded to ensure that there were sufficient observations for each strata. Other variables (e.g., tobacco consumption) were recoded to ensure that the baseline stratum would have more observations, thus ensuring more stable estimates than if the current coding was used. Quantitative age variables were transformed into age brackets [e.g., 15–19, 20–24 years old, etc.] so that the effect of having similar ages on the outcome could be studied. The midpoint was assigned as the ‘score’ for each age group [e.g., the score ‘17’ were assigned to those who were aged 15–19; the score ‘22’ were assigned to those who were aged 20–24, etc.]. Condom use variables were recoded such that the baseline would be those who have never had sexual intercourse. Those who have used condoms consistently would also be noted with this variable. Similarly, variables on employment status or educational attainment of partner were recoded such that the baseline would be those who do not have partners at present.

Score variables (e.g., HIV knowledge score, women’s empowerment, tolerance to domestic violence) were aggregated from many questions. HIV knowledge score were derived from the following questions: [ 1 ] Ever heard of AIDS; [ 2 ] Reduce risk of getting HIV: Always use condoms during sex; [ 3 ] Reduce risk of getting HIV: have one sex partner only, who has no other partners; [ 4 ] Can get HIV from mosquito bites; [ 5 ] Can get HIV by sharing food with person who has AIDS; [ 6 ] A healthy looking person can have HIV; and [ 7 ] Can get AIDS by shaking hands. Tolerance to domestic violence score was aggregated from the following questions: [ 1 ] Beating justified if wife goes out without telling husband; [ 2 ] Beating justified if wife neglects the children; [ 3 ] Beating justified if wife argues with husband; [ 4 ] Beating justified if wife refuses to have sex with husband; [ 5 ] Beating justified if wife burns the food. Women’s empowerment score was derived from the following questions: [ 1 ] Who decides on your healthcare; [ 2 ] Who decides on large household purchases; [ 3 ] Who decides on daily household purchases; [ 4 ] Who decides on visits to family or relatives; and [ 5 ] Who decides what to do with money husband earns. For the HIV knowledge score questions, one point will be given for each correct answer, while no points will be given for incorrect or ‘don’t know’ answers. For tolerance to domestic violence questions, one point will be given for each ‘no’ answer while no points will be given for ‘don’t know’ answers. For each women empowerment questions, two points were given for each ‘respondent only’ answer, one point were given for each ‘respondent and partner’ answer and no points were given for each ‘other answers’. The points from each question were added to come up with the HIV knowledge score, women’s empowerment score, and tolerance to domestic violence score. A respondent with missing data in any of the questions that make up a score will not have an aggregate score. The aggregated score was left as a continuous variable so that the effect of a one-point increase in these variables on HIV testing can be quantified.

All data management and analyses were carried out in Stata/IC 14.0 [ 26 ].

Data analysis

After preliminary cleaning, the dataset was declared as survey data and the sampling weights and strata (i.e., urban and rural, regions) were defined. All subsequent analyses, if applicable, were weighted. The distributions of each variable were determined by noting the respective histograms and measures of central tendency for continuous variables, and frequencies and proportions for categorical variables. For the descriptive analyses, weighted means and proportions will be shown; however, counts, medians, and modes will not be weighted.

The association of the exposures with HIV testing were examined using Pearson’s χ 2 test (for categorical exposure variables), adjusted Wald test (for normally-distributed continuous exposure variables), or the Wilcoxon rank-sum test (for skewed continuous exposure variables). The Pearson’s χ 2 test and the adjusted Wald test will be weighted; however, the Wilcoxon rank-sum test is not weighted because of the lack of applicable non-parametric statistical tests for weighted data. Those with missing data were not included in computing for the p-values for these tests. Crude odds ratios (OR) for each of the associations between exposure and the outcome were estimated using logistic regression for survey data.

Once the crude OR for this association were obtained, variables that might be in the causal pathway of other variables were excluded from the analyses. The remaining variables were then classified into whether they are proximal or distal risk factors. Proximal risk factors (PRFs) can be defined as factors that are thought to be closer to the outcome in a causal diagram, while distal risk factors (DRFs) were factors that were farther from the outcome and may indirectly contribute to causing it [ 27 ]. After this, a variable was generated to indicate respondents who do not have missing data for any of the remaining variables. Multivariate analyses were only carried out for respondents who have complete data for all of the variables of interest. To determine the order in which variables will be introduced into the final model, logistic regression for survey data was used to assess the effect of each PRF, adjusting for the DRFs with a p≤0.20 in the bivariate analyses. Adjusted OR of each PRF, as well as corresponding p-values were noted.

Logistic regression for survey data was used in the analyses of these associations. In building the final model for the determinants of HIV testing, DRFs were added into the model with the variable having the smallest p-value added first, then the second smallest p-value added second, and so on, until all DRFs with p≤0.20 from the bivariate analysis are in the model. After this, PRFs were added to the model starting with those with the smallest p-values in the analysis adjusting for DRFs until all the PRFs with p≤0.20 in the analyses adjusting for DRFs were added, or the maximum number of parameters was reached. While p-value cutoffs are not to be blindly followed in studying causal relationships in epidemiology, they may aid in variable selection to prevent models from being too overly-parameterized [ 28 , 29 ]. The maximum number of parameters for the final model are contingent on the effective sample size for the multivariate analysis, taking into consideration the ‘rule of 10’ events per parameter estimated [ 30 ].

At any point in the building of the final model, test for departure from the linearity assumption was carried out by observing the stratum-specific ORs, and running the contrast command in Stata once a quantitative ordinal variable (e.g., age group, wealth index, etc.) was added to the model. Since the midpoint of each age group was used as the ‘score’, parameters of a common linear trend would not only estimate the common linear effect of the age groups on the outcome, but also the common change in effect on the outcome per unit change in age [ 31 ]. In addition, model estimates were also observed for signs of multicollinearity or separation every time a variable is added. Variables with problematic estimates may be excluded from the analysis.

Considering that assessing effect measure modification (EMM) was not among the objectives, and that Mantel-Haenszel methods cannot be used in the analysis of survey data [ 32 ], no assessment of EMM for any of the variables was carried out. Furthermore, no observations were deleted from the analyses to ensure that standard errors can be computed correctly [ 33 ]. Missing data were handled by presenting them in the univariate analyses and excluding respondents who have missing data in any of the variables of interest in the multivariate analyses.

Despite making several hypothesis tests, the level of significance was not adjusted. Instead, it was maintained at 0.05 all throughout the analysis as it is safer not to make adjustments for multiple comparisons in the analysis of empirical data to minimize errors in interpretation [ 34 ].

The 2013 Philippine NDHS has received ethical approval from ICF Macro Institutional Review Board (Project No.: 31561.00.000.00) dated July 1, 2010. This analysis has received ethical approval from the London School of Hygiene and Tropical Medicine MSc Ethics Committee (Reference No.: 15014).

The 2013 Philippine NDHS collected data from 16,437 Filipino women aged 15–49 years old. Interviews were completed for 16,155 individuals, with a 98.3% response rate. Except for counts, ranges, and non-parametric results, subsequent statistics shown are all weighted.

Only 372 (2.4%) respondents have ever tested for HIV. Most of the respondents finished secondary education, are married, do not use condom, do not use traditional contraception, are Roman Catholic, and have weekly television access. However, a substantial proportion of respondents have no data on condom access, age group of partner, and educational attainment of partner. This is predominantly because they have not had any sexual partners yet and/or have not had a partner at present. Among the categorical exposure variables and without adjusting for confounding, age of respondent, educational attainment of respondent, employment status of respondent, civil status, age at first intercourse, condom use, condom access, knowledge of condom source, usage of traditional contraception, tobacco use, educational attainment of partner, socio-economic status, and newspaper, television, and internet access were found to be associated with having ever tested for HIV ( Table 1 ). All of these factors are positively associated with having ever tested for HIV, except for condom access and condom source. The negative association of these latter two variables with HIV testing denote that not having condom access and not knowing a condom source is a determinant of never testing for HIV.

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https://doi.org/10.1371/journal.pone.0232620.t001

Around 38% of the respondents have never had sexual intercourse, and majority do not have more than one sexual partner throughout their lifetime. Imputed age at first intercourse ranged from 7 to 47 years old. There are 5,891 (37.0) respondents who do not have children, and around 4,480 (28.3%) having only one or two children. Most of the respondents have a high (≥5/7) HIV knowledge score, have a high women empowerment score (≥6/10), and a low tolerance to domestic violence. The distributions of the number of lifetime sexual partners and HIV knowledge score were found to differ between those who were tested for HIV and those who were never tested for HIV. Despite these, none of the quantitative exposure variables had shown a strong evidence of association with HIV testing ( Table 2 ).

https://doi.org/10.1371/journal.pone.0232620.t002

For the multivariate analysis, distal risk factors that have a p≤0.20 in the cross-tabulations are age of respondent, highest educational attainment of respondent, employment status, civil status, tobacco use, highest educational attainment of partner, socio-economic status, domicile, religion, newspaper access, television access, and internet access. Proximal risk factors that have a p≤0.20 in the cross-tabulations are age at first intercourse, condom use, condom access, knowledge of condom source, traditional contraception, number of children, number of lifetime sexual partners and HIV knowledge score. However, because there is collinearity between knowledge of condom source and condom access, and because the latter has a lot of missing data, it will not be among the variables that will be considered in the analysis. Only 8,578 (53.2%) respondents have complete data for the variables that are considered in the multivariate analysis. Out of these, 243 (2.8%) have underwent HIV testing ( Table 3 ).

https://doi.org/10.1371/journal.pone.0232620.t003

In building the final model, tests for linear trend were run for age of respondent, age at first sexual intercourse, and socio-economic status. Age of respondent (p = 0.27) and age at first sexual intercourse (p = 0.92) did not show evidence of deviation from a linear trend, but there is an evidence for deviation of a linear trend for socio-economic status (p<0.01), which meant that stratum-specific ORs were shown for socio-economic status instead of common ORs.

After adjusting for other variables, having tertiary education (adjusted odds ratio (aOR) = 2.15; 95% Confidence Interval (CI): 1.15–4.04), being unmarried but living together with partner (aOR = 1.72; 95% CI: 1.19–2.48), tobacco use (aOR = 1.87; 95% CI: 1.13–3.11); belonging to the middle class (aOR = 2.72; 95% CI: 1.30–5.67), richer (aOR = 3.00; 95% CI: 1.37–5.68), and richest (aOR = 4.14; 95% CI: 1.80–5.91) populations, having weekly television access (aOR = 1.75; 95% CI: 1.04–2.94) or internet access (aOR = 2.01; 95% CI: 1.35–3.00), living in a rural area (aOR = 1.87; 95% CI: 1.34–2.61); and being a Muslim (aOR = 2.30; 95% CI: 1.15–4.57) were associated with higher odds of HIV testing among Filipino women aged 15–49.

Only around 2% of Filipino women have had HIV testing throughout their lifetimes, implying that there is still substantial work to be done in promoting HIV testing to Filipino women to meet DOH and UNAIDS targets. Women’s educational attainment, civil status, tobacco use, socio-economic status, television and internet access, domicile, and religion showed strong evidence of association with HIV testing. This information could be used to guide the development of interventions to promote HIV testing among Filipino women.

These associations were similar to the findings of other studies. Specifically, there seems to be an increasing propensity for HIV testing among more educated or wealthier respondents, regardless of gender [ 7 , 16 ]. A study conducted in the United States also found that smoking was found to be strongly associated with HIV testing. Accordingly, the said study explains that smokers might be more likely to undergo HIV testing because being a smoker is associated with risky sexual behaviors and/or drug use, the latter two are known independent risk factors for HIV [ 35 ]. Due to certain religious taboos, HIV testing remains very low among some religious groups in the country. However, the odds of HIV testing are highest among Muslims. While there are no studies explaining this phenomenon in the Philippines, a study conducted in Malaysia explains that in their country, Muslim religious leaders were supportive of HIV testing because it provides a protective mechanism in line with Islamic teachings [ 36 ]. The specifics of the association between media exposure and HIV testing was examined in detail in this study and was found to be similar to those that are found in other settings [ 16 , 17 ]. Frequent exposure to television and Internet also increases the probability of exposure to HIV information, education, and communication (IEC) campaigns promoting HIV testing disseminated through these forms of media, thus promoting HIV testing.

There were also differences in the findings of this study with what has been published in literature. In this analysis, older individuals were found to be more likely to have undergone HIV testing than younger respondents, but this trend is the exact opposite of what was found in Burkina Faso, where older women were found to be less likely to test than younger ones. The same study in Burkina Faso found that living in a rural area inhibits HIV testing [ 16 ], while this analysis found that those from rural areas are more likely to have undergone HIV testing as compared to those from urban areas. Without adjusting for confounders, we found several factors to be associated with HIV testing in this analysis, but a secondary analysis of data collected on 2003 from Filipino males show that only HIV knowledge is strongly associated with getting HIV test result [ 7 ].

While consistency of results across populations or circumstances strengthen evidence for causation [ 37 ], its absence does not necessarily mean that results are no longer valid nor useful. A possible reason explaining the differences in the effect of age on HIV testing is the difference in how age was handled in the analyses. This study grouped respondents on five-year age groups, while other studies grouped respondents on 10-year groups [ 16 , 22 ]. Another possible reason for the differences between the findings of this study and others is that the populations and contexts on the studies being compared might be inherently different. Differences in social, economic and political context underpinning HIV epidemiology and response should not be ignored in comparing findings from different settings [ 38 – 41 ]. Findings from the older study involving Filipino males may differ from the current study due to gender differences. Secular changes may also explain why results differed between the previous study and this analysis [ 7 ].

The study presents several salient points of concern. First, the prevalence of HIV testing remains to be very low. Second, the association of socio-economic status and highest educational attainment with HIV testing highlights inequities in access and utilization of HIV testing services, despite it being offered for free in government facilities. This is ostensibly explained by low awareness of HIV testing, and an even lower awareness that it is offered for free [ 3 ]. Third, the Philippine DOH has made significant strides to encourage HIV testing among pregnant women [ 3 ], but as the results show, number of children was not found to be associated with HIV testing which highlight the need to do more in promoting HIV testing among pregnant women. Fourth, the lower odds of testing among those who are from urban areas are worrying because urban centers in the Philippines are where HIV cases are rapidly rising.

Despite these worrying conclusions, the study is best interpreted with its limitations in mind. The exclusion of almost half of the respondents in the multivariate analysis due to missing data underlines the possibility of selection bias. The respondents who were excluded were mostly those who do not have partners, or have never had sexual intercourse, because these respondents did not have data for educational attainment of partner. The exclusion of these respondents also meant that the baseline for the condom use variable are no longer those that have never had intercourse, as in the univariate analysis, but those who did not use condom in their last intercourse. This also meant that the baseline for the civil status variable are now those who are married, instead of those who were never in union as in the univariate analysis. A separate model was considered for those who do not have partners or those who never had sexual intercourse, but the very low proportion of respondents who tested for HIV for these populations meant that such a model might have low statistical power. Not to mention, those who never had sexual intercourse is deemed to have low risk in developing HIV as HIV is mostly transmitted sexually here in the Philippines. Given this, it should be kept in mind that the findings of this analysis may only be generalized to those who have already had sexual partners.

Alternative variable selection strategies emphasize that all known confounders should be controlled for in the model [ 42 ]. From this line of reasoning, there would still be residual confounding as we have not controlled for variables either because they were not collected in the original dataset (i.e., social support, drug use, etc. and other factors working beyond the individual level), or were excluded due to the specified p-value cutoff in the Methodology. However, controlling for all known confounders might lead to overly parameterized models, especially that our proportion of HIV testers is very low. It is for this reason that p-value cut-offs were used to select variables to include in the model. Even the multivariate model itself fails to meet the ‘rule-of-10’, having estimated 29 parameters on 243 events (i.e., people who tested for HIV), giving us 8.4 events per parameter. However, simulation studies have shown that the ‘rule-of-10’ can be relaxed to up to five events per parameter without expecting issues in chances of type-I error, problematic confidence intervals, and high relative bias [ 30 ].

Cross-sectional studies such as this analysis are especially susceptible to reverse causality, especially for data that may vary with time. This is often a problem for this study design as both exposure and outcome data are collected simultaneously. This prevents ascertainment of the temporal direction of the associations found in the study [ 43 ].

Another issue that usually affect HIV studies using self-report data, including this analysis, is response bias [ 44 ]. This was apparent for age at first sexual intercourse, which necessitated the use of imputed data. This also implies that sexual behavior (e.g., condom use, etc.) and other health data collected from the respondents should be interpreted cautiously due to the possibility of Hawthorne effect [ 45 ]. Ultimately, this implies that conclusions drawn from this analysis is only as good as the quality of data provided by the respondents.

Most importantly, there have been developments in HIV testing in the Philippines since the data was collected on 2013. On 2016, the country has piloted rapid diagnostic screening tests among high-burden cities in the country to increase uptake of HIV testing. These rapid diagnostic tests have the advantage of being cheaper and having a faster turn-around time as compared to current Western blot-based confirmatory tests [ 3 , 46 , 47 ]. However, despite the rollout of these initiatives, HIV testing remains very low and falls short of the 90-90-90 target set by the DOH and UNAIDS [ 3 ]. On 2019, the country has started the implementation of the new Philippine HIV and AIDS Policy Act. Among the provisions of this new law is allowing persons aged 15–18 to undergo HIV testing without parental consent and allowing pregnant and other adolescents younger than 15 years old and engaging in high-risk behavior to undergo testing without parental consent [ 48 ]. Owing to its recent implementation, however, we are yet to measure how this new law affects uptake and utilization of HIV testing, especially among Filipino women.

Despite these weaknesses and the policy changes since the data was collected, these findings should still be considered in formulating public health interventions to promote HIV testing, considering the dearth of evidence exploring this phenomenon and the urgency of the HIV situation in the Philippines. Further research should be undertaken to elucidate the relationships of some exposures with HIV testing to improve on the weaknesses of this study as well as assess the effect of new policy developments on uptake and utilization of HIV testing among Filipino women.

The low proportion of Filipino women who have ever tested for HIV is a call to strengthen efforts to promote HIV testing. Information on its determinants can help in the formulation and implementation of interventions and which segments of the population should be targeted by these interventions. Information, education, and communication campaigns to promote HIV testing and to dispel myths surrounding it should be disseminated via television or Internet. Such campaigns should target those who have lower socio-economic status, those who have low educational attainments, and those who live in urban areas. Further research to identify determinants of HIV testing, especially among populations that were not studied yet, should be done to identify segments of the population that should be reached by interventions to promote HIV testing. Further research to assess the impact of recent policies on HIV testing should likewise be conducted. Studies and implementation research focusing on availability, accessibility, and acceptability of HIV testing, including novel and alternative approaches, such as self-testing [ 46 , 49 ] and use of technology [ 50 ] should likewise be conducted. Only through the promotion of HIV testing, and its subsequent uptake by the population, will the DOH and UNAIDS reach their targets for the Philippines.

Supporting information

S1 appendix. definition of variables and coding manual..

https://doi.org/10.1371/journal.pone.0232620.s001

Acknowledgments

We thank the DHS Program for lending us the 2013 Philippine National Demographic and Health Survey dataset. We are also grateful for the comments of Ms. Arianna Maever L. Amit and anonymous reviewer/s from the London School of Hygiene and Tropical Medicine for improving this manuscript.

• View Article
• Google Scholar
• PubMed/NCBI
• 3. Department of Health (Philippines)-Epidemiology Bureau. State of the Philippine HIV epidemic 2016: Facing challenges, forging solutions [Internet]. [cited 2018 Feb 11]. Available from: http://www.doh.gov.ph/sites/default/files/publications/publication__nonSerials_State%20of%20HIV%20Epidemic%20in%20the%20Philippines.pdf
• 6. Department of Health (Philippines) Epidemiology Bureau. HIV/AIDS & ART registry of the Philippines (July 2019) [Internet]. 2019 [cited 2019 Dec 28]. Available from: https://drive.google.com/drive/folders/1GiUUoZoi87A_WVX-Zt_3p6exZpo3S59K
• 9. Philippine Statistics Authority [Philippines], ICF International. National Demographic and Health Survey (Philippines) 2013 [Internet]. 2014. Available from: https://dhsprogram.com/pubs/pdf/fr294/fr294.pdf
• 12. World Health Organization, Deutsche Gesellschaft für Technische Zusammenarbeit, Joint United Nations Programme on HIV/AIDS, International HIV/AIDS Alliance. Scaling-up HIV testing and counselling services: a toolkit for programme managers. Geneva: World Health Organization; 2005.
• 13. World Health Organization—Western Pacific Region. Policy brief: transgender health and HIV in the Philippines. Manila: WHO Regional Office for the Western Pacific; 2016.
• 15. UNAIDS. 90-90-90: An ambitious treatment target to help end the AIDS epidemic [Internet]. 2017 [cited 2019 May 28]. Available from: https://www.unaids.org/en/resources/909090
• 25. The DHS Program—Philippines: Standard DHS, 2013 Dataset [Internet]. [cited 2018 Jul 5]. Available from: https://www.dhsprogram.com/data/dataset/Philippines_Standard-DHS_2013.cfm?flag=0
• 26. Stata 14.0. College Station, TX: StataCorp; 2015.
• 27. World Health Organization. The World Health Report (2002)—Chapter 2: Key goals of global risk assessment [Internet]. WHO. 2002 [cited 2018 Aug 18]. Available from: http://www.who.int/whr/2002/chapter2/en/index4.html
• 28. Katz MH. Multivariable analysis: a practical guide for clinicians. 2nd ed. Cambridge; New York: Cambridge University Press; 2006. 203 p.
• 31. Clayton D, Hills M. Statistical methods in epidemiology. Oxford: Oxford University Press; 1992.
• 33. UCLA Statistical Consulting Group. Applied survey data analysis in Stata 13 [Internet]. [cited 2018 Aug 29]. Available from: https://stats.idre.ucla.edu/stata/seminars/applied-svy-stata13/
• 47. Health Technology Assessment Study Group—Health Policy Development and Planning Bureau. Rapid HIV diagnostic algorithm (rHIVda) for the Philippines [Internet]. Department of Health (Philippines); 2018. Available from: https://www.doh.gov.ph/sites/default/files/publications/IB_rHIVda.pdf
• 48. Republic Act No. 11166 | GOVPH [Internet]. Official Gazette of the Republic of the Philippines. [cited 2020 Apr 9]. Available from: https://www.officialgazette.gov.ph/2018/12/20/republic-act-no-11166/

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HIV/AIDS risk in the Philippines : focus on adolescents and young adults

This paper focuses on HIV/AIDS risk in the Philippines, especially adolescents and young adults.

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• Published: 24 November 2021

A study of awareness on HIV/AIDS among adolescents: A Longitudinal Study on UDAYA data

• Shobhit Srivastava   ORCID: orcid.org/0000-0002-7138-4916 1 ,
• Shekhar Chauhan   ORCID: orcid.org/0000-0002-6926-7649 2 ,
• Ratna Patel   ORCID: orcid.org/0000-0002-5371-7369 3 &
• Pradeep Kumar   ORCID: orcid.org/0000-0003-4259-820X 1  

Scientific Reports volume  11 , Article number:  22841 ( 2021 ) Cite this article

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Acquired Immunodeficiency Syndrome caused by Human Immunodeficiency Virus (HIV) poses a severe challenge to healthcare and is a significant public health issue worldwide. This study intends to examine the change in the awareness level of HIV among adolescents. Furthermore, this study examined the factors associated with the change in awareness level on HIV-related information among adolescents over the period. Data used for this study were drawn from Understanding the lives of adolescents and young adults, a longitudinal survey on adolescents aged 10–19 in Bihar and Uttar Pradesh. The present study utilized a sample of 4421 and 7587 unmarried adolescent boys and girls, respectively aged 10–19 years in wave-1 and wave-2. Descriptive analysis and t-test and proportion test were done to observe changes in certain selected variables from wave-1 (2015–2016) to wave-2 (2018–2019). Moreover, random effect regression analysis was used to estimate the association of change in HIV awareness among unmarried adolescents with household and individual factors. The percentage of adolescent boys who had awareness regarding HIV increased from 38.6% in wave-1 to 59.9% in wave-2. Among adolescent girls, the percentage increased from 30.2 to 39.1% between wave-1 & wave-2. With the increase in age and years of schooling, the HIV awareness increased among adolescent boys ([Coef: 0.05; p  < 0.01] and [Coef: 0.04; p  < 0.01]) and girls ([Coef: 0.03; p  < 0.01] and [Coef: 0.04; p  < 0.01]), respectively. The adolescent boys [Coef: 0.06; p  < 0.05] and girls [Coef: 0.03; p  < 0.05] who had any mass media exposure were more likely to have an awareness of HIV. Adolescent boys' paid work status was inversely associated with HIV awareness [Coef: − 0.01; p  < 0.10]. Use of internet among adolescent boys [Coef: 0.18; p  < 0.01] and girls [Coef: 0.14; p  < 0.01] was positively associated with HIV awareness with reference to their counterparts. There is a need to intensify efforts in ensuring that information regarding HIV should reach vulnerable sub-groups, as outlined in this study. It is important to mobilize the available resources to target the less educated and poor adolescents, focusing on rural adolescents.

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Introduction.

Acquired Immunodeficiency Syndrome (AIDS) caused by Human Immunodeficiency Virus (HIV) poses a severe challenge to healthcare and is a significant public health issue worldwide. So far, HIV has claimed almost 33 million lives; however, off lately, increasing access to HIV prevention, diagnosis, treatment, and care has enabled people living with HIV to lead a long and healthy life 1 . By the end of 2019, an estimated 38 million people were living with HIV 1 . More so, new infections fell by 39 percent, and HIV-related deaths fell by almost 51 percent between 2000 and 2019 1 . Despite all the positive news related to HIV, the success story is not the same everywhere; HIV varies between region, country, and population, where not everyone is able to access HIV testing and treatment and care 1 . HIV/AIDS holds back economic growth by destroying human capital by predominantly affecting adolescents and young adults 2 .

There are nearly 1.2 billion adolescents (10–19 years) worldwide, which constitute 18 percent of the world’s population, and in some countries, adolescents make up as much as one-fourth of the population 3 . In India, adolescents comprise more than one-fifth (21.8%) of the total population 4 . Despite a decline projection for the adolescent population in India 5 , there is a critical need to hold adolescents as adolescence is characterized as a period when peer victimization/pressure on psychosocial development is noteworthy 6 . Peer victimization/pressure is further linked to risky sexual behaviours among adolescents 7 , 8 . A higher proportion of low literacy in the Indian population leads to a low level of awareness of HIV/AIDS 9 . Furthermore, the awareness of HIV among adolescents is quite alarming 10 , 11 , 12 .

Unfortunately, there is a shortage of evidence on what predicts awareness of HIV among adolescents. Almost all the research in India is based on beliefs, attitudes, and awareness of HIV among adolescents 2 , 12 . However, few other studies worldwide have examined mass media as a strong predictor of HIV awareness among adolescents 13 . Mass media is an effective channel to increase an individuals’ knowledge about sexual health and improve understanding of facilities related to HIV prevention 14 , 15 . Various studies have outlined other factors associated with the increasing awareness of HIV among adolescents, including; age 16 , 17 , 18 , occupation 18 , education 16 , 17 , 18 , 19 , sex 16 , place of residence 16 , marital status 16 , and household wealth index 16 .

Several community-based studies have examined awareness of HIV among Indian adolescents 2 , 10 , 12 , 20 , 21 , 22 . However, studies investigating awareness of HIV among adolescents in a larger sample size remained elusive to date, courtesy of the unavailability of relevant data. Furthermore, no study in India had ever examined awareness of HIV among adolescents utilizing information on longitudinal data. To the author’s best knowledge, this is the first study in the Indian context with a large sample size that examines awareness of HIV among adolescents and combines information from a longitudinal survey. Therefore, this study intends to examine the change in the awareness level of HIV among adolescents. Furthermore, this study examined the factors associated with a change in awareness level on HIV-related information among adolescents over the period.

Data and methods

Data used for this study were drawn from Understanding the lives of adolescents and young adults (UDAYA), a longitudinal survey on adolescents aged 10–19 in Bihar and Uttar Pradesh 23 . The first wave was conducted in 2015–2016, and the follow-up survey was conducted after three years in 2018–2019 23 . The survey provides the estimates for state and the sample of unmarried boys and girls aged 10–19 and married girls aged 15–19. The study adopted a systematic, multi-stage stratified sampling design to draw sample areas independently for rural and urban areas. 150 primary sampling units (PSUs)—villages in rural areas and census wards in urban areas—were selected in each state, using the 2011 census list of villages and wards as the sampling frame. In each primary sampling unit (PSU), households to be interviewed were selected by systematic sampling. More details about the study design and sampling procedure have been published elsewhere 23 . Written consent was obtained from the respondents in both waves. In wave 1 (2015–2016), 20,594 adolescents were interviewed using the structured questionnaire with a response rate of 92%.

Moreover, in wave 2 (2018–2019), the study interviewed the participants who were successfully interviewed in 2015–2016 and who consented to be re-interviewed 23 . Of the 20,594 eligible for the re-interview, the survey re-interviewed 4567 boys and 12,251 girls (married and unmarried). After excluding the respondents who gave an inconsistent response to age and education at the follow-up survey (3%), the final follow-up sample covered 4428 boys and 11,864 girls with the follow-up rate of 74% for boys and 81% for girls. The effective sample size for the present study was 4421 unmarried adolescent boys aged 10–19 years in wave-1 and wave-2. Additionally, 7587 unmarried adolescent girls aged 10–19 years were interviewed in wave-1 and wave-2 23 . The cases whose follow-up was lost were excluded from the sample to strongly balance the dataset and set it for longitudinal analysis using xtset command in STATA 15. The survey questionnaire is available at https://dataverse.harvard.edu/file.xhtml?fileId=4163718&version=2.0 & https://dataverse.harvard.edu/file.xhtml?fileId=4163720&version=2.0 .

Outcome variable

HIV awareness was the outcome variable for this study, which is dichotomous. The question was asked to the adolescents ‘Have you heard of HIV/AIDS?’ The response was recorded as yes and no.

Exposure variables

The predictors for this study were selected based on previous literature. These were age (10–19 years at wave 1, continuous variable), schooling (continuous), any mass media exposure (no and yes), paid work in the last 12 months (no and yes), internet use (no and yes), wealth index (poorest, poorer, middle, richer, and richest), religion (Hindu and Non-Hindu), caste (Scheduled Caste/Scheduled Tribe, Other Backward Class, and others), place of residence (urban and rural), and states (Uttar Pradesh and Bihar).

Exposure to mass media (how often they read newspapers, listened to the radio, and watched television; responses on the frequencies were: almost every day, at least once a week, at least once a month, rarely or not at all; adolescents were considered to have any exposure to mass media if they had exposure to any of these sources and as having no exposure if they responded with ‘not at all’ for all three sources of media) 24 . Household wealth index based on ownership of selected durable goods and amenities with possible scores ranging from 0 to 57; households were then divided into quintiles, with the first quintile representing households of the poorest wealth status and the fifth quintile representing households with the wealthiest status 25 .

Statistical analysis

Descriptive analysis was done to observe the characteristics of unmarried adolescent boys and girls at wave-1 (2015–2016). In addition, the changes in certain selected variables were observed from wave-1 (2015–2016) to wave-2 (2018–2019), and the significance was tested using t-test and proportion test 26 , 27 . Moreover, random effect regression analysis 28 , 29 was used to estimate the association of change in HIV awareness among unmarried adolescents with household factors and individual factors. The random effect model has a specific benefit for the present paper's analysis: its ability to estimate the effect of any variable that does not vary within clusters, which holds for household variables, e.g., wealth status, which is assumed to be constant for wave-1 and wave-2 30 .

Table 1 represents the socio-economic profile of adolescent boys and girls. The estimates are from the baseline dataset, and it was assumed that none of the household characteristics changed over time among adolescent boys and girls.

Figure  1 represents the change in HIV awareness among adolescent boys and girls. The percentage of adolescent boys who had awareness regarding HIV increased from 38.6% in wave-1 to 59.9% in wave-2. Among adolescent girls, the percentage increased from 30.2% in wave-1 to 39.1% in wave-2.

The percenate of HIV awareness among adolescent boys and girls, wave-1 (2015–2016) and wave-2 (2018–2019).

Table 2 represents the summary statistics for explanatory variables used in the analysis of UDAYA wave-1 and wave-2. The exposure to mass media is almost universal for adolescent boys, while for adolescent girls, it increases to 93% in wave-2 from 89.8% in wave-1. About 35.3% of adolescent boys were engaged in paid work during wave-1, whereas in wave-II, the share dropped to 33.5%, while in the case of adolescent girls, the estimates are almost unchanged. In wave-1, about 27.8% of adolescent boys were using the internet, while in wave-2, there is a steep increase of nearly 46.2%. Similarly, in adolescent girls, the use of the internet increased from 7.6% in wave-1 to 39.3% in wave-2.

Table 3 represents the estimates from random effects for awareness of HIV among adolescent boys and girls. It was found that with the increases in age and years of schooling the HIV awareness increased among adolescent boys ([Coef: 0.05; p  < 0.01] and [Coef: 0.04; p  < 0.01]) and girls ([Coef: 0.03; p  < 0.01] and [Coef: 0.04; p  < 0.01]), respectively. The adolescent boys [Coef: 0.06; p  < 0.05] and girls [Coef: 0.03; p  < 0.05] who had any mass media exposure were more likely to have an awareness of HIV in comparison to those who had no exposure to mass media. Adolescent boys' paid work status was inversely associated with HIV awareness about adolescent boys who did not do paid work [Coef: − 0.01; p  < 0.10]. Use of the internet among adolescent boys [Coef: 0.18; p  < 0.01] and girls [Coef: 0.14; p  < 0.01] was positively associated with HIV awareness in reference to their counterparts.

The awareness regarding HIV increases with the increase in household wealth index among both adolescent boys and girls. The adolescent girls from the non-Hindu household had a lower likelihood to be aware of HIV in reference to adolescent girls from Hindu households [Coef: − 0.09; p  < 0.01]. Adolescent girls from non-SC/ST households had a higher likelihood of being aware of HIV in reference to adolescent girls from other caste households [Coef: 0.04; p  < 0.01]. Adolescent boys [Coef: − 0.03; p  < 0.01] and girls [Coef: − 0.09; p  < 0.01] from a rural place of residence had a lower likelihood to be aware about HIV in reference to those from the urban place of residence. Adolescent boys [Coef: 0.04; p  < 0.01] and girls [Coef: 0.02; p  < 0.01] from Bihar had a higher likelihood to be aware about HIV in reference to those from Uttar Pradesh.

This is the first study of its kind to address awareness of HIV among adolescents utilizing longitudinal data in two indian states. Our study demonstrated that the awareness of HIV has increased over the period; however, it was more prominent among adolescent boys than in adolescent girls. Overall, the knowledge on HIV was relatively low, even during wave-II. Almost three-fifths (59.9%) of the boys and two-fifths (39.1%) of the girls were aware of HIV. The prevalence of awareness on HIV among adolescents in this study was lower than almost all of the community-based studies conducted in India 10 , 11 , 22 . A study conducted in slums in Delhi has found almost similar prevalence (40% compared to 39.1% during wave-II in this study) of awareness of HIV among adolescent girls 31 . The difference in prevalence could be attributed to the difference in methodology, study population, and study area.

The study found that the awareness of HIV among adolescent boys has increased from 38.6 percent in wave-I to 59.9 percent in wave-II; similarly, only 30.2 percent of the girls had an awareness of HIV during wave-I, which had increased to 39.1 percent. Several previous studies corroborated the finding and noticed a higher prevalence of awareness on HIV among adolescent boys than in adolescent girls 16 , 32 , 33 , 34 . However, a study conducted in a different setting noticed a higher awareness among girls than in boys 35 . Also, a study in the Indian context failed to notice any statistical differences in HIV knowledge between boys and girls 18 . Gender seems to be one of the significant determinants of comprehensive knowledge of HIV among adolescents. There is a wide gap in educational attainment among male and female adolescents, which could be attributed to lower awareness of HIV among girls in this study. Higher peer victimization among adolescent boys could be another reason for higher awareness of HIV among them 36 . Also, cultural double standards placed on males and females that encourage males to discuss HIV/AIDS and related sexual matters more openly and discourage or even restrict females from discussing sexual-related issues could be another pertinent factor of higher awareness among male adolescents 33 . Behavioural interventions among girls could be an effective way to improving knowledge HIV related information, as seen in previous study 37 . Furthermore, strengthening school-community accountability for girls' education would augment school retention among girls and deliver HIV awareness to girls 38 .

Similar to other studies 2 , 10 , 17 , 18 , 39 , 40 , 41 , age was another significant determinant observed in this study. Increasing age could be attributed to higher education which could explain better awareness with increasing age. As in other studies 18 , 39 , 41 , 42 , 43 , 44 , 45 , 46 , education was noted as a significant driver of awareness of HIV among adolescents in this study. Higher education might be associated with increased probability of mass media and internet exposure leading to higher awareness of HIV among adolescents. A study noted that school is one of the important factors in raising the awareness of HIV among adolescents, which could be linked to higher awareness among those with higher education 47 , 48 . Also, schooling provides adolescents an opportunity to improve their social capital, leading to increased awareness of HIV.

Following previous studies 18 , 40 , 46 , the current study also outlines a higher awareness among urban adolescents than their rural counterparts. One plausible reason for lower awareness among adolescents in rural areas could be limited access to HIV prevention information 16 . Moreover, rural–urban differences in awareness of HIV could also be due to differences in schooling, exposure to mass media, and wealth 44 , 45 . The household's wealth status was also noted as a significant predictor of awareness of HIV among adolescents. Corroborating with previous findings 16 , 33 , 42 , 49 , this study reported a higher awareness among adolescents from richer households than their counterparts from poor households. This could be because wealthier families can afford mass-media items like televisions and radios for their children, which, in turn, improves awareness of HIV among adolescents 33 .

Exposure to mass media and internet access were also significant predictors of higher awareness of HIV among adolescents. This finding agrees with several previous research, and almost all the research found a positive relationship between mass-media exposure and awareness of HIV among adolescents 10 . Mass media addresses such topics more openly and in a way that could attract adolescents’ attention is the plausible reason for higher awareness of HIV among those having access to mass media and the internet 33 . Improving mass media and internet usage, specifically among rural and uneducated masses, would bring required changes. Integrating sexual education into school curricula would be an important means of imparting awareness on HIV among adolescents; however, this is debatable as to which standard to include the required sexual education in the Indian schooling system. Glick (2009) thinks that the syllabus on sexual education might be included during secondary schooling 44 . Another study in the Indian context confirms the need for sex education for adolescents 50 , 51 .

Limitations and strengths of the study

The study has several limitations. At first, the awareness of HIV was measured with one question only. Given that no study has examined awareness of HIV among adolescents using longitudinal data, this limitation is not a concern. Second, the study findings cannot be generalized to the whole Indian population as the study was conducted in only two states of India. However, the two states selected in this study (Uttar Pradesh and Bihar) constitute almost one-fourth of India’s total population. Thirdly, the estimates were provided separately for boys and girls and could not be presented combined. However, the data is designed to provide estimates separately for girls and boys. The data had information on unmarried boys and girls and married girls; however, data did not collect information on married boys. Fourthly, the study estimates might have been affected by the recall bias. Since HIV is a sensitive topic, the possibility of respondents modifying their responses could not be ruled out. Hawthorne effect, respondents, modifying aspect of their behaviour in response, has a role to play in HIV related study 52 . Despite several limitations, the study has specific strengths too. This is the first study examining awareness of HIV among adolescent boys and girls utilizing longitudinal data. The study was conducted with a large sample size as several previous studies were conducted in a community setting with a minimal sample size 10 , 12 , 18 , 20 , 53 .

The study noted a higher awareness among adolescent boys than in adolescent girls. Specific predictors of high awareness were also noted in the study, including; higher age, higher education, exposure to mass media, internet use, household wealth, and urban residence. Based on the study findings, this study has specific suggestions to improve awareness of HIV among adolescents. There is a need to intensify efforts in ensuring that information regarding HIV should reach vulnerable sub-groups as outlined in this study. It is important to mobilize the available resources to target the less educated and poor adolescents, focusing on rural adolescents. Investment in education will help, but it would be a long-term solution; therefore, public information campaigns could be more useful in the short term.

WHO. HIV/AIDS . https://www.who.int/news-room/fact-sheets/detail/hiv-aids (2020).

Singh, A. & Jain, S. Awareness of HIV/AIDS among school adolescents in Banaskantha district of Gujarat. Health Popul.: Perspect. Issues 32 , 59–65 (2009).

Google Scholar  

WHO & UNICEF. adolescents Health: The Missing Population in Universal Health Coverage . 1–31 https://www.google.com/search?q=adolescents+population+WHO+report&rlz=1C1CHBF_enIN904IN904&oq=adolescents+population+WHO+report&aqs=chrome..69i57.7888j1j7&sourceid=chrome&ie=UTF-8 (2018).

Chauhan, S. & Arokiasamy, P. India’s demographic dividend: state-wise perspective. J. Soc. Econ. Dev. 20 , 1–23 (2018).

Tiwari, A. K., Singh, B. P. & Patel, V. Population projection of India: an application of dynamic demographic projection model. JCR 7 , 547–555 (2020).

Troop-Gordon, W. Peer victimization in adolescence: the nature, progression, and consequences of being bullied within a developmental context. J. Adolesc. 55 , 116–128 (2017).

PubMed   Google Scholar  

Dermody, S. S., Friedman, M., Chisolm, D. J., Burton, C. M. & Marshal, M. P. Elevated risky sexual behaviors among sexual minority girls: indirect risk pathways through peer victimization and heavy drinking. J. Interpers. Violence 35 , 2236–2253 (2020).

Lee, R. L. T., Loke, A. Y., Hung, T. T. M. & Sobel, H. A systematic review on identifying risk factors associated with early sexual debut and coerced sex among adolescents and young people in communities. J. Clin. Nurs. 27 , 478–501 (2018).

Gurram, S. & Bollampalli, B. A study on awareness of human immunodeficiency virus among adolescent girls in urban and rural field practice areas of Osmania Medical College, Hyderabad, Telangana, India. (2020).

Jain, R., Anand, P., Dhyani, A. & Bansal, D. Knowledge and awareness regarding menstruation and HIV/AIDS among schoolgoing adolescent girls. J. Fam. Med. Prim Care 6 , 47–51 (2017).

Kawale, S., Sharma, V., Thaware, P. & Mohankar, A. A study to assess awareness about HIV/AIDS among rural population of central India. Int. J. Commun. Med. Public Health 5 , 373–376 (2017).

Lal, P., Nath, A., Badhan, S. & Ingle, G. K. A study of awareness about HIV/AIDS among senior secondary school Children of Delhi. Indian J. Commun. Med. 33 , 190–192 (2008).

CAS   Google Scholar  

Bago, J.-L. & Lompo, M. L. Exploring the linkage between exposure to mass media and HIV awareness among adolescents in Uganda. Sex. Reprod. Healthcare 21 , 1–8 (2019).

McCombie, S., Hornik, R. C. & Anarfi, J. K. Effects of a mass media campaign to prevent AIDS among young people in Ghana . Public Health Commun. 163–178 (Routledge, 2002). https://doi.org/10.4324/9781410603029-17 .

Sano, Y. et al. Exploring the linkage between exposure to mass media and HIV testing among married women and men in Ghana. AIDS Care 28 , 684–688 (2016).

Oginni, A. B., Adebajo, S. B. & Ahonsi, B. A. Trends and determinants of comprehensive knowledge of HIV among adolescents and young adults in Nigeria: 2003–2013. Afr. J. Reprod. Health 21 , 26–34 (2017).

Rahman, M. M., Kabir, M. & Shahidullah, M. Adolescent knowledge and awareness about AIDS/HIV and factors affecting them in Bangladesh. J. Ayub. Med. Coll. Abbottabad 21 , 3–6 (2009).

Yadav, S. B., Makwana, N. R., Vadera, B. N., Dhaduk, K. M. & Gandha, K. M. Awareness of HIV/AIDS among rural youth in India: a community based cross-sectional study. J. Infect. Dev. Countries 5 , 711–716 (2011).

Alhasawi, A. et al. Assessing HIV/AIDS knowledge, awareness, and attitudes among senior high school students in Kuwait. MPP 28 , 470–476 (2019).

Chakrovarty, A. et al. A study of awareness on HIV/AIDS among higher secondary school students in Central Kolkata. Indian J. Commun. Med. 32 , 228 (2007).

Katoch, D. K. S. & Kumar, A. HIV/AIDS awareness among students of tribal and non-tribal area of Himachal Pradesh. J. Educ. 5 , 1–9 (2017).

Shinde, M., Trivedi, A., Shinde, A. & Mishra, S. A study of awareness regarding HIV/AIDS among secondary school students. Int. J. Commun. Med. Public Health https://doi.org/10.18203/2394-6040.ijcmph20161611 (2016).

Article   Google Scholar  

Council, P. UDAYA, adolescent survey, Bihar and Uttar Pradesh, 2015–16. Harvard Dataverse https://doi.org/10.7910/DVN/RRXQNT (2018).

Kumar, P. & Dhillon, P. Household- and community-level determinants of low-risk Caesarean deliveries among women in India. J. Biosoc. Sci. 53 , 55–70 (2021).

Patel, S. K., Santhya, K. G. & Haberland, N. What shapes gender attitudes among adolescent girls and boys? Evidence from the UDAYA Longitudinal Study in India. PLoS ONE 16 , e0248766 (2021).

CAS   PubMed   PubMed Central   Google Scholar  

Fan, C., Wang, L. & Wei, L. Comparing two tests for two rates. Am. Stat. 71 , 275–281 (2017).

MathSciNet   Google Scholar  

Kim, T. K. T test as a parametric statistic. Korean J. Anesthesiol. 68 , 540–546 (2015).

PubMed   PubMed Central   Google Scholar  

Bell, A., Fairbrother, M. & Jones, K. Fixed and random effects models: making an informed choice. Qual. Quant. 53 , 1051–1074 (2019).

Jarrett, R., Farewell, V. & Herzberg, A. Random effects models for complex designs. Stat. Methods Med. Res. 29 , 3695–3706 (2020).

MathSciNet   CAS   PubMed   PubMed Central   Google Scholar  

Neuhaus, J. M. & Kalbfleisch, J. D. Between- and within-cluster covariate effects in the analysis of clustered data. Biometrics 54 , 638–645 (1998).

CAS   PubMed   MATH   Google Scholar  

Kaur, G. Factors influencing HIV awareness amongst adolescent women: a study of slums in Delhi. Demogr. India 47 , 100–111 (2018).

Alene, G. D., Wheeler, J. G. & Grosskurth, H. Adolescent reproductive health and awareness of HIV among rural high school students, North Western Ethiopia. AIDS Care 16 , 57–68 (2004).

CAS   PubMed   Google Scholar  

Oljira, L., Berhane, Y. & Worku, A. Assessment of comprehensive HIV/AIDS knowledge level among in-school adolescents in eastern Ethiopia. J. Int. AIDS Soc. 16 , 17349 (2013).

Samkange-Zeeb, F. N., Spallek, L. & Zeeb, H. Awareness and knowledge of sexually transmitted diseases (STDs) among school-going adolescents in Europe: a systematic review of published literature. BMC Public Health 11 , 727 (2011).

Laguna, E. P. Knowledge of HIV/AIDS and unsafe sex practices among Filipino youth. in 15 (PAA, 2004).

Teitelman, A. M. et al. Partner violence, power, and gender differences in South African adolescents’ HIV/sexually transmitted infections risk behaviors. Health Psychol. 35 , 751–760 (2016).

Oberth, G. et al. Effectiveness of the Sista2Sista programme in improving HIV and other sexual and reproductive health outcomes among vulnerable adolescent girls and young women in Zimbabwe. Afr. J. AIDS Res. 20 , 158–164 (2021).

DeSoto, J. et al. Using school-based early warning systems as a social and behavioral approach for HIV prevention among adolescent girls. Preventing HIV Among Young People in Southern and Eastern Africa 280 (2020).

Ochako, R., Ulwodi, D., Njagi, P., Kimetu, S. & Onyango, A. Trends and determinants of Comprehensive HIV and AIDS knowledge among urban young women in Kenya. AIDS Res. Ther. 8 , 11 (2011).

Peltzer, K. & Supa, P. HIV/AIDS knowledge and sexual behavior among junior secondary school students in South Africa. J. Soc. Sci. 1 , 1–8 (2005).

Shweta, C., Mundkur, S. & Chaitanya, V. Knowledge and beliefs about HIV/AIDS among adolescents. WebMed Cent. 2 , 1–9 (2011).

Anwar, M., Sulaiman, S. A. S., Ahmadi, K. & Khan, T. M. Awareness of school students on sexually transmitted infections (STIs) and their sexual behavior: a cross-sectional study conducted in Pulau Pinang, Malaysia. BMC Public Health 10 , 47 (2010).

Cicciò, L. & Sera, D. Assessing the knowledge and behavior towards HIV/AIDS among youth in Northern Uganda: a cross-sectional survey. Giornale Italiano di Medicina Tropicale 15 , 29–34 (2010).

Glick, P., Randriamamonjy, J. & Sahn, D. E. Determinants of HIV knowledge and condom use among women in madagascar: an analysis using matched household and community data. Afr. Dev. Rev. 21 , 147–179 (2009).

Rahman, M. Determinants of knowledge and awareness about AIDS: Urban-rural differentials in Bangladesh. JPHE 1 , 014–021 (2009).

Siziya, S., Muula, A. S. & Rudatsikira, E. HIV and AIDS-related knowledge among women in Iraq. BMC. Res. Notes 1 , 123 (2008).

Gao, X. et al. Effectiveness of school-based education on HIV/AIDS knowledge, attitude, and behavior among secondary school students in Wuhan, China. PLoS ONE 7 , e44881 (2012).

ADS   CAS   PubMed   PubMed Central   Google Scholar  

Kotecha, P. V. et al. Reproductive health awareness among urban school going adolescents in Vadodara city. Indian J. Psychiatry 54 , 344–348 (2012).

Dimbuene, T. Z. & Defo, K. B. Fostering accurate HIV/AIDS knowledge among unmarried youths in Cameroon: do family environment and peers matter?. BMC Public Health 11 , 348 (2011).

Kumar, R. et al. Knowledge attitude and perception of sex education among school going adolescents in Ambala District, Haryana, India: a cross-sectional study. J. Clin. Diagn. Res. 11 , LC01–LC04 (2017).

ADS   PubMed   PubMed Central   Google Scholar  

Tripathi, N. & Sekher, T. V. Youth in India ready for sex education? Emerging evidence from national surveys. PLoS ONE 8 , e71584 (2013).

Rosenberg, M. et al. Evidence for sample selection effect and Hawthorne effect in behavioural HIV prevention trial among young women in a rural South African community. BMJ Open 8 , e019167 (2018).

Gupta, P., Anjum, F., Bhardwaj, P., Srivastav, J. & Zaidi, Z. H. Knowledge about HIV/AIDS among secondary school students. N. Am. J. Med. Sci. 5 , 119–123 (2013).

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This paper was written using data collected as part of Population Council’s UDAYA study, which is funded by the Bill and Melinda Gates Foundation and the David and Lucile Packard Foundation. No additional funds were received for the preparation of the paper.

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Conception and design of the study: S.S. and P.K.; analysis and/or interpretation of data: P.K. and S.S.; drafting the manuscript: S.C., and R.P.; reading and approving the manuscript: S.S., P.K., S.C. and R.P.

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Reimagining the Future of HIV Service Implementation in the Philippines Based on Lessons from COVID-19

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• Published: 25 May 2020
• Volume 24 , pages 3003–3005, ( 2020 )

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• Amiel Nazer C. Bermudez 1 , 3 &
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The Philippines has been characterized as having one of the fastest growing HIV epidemics in the world, following from the rapid and continued rise in new diagnoses since 2007 [ 1 ]. Community-based organizations (CBOs) play an important role in the Philippine government’s efforts to mitigate the HIV epidemic. Confronted with multiple challenges imposed by the COVID-19 epidemic, HIV-focused CBOs have implemented new practices to ensure continuous provision of treatment, care, and support services for persons living with HIV (PLHIV). In light of the country’s nascent and evolving HIV policies, newly developed strategies in the delivery of HIV services can provide a blueprint for reimagining HIV program implementation in the Philippines, both during and beyond the COVID-19 crisis.

Adaptations in HIV Service Delivery Due to COVID-19

The COVID-19 epidemic emerged in the Philippines during a crucial time in the country’s response to the HIV epidemic. National capacity to test, treat, and prevent further infections was initially challenged by limitations in healthcare infrastructure, human resources to provide HIV-related services, and lack of local HIV research to guide country-specific policies [ 2 ]. The government passed the updated Philippine HIV and AIDS Policy Act (Republic Act 11166) in 2019, committing to a multi-sectoral approach to ensure access to prevention and testing programs as well as investment in treatment, care, and support services for persons living with HIV [ 3 ]. However, unforeseen challenges emerging in the context of the COVID-19 epidemic reveal areas for considering long-term strategies to HIV service delivery by Philippines-based CBOs in future crisis conditions.

The implementation of community quarantine measures due to COVID-19 in most parts of the Philippines has restricted transportation services to individuals performing essential functions. As such, CBO staff and volunteers who perform HIV screening, counseling, and referrals must work remotely, thereby restricting the number of clients they can serve. This limited capacity for HIV screening, and pre- and post-test counselling provided by CBOs can lead to delays in HIV diagnosis and further delays in the initiation of treatment. In response to the need for providing ongoing support during the COVID-19 crisis, some CBOs have designated “skeletal workforces” comprising a subset of core staff/volunteers who continue to deliver basic services to PLHIV and members of high-risk groups, even during the most acute phases of community quarantine implementation and physical distancing measures. For example, skeletal workforces can ensure that PLHIV receive critical counseling and treatment referrals, and can provide community-based HIV screening (e.g. using rapid HIV test kits) and linkage to confirmatory testing. Designation of skeletal workforces at HIV-focused CBOs will be an adaptive strategy beyond the COVID-19 crisis, in order to assure provision of basic HIV services during future emergency conditions that compromise CBOs’ full organizational capacities.

Face-to-face consultations between PLHIV and providers have decreased or ceased due to travel restrictions and physical distancing advisories. These changes have serious consequences for PLHIV who must address health problems on their own or with minimal support, without the benefit of expert advice. Some CBOs have responded to this challenge by creating and maintaining online platforms, and adapting telemedicine for clinical consultations and counseling. However, an arising concern relates to confidentiality of patient information, especially if data privacy safeguards are not observed. In addition, access to telemedicine platforms is premised on quality access to telecommunication services (e.g. decent internet connection, mobile phone data). Thus, economically-disadvantaged PLHIV and those in rural locations may have limited access to these technologies. These emerging issues must be addressed by Philippines-based CBOs if telemedicine or remote counseling strategies are used in future service delivery.

Travel restrictions and physical distancing measures in the Philippines have also disrupted the supply and distribution chain for essential ARV drugs, which may decrease adherence to treatment. The Philippine Department of Health (DOH) has recommended that ART treatment centers and primary HIV facilities adopt innovative and assertive medication delivery strategies to ensure access to treatment, while also minimizing risk for patient and staff exposure to COVID-19 [ 4 ]. In response, CBOs have started delivering ART medications to PLHIV at designated drop-off points. These “courier” services are initiated through online requests submitted by PLHIV, which detail the location and preferred time/date of delivery. This service has been aided by the development of mobile applications that include a map of ARV medication distribution points. However, access to these technologies may be limited for economically and technologically disadvantaged PLHIV. In addition, access to drop-off points remains challenging in geographic settings outside of main metropolitan areas such as Metro Manila and Metro Cebu. The topography of the Philippines complicates the scalability of this innovative medication delivery strategy (e.g., due to the country’s mountainous terrain, archipelago dispersion, and limited roads system in rural settings). Sustainability of “courier” services beyond the COVID-19 crisis depends on CBOs’ human, financial, and material resources to provide app-based medication delivery. Given the unclear duration of the COVID-19 crisis and the possible diversion of donor support from CBOs to health care facilities treating COVID-19 patients, CBOs may not be able to sustainably finance these initiatives.

A Reimagined Blueprint for the Provision of HIV Treatment, Care and Support Services

Despite challenges in the provision of HIV treatment, care, and support services arising from the COVID-19 epidemic in the Philippines, CBOs have found ways to continue provision of life-sustaining services. Although these innovative approaches have risen out of epidemic necessity, they are worth considering as key components in the future of the Philippines’ HIV policy implementation.

First, online service delivery (e.g., counseling, treatment referrals) should be a viable and acceptable option for HIV-service organizations, both during and beyond the COVID-19 crisis. Expanding ways by which PLHIV can access these services can help unburden the health system by prioritizing facility-based service delivery to more urgent cases. However, these online platforms should be configured in such a way that data privacy is protected. In addition, CBOs and healthcare settings must provide appropriate training, supervision, and support to staff and providers whose roles might shift to telemedicine.

Second, innovative strategies to improve the supply chain of ART medications to PLHIV can arise from the COVID-19 crisis. The DOH can consider designating district-level health facilities as ART treatment hubs, in order to more equitably reach PLHIV outside of the country’s major metropolitan settings. The adoption of app-based ART delivery and courier services by CBOs is an innovative practice holding promise for further scalability. Further investment and development of public–private partnerships between the government, technology companies, and private courier services are needed to sustain this service.

Third, the DOH should reconsider its policy specifying that PLHIV can only avail their supply of ARV drugs from a designated treatment hub. This requirement is limiting in both COVID-19 and post-COVID-19 contexts, exemplified by recent travel restrictions that have stranded PLHIV in areas far from their designated treatment hub. Recent DOH guidelines in response to the COVID-19 crisis have relaxed this rule, by stipulating that PLHIV affected by the community quarantine can obtain their ART medications from other treatment facilities [ 4 ]. Retention of this policy can minimize patients’ barriers to ARV medications attributed to their location and geography. Moreover, multi-month ARV drug prescriptions can minimize the need for repeated travel to treatment hubs.

In summary, the COVID-19 crisis provides an opportunity to consider key gaps and weaknesses in HIV service delivery in the Philippines. It is instructive to reflect on innovative practices adopted by CBOs in the context of the COVID-19 crisis that have been made to ensure the continued provision of treatment, care, and support services for PLHIV. Although the immediate, acute challenges imposed by the COVID-19 crisis might abate with time, there will likely emerge other epidemiological, natural, or human-made crises that restrict healthcare and CBO capacities to provide life-sustaining HIV services. The Philippines must not be caught unprepared for dealing with these eventualities, and must reimagine and invest in more innovative, assertive, and sustainable HIV service delivery strategies.

Joint United Nations Programme on HIV/AIDS. UNAIDS Report on the Global AIDS Pandemic. 2012. https://www.unaids.org/sites/default/files/media_asset/20121120_UNAIDS_Global_Report_2012_with_annexes_en_1.pdf .

World Health Organization. External review of the national health sector response to HIV and sexually transmitted infections 2013: Republic of the Philippines. Geneva: World Health Organization. 2015. https://iris.wpro.who.int/bitstream/handle/10665.1/11217/9789290617068_eng.pdf .

Congress of the Philippines. Republic Act No. 11166. 2018. https://www.officialgazette.gov.ph/2018/12/20/republic-act-no-11166/ .

Department of Health (Philippines). 2020. Advisory: Access to Antiretroviral (ARV) Drugs of People Living with HIB (PLHIV) Amidst Enhanced Community Quarantine. Philippines.

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Acknowledgements

Authors were supported by grants from NIH Fogarty International Center (D43TW000237) and NIAID (P30AI042853). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. We wish to convey our appreciation to the following community-based organizations who provide treatment, care, and support services for persons living with HIV in the Philippines: The Red Whistle, LoveYourself, Inc., Pinoy Plus Advocacy Pilipinas Inc., Positive Action Foundation Philippines, Inc. (PAFPI), MapBeks, and Sustained Health Initiative of the Philippines (SHIP).

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Quilantang, M.I.N., Bermudez, A.N.C. & Operario, D. Reimagining the Future of HIV Service Implementation in the Philippines Based on Lessons from COVID-19. AIDS Behav 24 , 3003–3005 (2020). https://doi.org/10.1007/s10461-020-02934-x

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HIV in the Philippines: A Persisting Public Health Crisis Closely Tied To Social Stigma

By Emily Mrakovcic

Illustration by Ella Olea

Introduction

Human immunodeficiency virus, also known as HIV, is present in several regions around the world. Although the virus has the same transmission mechanisms and symptoms regardless of its locality, HIV is experienced very differently across the globe.¹ This is due to several cultural and social factors impacting how HIV is viewed and treated. The Philippines is one country where the way individuals view HIV heavily impacts its transmission and treatment. 2 Due to stigma and discrimination surrounding HIV, the Philippines is currently experiencing the fastest-growing HIV epidemic in the Western Pacific. 3   Specifically, stigma and discrimination against men who have sex with men (MSM) and HIV-positive MSM have significantly boosted the proliferation of the virus. 4 MSM with HIV in the Philippines face an intersection of stigma: on the one hand they experience stigma toward their sexual orientation, and on the other hand, they experience stigma toward their HIV status. 4   Because of the stigma MSM encounter, they face several barriers to HIV prevention, testing and treatment. 5 Approximately 70 percent of HIV cases in the Philippines are among MSM, 3 yet over three-quarters of MSM in the Philippines have never obtained an HIV test. 2   Not only do MSM feel discouraged from seeking care, but healthcare facilities are failing to provide adequate services for this at-risk population. 4  Understanding the social determinants of HIV transmission in the Philippines is needed to provide insight as to why MSM are disproportionately infected with the virus. 

In a country where discrimination is still legal in some contexts, and only 73 percent of Filipinos say society should accept homosexuality, 6  discrimination against MSM is not uncommon. Homosexuality is legal, but LGBTQ+ individuals cannot adopt children, conversion therapy is not banned, and gay marriage is not recognized. 6 Overall, Philippine views of homosexuality reflect an attitude that is tolerant, but not accepting, of LGBTQ+ individuals. This view often results in discrimination within workplaces and social circles. 3 Attitudes toward HIV-positive individuals are also stigmatized, as HIV infection is often equated to sin and immorality. 5 Strong roots in Catholicism coupled with poor HIV education are some of the main drivers of both HIV and sexual orientation-related stigma. 4  Together, this array of stigma and discrimination solidify as barriers to HIV testing and treatment within the health care system. 

Individuals with HIV have viral loads, which are measurements of the amount of virus present inside the body. 7 A high viral load indicates a large amount of HIV in the blood. When an individual has a high viral load, they are very contagious. Conversely, when an individual has a low viral load, they have a low amount of HIV in their blood and are unlikely to transmit the virus. 8 In the Philippines, where treatment services such as antiretroviral therapy (ART) are not sufficiently provided and made accessible, a failure to treat is also a failure to prevent. When treatment services do not successfully suppress the viral loads of affected populations, not only do infected individuals become sicker, but they also have the potential to spread the virus. 7

The research question I will address in this paper is: How do stigma and discrimination toward MSM in the Philippines impact their access to prevention, testing, and treatment services for HIV? Through this question, two general ideas can be explored through peer-reviewed literature. Firstly, the question will explore how the desire of MSM to seek prevention, testing, and treatment is affected by experiences of stigma and discrimination in multiple capacities. The question will also explore how discrimination within healthcare facilities, in addition to the failure of healthcare facilities to accommodate for discrimination experienced outside of the healthcare setting, contributes to the lack of appropriate HIV care for MSM. 

When conducting a literature search, I used the PubMed and Embase search engines. Through these search engines, I accessed peer-reviewed articles from the Multidisciplinary Digital Publishing Institute, National Library of Medicine, Guilford Journals, BMC Public Health, and Taylor & Francis Online. Keywords I used to search for material were “HIV/AIDS,” “HIV,” “MSM” and “the Philippines.” Generally, I looked for articles published in the last five years to capture the most recent updates on the epidemic.

HIV Infection Incidence Among MSM

For the past two decades, the Philippines’ HIV epidemic has been driven by sexual transmission among MSM. 9 However, the incidence of HIV infection among MSM was not extensively evaluated until a study titled “HIV incidence among men who have sex with men (MSM) in Metro Manila, the Philippines: A prospective cohort study 2014-2018” was conducted by Rossana Ditangco and Mary Lorraine Mationg. The purpose of this study was to determine the incidence of HIV infection and its associated risk factors among MSM in Metro Manila, the largest metropolitan area in the Philippines. By understanding the epidemiology of the outbreak, Ditangco and Mationg hoped to assist in the formulation of relevant biomedical and socio-behavioral interventions. Participants were 18 or older, Metro Manila residents, and confirmed HIV-negative. All participants had anal or oral sex in the past 12 months. The researchers administered in-person questionnaire interviews and HIV tests every 3 months to all 708 participants. Data was collected on participant knowledge, attitudes, and practices regarding HIV and AIDS. During the follow-up period, 56 new cases were recorded, resulting in an incidence rate of 2.7 cases per 100 patient years. 9 The study found that having two or more sexual partners and having anal sex without a condom in the past 3 months were factors significantly associated with HIV infection. 9  High incidence was also recorded among the 18-24 year age range; 9 Ditangco and Mationg hypothesized that this may reflect the sexually active nature of young MSM. Overall, there was a high HIV incidence rate among Filipino MSM. 9  The findings from this study highlight the need for effective HIV prevention, surveillance, and treatment strategies. Additionally, based on these findings, younger MSM aged 18-24 should be a focus of interventions. Although this study provides limited insight into the stigma and discrimination faced by MSM, baseline effects of certain risk factors, such as sexual activity and condom use, were established. Understanding HIV incidence among this key population provides a strong epidemiological foundation to build upon with social and cultural context.

Drivers and Experiences of Stigma and Discrimination

At a time of explosive HIV transmission in the Philippines, there was little understanding of MSM experiences with HIV-related stigma. 10 In 2017, a study titled “‘An Evil Lurking Behind You’: Drivers, Experiences, and Consequences of HIV-Related Stigma Among Men Who Have Sex With Men With HIV in Manila, Philippines” was conducted by Alexander C. Adia et al. to understand MSM experiences with HIV-related stigma and how these experiences subsequently influence their behaviors and qualities of life. The study consisted of 21-hour-long interviews of both MSM living with HIV and community-based organization workers. Participants resided in Manila and were required to be able to communicate in English. The interviews were designed to capture specific patterns of stigma that MSM living with HIV experienced and internalized. Stigma resulting in mental health issues, delays in HIV testing, and avoidance of health services were the main points qualitatively measured during the interviews. The study found that a majority of MSM participants were affected by an intersection of HIV-related stigma and sexual orientation-related stigma. 10 These stigmas were often rooted in ideas of morality, dirtiness, and sin. 10  Participant #4 reported difficulty seeking treatment due to peers blaming them for their diagnosis and labeling them as promiscuous, and a sex addict, because of their serostatus and sexual orientation. Participant #16 mentioned that, due to being HIV-positive, they were ostracized from communities they were formerly a part of. Additionally, several participants expressed signs of internalized stigma, stating that they deserved to get HIV as a consequence of their wrongdoings, such as identifying as gay. 10 Overall, the study identified three main ways that stigma serves as a barrier to HIV treatment: detering MSM from seeking treatment despite its availability, creating attitudes that reduce the urgency to take HIV medication, and impeding disclosure of HIV status, thus resulting in HIV-positive MSM not promptly receiving the treatment they need. 10  The study concluded that public health strategies must be developed to address discrimination at both societal and individual levels to reduce stigma-related harms.

Law and policy are powerful tools capable of improving the lives of people facing discrimination due to a diagnosis. Attempting within the law to reform existing structural inequalities may have a positive impact on societal attitudes toward HIV-positive individuals. 11 However, before this study, there was minimal research on the role legal protections in the Philippines play in improving the well-being of people living with HIV (PLHIV). 11 In 2019, Alexander C. Adia et al. conducted a study titled “Sword and Shield: Perceptions of law in empowering and protecting HIV-positive men who have sex with men in Manila, Philippines” that aimed to examine how MSM living with HIV perceive HIV-related legal protections, and how these protections subsequently influence their lives. Currently, the Philippines has a law, Republic Act 11166, that contains several anti-discrimination provisions. 11 The study conducted one hour-long semi-structured interviews with 21 participants to gauge how MSM living with HIV experience the impacts of Republic Act 11166. The participants were HIV-positive MSM living in Metro Manila, aged 18 years and above, and able to communicate in English. The study identified two overarching feelings experienced by participants as a result of the law: empowerment and protection. 11 Participants reported that the law helped them feel normal in social settings they previously felt disconnected from. 11 Additionally, participants derived empowerment from the law because it displayed government commitment to deterring discrimination. 11 The law also allowed for more positive and beneficial discussions regarding HIV to occur among MSM living with HIV. 11  However, the interviews also highlighted some participant concerns, such as the efficacy of the aforementioned legal protections. They worried that companies and local governments may only treat the law as a suggestion. 11 Additionally, concerns were raised about the law lacking the authority to counter social discrimination in the workplace or social circles. 11  Overall, however, the findings show that Republic Act 11166 has alleviated internalized stigma and feelings of powerlessness among MSM in the study. The necessity of legal justice and human rights advocacy in HIV treatment highlights the role stigma plays in shaping the HIV epidemic in the Philippines.

Although HIV is mainly transmitted through MSM, HIV testing uptake among this demographic remains low. 12 This is mainly due to poor coordination of care within the Philippines’ health care system. 12 A study conducted by Jan W. de Lind van Wijngaarden et al., titled “‘I am not promiscuous enough!’: Exploring the low uptake of HIV testing by gay men and other men who have sex with men in Metro Manila, Philippines,” aims to explain why a significant proportion of Metro Manila-based MSM lacked access to HIV testing and treatment services. The goal of collecting this data was to reform health services to be more accessible, effective, efficient, equitable, and MSM-friendly. 12  48 MSM from Metro Manila were recruited by their level of engagement with the HIV care cascade. The HIV care cascade consists of four levels: diagnosis, linkage to care, receipt of care, and retention of care. 12 Case series interviews were designed to explore barriers to the uptake of HIV services. The study found that the main reasons to postpone treatment were higher socioeconomic class, feelings of moral superiority to other gay-identifying men, lack of proximity to the testing facility, fear of what will happen once infected, fear of stigma pertaining to serostatus or sexual orientation, fear of ART side effects, and fear of high health care expenses. 12 Misconceptions regarding HIV and ART were also observed. Some participants believed that feeling physically fit meant that they could not be sick. 12 Additionally, if a potential sexual partner appeared healthy, participants reported feeling less inclined to use a condom. Social stigma excludes HIV from health education conversations, thus contributing to the aforementioned misconceptions. However, other concerns expressed by participants were not misconceptions, but striking realities. Participants feared loss of support from friends or family upon receiving an HIV diagnosis. 12 Additionally, fear of discrimination often translated into concerns regarding testing confidentiality, 12 which was of the utmost importance to most participants. The data overall shows that most participants did not see a need to get tested, despite significant risk. Even participants who acknowledged their high-risk status did not feel compelled to get tested. 12 A major determining factor in this choice was fear of what would happen upon testing positive. 12  Potential solutions outlined by the researchers were increasing testing locations, hiring non-medical outreach workers to enhance service delivery, and providing cost-free knowledge of HIV to help tackle commonly held misconceptions. All of these solutions aim to bridge existing gaps within the current healthcare system, thus enhancing the transition from one level of the HIV care cascade to the next.  

The HIV Health Care System

Healthcare providers are essential to curbing any epidemic, and the way providers structure their delivery of care can have lasting effects on the healthcare system as a whole. The purpose of Arjee J. Restar’s study, “Prioritizing HIV Services for Transgender Women and Men Who Have Sex With Men in Manila, Philippines: An Opportunity for HIV Provider Interactions,” was to examine healthcare provider attitudes, perceived competencies, and abilities to prioritize the provision of HIV-related services to MSM. One-on-one qualitative interviews examined factors that may have impacted HIV prevention and treatment services for MSM. 15 HIV providers residing in Manila were interviewed. All providers were over the age of 18 and had a history of serving MSM. Restar et al. found that a majority of providers had overall positive attitudes toward all patients in their practices. Most providers valued equality for all of their patients but reported that despite their willingness to provide care to MSM, their actual competencies to provide context-specific care were not up to par. 13  This lack of competency was often due to one of three main reasons: not knowing the health needs of MSM, having little training with HIV, or having difficulty being sensitive to patient gender and sexual orientation. 13 Some providers expressed interest in learning more about LGTBQ+ individuals in their practices but lacked knowledge of the lived experiences of these patients. 13 Additionally, some providers reported that their facilities did not offer training specifically tailored to providing HIV services to MSM. 13  The study conveys an overall lack of preparedness among many providers regarding delivering MSM and HIV-specific care. The findings of this study also indicate the importance of not just patient-focused interventions, but provider-focused interventions as well. Healthcare providers require cultural competence to deliver HIV-sensitive services. This study indicates the need for a shift to more specific interventions tailored to meet the needs of key populations. 

The HIV care cascade, designed to examine the engagement of PLHIV with medical care, previously lacked sufficient data on non-heterosexual populations, despite MSM being disproportionately affected by the epidemic. 14 A study conducted by Marisse Nepomuceno et al., titled “A descriptive retrospective study on HIV care cascade in a tertiary hospital in the Philippines,” sought to describe the HIV care cascade at the tertiary level in a hospital-affiliated HIV clinic after the adoption of the test-and-treat strategy. The test-and-treat strategy screens patients for HIV infection and provides treatment soon after a positive test result, thus bridging the gap between testing and treatment. 14 A descriptive, retrospective cohort study was conducted. Researchers reviewed the medical records of patients enrolled at the University of the Philippines’ Philippine General Hospital in Manila. Demographic and clinical data relevant to each stage of the HIV care cascade were collected in order to understand the linkage to care, ART initiation, retention in care, and virologic suppression. 584 participants were included; all were receiving treatment from the Philippine General Hospital and were aged 18 or older. Ninety one percent were male, and 55.6 percent contracted HIV from male-male sex. 14 Ninety-nine point five percent of patients were linked to care following diagnosis, 95 percent of patients initiated ART, 78.8 percent of patients were retained in care and maintained ART, 47.9 percent of patients had their HIV viral load tested in follow-up, and 45.5 percent of patients achieved viral suppression. 14 Additionally, of the 99.5 percent of patients who were linked to care, 10 percent of these patients were linked to care more than 12 months following their diagnosis. 14  This is especially concerning with HIV, as failure to achieve viral suppression allows for further transmission. Overall, this study captured the substantial loss of patients throughout the HIV care cascade. The study concluded that many gaps are remaining in the cascade. Nepomuceno et al. suggested the use of outreach programs and telemedicine to enhance adherence to ART and viral load testing. Traditional medical facilities may lack the capacity to fulfill all medical needs of MSM living with HIV, but these needs can still be met if some responsibility for care is shifted to informal care settings, such as community-based programs.

The Intersection of Health Care and Stigma

Structural, social, and behavioral factors all impact HIV service uptake among MSM. 15 Understanding these factors is critical when developing culturally competent care models. A study conducted by Arjee J. Restar et al., “Differences in HIV risk and healthcare engagement factors in Filipinx transgender women and cisgender men who have sex with men who reported being HIV negative, HIV positive or HIV unknown,” aimed to understand HIV risk and health care engagement among at-risk individuals. An online cross-sectional survey examined the structural, social, and behavioral factors impacting HIV service uptake among cisgender MSM. The survey assessed factors typically associated with HIV status, such as demographics, social marginalization, HIV risk, healthcare engagement, and substance abuse. 15 The study found that the most prominent barriers to healthcare engagement were discrimination by healthcare workers, clinic wait time, inconvenient location, and concerns about disclosing HIV status. 15  Roughly a third of participants reported sexual orientation, gender identity, or a lack of anti-LGBT discrimination policies as reasons for avoidance of HIV services. 15 The study also found that only 16 percent of cis-MSM participants had ever received an HIV test and knew of their HIV status. 15 Concurrently, MSM are more likely to engage in HIV-risk behaviors including drug and alcohol use, condomless sex, and sex work. 15  Restar et al. suggest harm reduction services, testing outreach, and community partner involvement to increase MSM engagement with HIV services. These solutions, both inside and outside the healthcare setting, acknowledge the social determinants responsible for MSM behaviors that increase their risk of HIV and decrease their odds of healthcare engagement. 

Testing rates among MSM, especially young MSM, remain low despite high rates of transmission. 16 The main model of HIV testing, facility-based testing, has proven to be unsuccessful in providing sufficient means of testing to MSM. 16 HIV self-testing (HIVST) is an alternative strategy to address this gap in testing. HIVST allows individuals to conduct their own rapid diagnostic tests and maintain result confidentiality. 16 So far, HIVST has successfully increased testing in other Asian countries, including China, Hong Kong, and Vietnam. 16 Jesal Gohil et al. conducted a study titled “Is the Philippines ready for HIV self-testing?” to measure perceived acceptability, feasibility, and challenges of HIVST among key informants and target users. Semi-structured interviews qualitatively assessed potential barriers, opportunities, and challenges regarding HIVST policy and regulation. Focus group discussions took place with 42 target users and 15 individuals involved with the provision of HIV testing programs. All participants resided in Metro Manila. The study found that MSM were receptive to HIVST due to its elements of convenience and privacy. 16 Linkage to HIV care following a positive test result was a point of concern for participants, but they also worried about stigma-related barriers they would face within the health care system upon initiation of care. 16 The study also found that pharmacies and community-based facilities, not traditional medical facilities, were popular choices for picking up tests. 16  Based on these findings, the study concluded that one of the largest problems associated with HIVST is not MSM willingness, but HIV-related stigma within the health care system. While HIVST allows individuals to take responsibility for their testing, they still lack control over what they will experience within the healthcare system following a positive diagnosis.

A key principle to treating HIV, U=U, asserts that if HIV is undetected, it is also untransmittable. 17 If an HIV-positive individual adheres to their ART regimen, then their viral load will remain low enough to prevent transmission. 17 This idea highlights the importance of viewing treatment as prevention. Thus, supporting adherence to ART is crucial to managing HIV. Cara O’Connor et al. conducted a study titled “Risk factors affecting adherence to antiretroviral therapy among HIV patients in Manila, Philippines: a baseline cross-sectional analysis of the Philippines Connect for Life Study” to measure treatment adherence and to identify whether ART adherence requires additional interventions to increase its effectiveness. Such an analysis would provide the groundwork for adherence interventions specifically tailored to MSM. A cross-sectional analysis was conducted using a framework that gathered information on HIV-related risk behaviors and adherence to ART. To guide data collection, questions were framed around demographics, clinical characteristics, HIV knowledge, risk behaviors, and adherence or lack thereof. 17 All 426 participants were HIV-positive and attending a clinic in Metro Manila that was a part of the Connect for Life Cohort Study. All participants were required to speak English and have a mobile phone. The study found that 100 percent adherence in the last 30 days was only achieved by 52.1 percent of participants. 17 Longer time on treatment, inconsistent condom use, and injection drug use were all associated with reduced adherence. 17 The most common reasons for missing medication were being too busy, forgetting, falling asleep, being away from home, or having a change in their daily routine. 17 Additionally, 44 percent of patients who skipped a pill at some point did so because they did not want to be seen taking their medication. 17 On the other hand, being in a relationship with an HIV-negative partner was associated with increased adherence. 17  These findings indicate a similarity between HIV-risk behaviors and nonadherence behaviors. The data also indicates a positive association between HIV knowledge and ART adherence. The data collected from this study underscores the need for interventions addressing treatment fatigue and social stigma. Interventions may accomplish this through the implementation of social support and harm reduction programs centered specifically around the struggles of MSM. 

Pre-exposure prophylaxis (PrEP) is the primary prevention mechanism for HIV. 18 To be effective, the pill must be taken once a day. Although PrEP has proven to be extremely successful in preventing HIV transmission, the uptake of HIV prevention services among MSM in the Philippines remains low. 18 Awareness and interest in PrEP are key determinants of successful uptake, but current levels of these feelings among MSM were unknown 18 until a study was conducted by Arjee Restar et al., titled “Characterizing Awareness of Pre-Exposure Prophylaxis for HIV Prevention in Manila and Cebu, Philippines: Web-Based Survey of Filipino Cisgender Men Who Have Sex With Men.” The purpose of this study was to examine levels of PrEP awareness and interest among cisgender MSM in the Philippines. The results of this study have the potential to guide the future rollout of PrEP programs. A quantitative web-based survey was designed to examine the relationship between PrEP awareness/interest and factors such as socioeconomic status, healthcare experiences, and access to HIV services. The study found overall high levels of awareness and interest in taking PrEP. While only 56.4 percent of participants had high HIV knowledge, 74.9 percent of participants were aware of PrEP, and 88.8 percent of participants were interested in taking the medication. 18 PrEP knowledge was more common than a high level of HIV knowledge. 18 The most frequently recorded reasons for lack of interest in PrEP were needing to know more information first and not liking medication in the form of pills. 18 Factors associated with greater odds of PrEP awareness were a college education or higher, having had an HIV test in the past, high HIV knowledge, and having discussed PrEP among friends. 18 Factors associated with lower odds of PrEP awareness were being straight-identified, experiencing health care discrimination due to sexual identity, and avoiding HIV services due to cost, sexual identity, or a lack of LGBT anti-discrimination policies. 18 Restar et al. concluded that there is a growing demand for PrEP in the Philippines. However, those who were less aware of PrEP either came from poorer, less educated backgrounds or encountered barriers in the HIV health care system. 18  To increase the likelihood of successful PrEP interventions, future actions must be taken to provide HIV education and reduce discrimination within the healthcare system.

Discussion 

Limitations: Assessment of the studies reveals some flaws among study designs and collected data. All of the studies were based in urban areas, primarily Manila. The lack of regard for rural areas may result in conclusions not entirely representative of all MSM in the Philippines. HIV knowledge and risk behaviors may vary among urban and rural areas depending on what resources and funding are available. Additionally, legal protections of Republic Act 11166 may be weaker in regions with less government oversight. Another weakness of some studies was that participation requirements potentially favored the participation of individuals from a higher socioeconomic class. Having to speak English or possess a phone may deter some individuals from partaking in the study, thus failing to assess the entirety of the target population. Bias could have also occurred in the studies that used self-reporting surveys and questionnaires, as participants may have misremembered information or been untruthful to avoid judgment. A final critique of many of these studies is a lack of specific, thorough solutions. After conducting extensive analyses of the HIV epidemic in the Philippines, many of the studies provided only brief and general descriptions of potential interventions.

Strengths: A significant strength of the research in this field is the high volume of qualitative studies conducted. When examining stigma and discrimination, no statistic can accurately capture the unique experiences of MSM pertaining to their serostatus and sexual orientation. The use of interviews and informal questioning provides a space for participants to openly share their experiences without being confined to black-and-white, yes-or-no questions. Additionally, the interviewing of healthcare providers by Restar et al. provided an alternative perspective that was beneficial to comprehensively understanding the HIV healthcare system.

The HIV epidemic among MSM in the Philippines continues to be a pressing public health issue, despite the growing body of research working to understand HIV in this specific context and provide potential solutions. Overall, the studies addressed in this synthesis had similar findings, thus reinforcing the idea that MSM in the Philippines receive inadequate HIV health care due to stigma and discrimination surrounding serostatus and sexual identity. I believe the studies in this synthesis provide sufficient, relevant data and evidence that adequately answer my research question. Stigma and discrimination are encountered by MSM among family, friends, peers, coworkers, and health providers alike. 11 All of these experiences of discrimination summate into trends of hesitancy to seek HIV health care, including but not limited to PrEP, 18  facility-based HIV testing, HIVST, ART, and follow-up viral load testing. 14 Additionally, just as MSM experience discrimination that deters them from seeking treatment, there are also factors within the health care system limiting MSM engagement with HIV services. Inadequate skills and knowledge of providers, 13 insufficient anti-discrimination policies, 18 and gaps of continuity within the HIV care cascade 14 are all shortcomings of the HIV health care system that serve as barriers to care for MSM. Stigma and discrimination may result in avoidance of testing, avoidance of treatment, nonadherence to treatment, or a lack of knowledge of available preventative and treatment services. 10 Additionally, several misconceptions resulting from HIV stigma further contribute to the aforementioned behaviors. 12  

Context-specific and community-based interventions that put patient-centeredness, convenience, and confidentiality at the forefront of their work have the potential to successfully reach a larger scale of MSM who are in need of preventative, testing, and treatment services. Future directions should incorporate these elements of care into both traditional medical facilities and outpatient clinics, community-based organizations, and educational programs. Stigma and discrimination toward these individuals are deeply rooted within Filipino culture, thus requiring solutions that are dispersed among a variety of support outlets accessible to MSM. Restructuring views toward MSM and PLHIV within both society and the health care system are critical for enacting meaningful change. Future research efforts may benefit from using already collected data to propel implementation-focused studies that aim to craft interventions specifically centered around both at-risk MSM and HIV-positive MSM.

• Aids I of M (US) C on a NS for. International Aspects of AIDS and HIV Infection . National Academies Press (US); 1986. https://www.ncbi.nlm.nih.gov/books/NBK219140/
• Sison OT, Baja ES, Bermudez ANC, et al. Association of anticipated HIV testing stigma and provider mistrust on preference for HIV self-testing among cisgender men who have sex with men in the Philippines. BMC Public Health . 2022;22(1). doi: https://doi.org/10.1186/s12889-022-14834-x
• Gangcuangco LMA, Eustaquio PC. The State of the HIV Epidemic in the Philippines: Progress and Challenges in 2023. Tropical Medicine and Infectious Disease . 2023;8(5):258. doi: https://doi.org/10.3390/tropicalmed8050258
• Bustamante J, Plankey MW. Identifying Barriers to HIV Testing Among Men Who Have Sex with Men (MSM) in the Philippines. Georgetown Medical Review . Published online July 18, 2022. doi: https://doi.org/10.52504/001c.36967
• Alibudbud R. The Philippine HIV crisis and the COVID-19 pandemic: A worsening crisis. Public Health . Published online September 2021. doi: https://doi.org/10.1016/j.puhe.2021.09.008
• Equaldex. LGBT Rights in Philippines | Equaldex. Equaldex.com. Published June 19, 2018. https://www.equaldex.com/region/philippines
• What Does HIV Viral Load Tell You? WebMD. https://www.webmd.com/hiv-aids/hiv-viral-load-what-you-need-to-know
• Centers for Disease Control and Prevention. HIV Basics. CDC. Published 2019. https://www.cdc.gov/hiv/basics/index.html
• Ditangco R, Mationg ML. HIV incidence among men who have sex with men (MSM) in Metro Manila, the Philippines: A prospective cohort study 2014–2018. Medicine . 2022;101(35):e30057. doi: https://doi.org/10.1097/MD.0000000000030057
• Adia AC, Bermudez ANC, Callahan MW, Hernandez LI, Imperial RH, Operario D. “An Evil Lurking Behind You”: Drivers, Experiences, and Consequences of HIV–Related Stigma Among Men Who Have Sex With Men With HIV in Manila, Philippines. AIDS Education and Prevention . 2018;30(4):322-334. doi: https://doi.org/10.1521/aeap.2018.30.4.322
• Adia AC, Restar AJ, Lee CJ, et al. Sword and Shield: Perceptions of law in empowering and protecting HIV-positive men who have sex with men in Manila, Philippines. Global Public Health . 2019;15(1):52-63. doi: https://doi.org/10.1080/17441692.2019.1622762
• de Lind van Wijngaarden JW, Ching AD, Settle E, van Griensven F, Cruz RC, Newman PA. “I am not promiscuous enough!”: Exploring the low uptake of HIV testing by gay men and other men who have sex with men in Metro Manila, Philippines. Melendez-Torres GJ, ed. PLOS ONE . 2018;13(7):e0200256. doi: https://doi.org/10.1371/journal.pone.0200256
• Restar AJ, Chan RCH, Adia A, et al. Prioritizing HIV Services for Transgender Women and Men Who Have Sex With Men in Manila, Philippines. Journal of the Association of Nurses in AIDS Care . 2019;31(4):1. doi: https://doi.org/10.1097/jnc.0000000000000131
• Nepomuceno M, Abad CL, Salvaña EM. A descriptive retrospective study on HIV care cascade in a tertiary hospital in the Philippines. Santella AJ, ed. PLOS ONE . 2023;18(1):e0281104. doi: https://doi.org/10.1371/journal.pone.0281104
• Restar AJ, Jin H, Ogunbajo A, et al. Differences in HIV risk and healthcare engagement factors in Filipinx transgender women and cisgender men who have sex with men who reported being HIV negative, HIV positive or HIV unknown. Journal of the International AIDS Society . 2020;23(8). doi: https://doi.org/10.1002/jia2.25582
• Gohil J, Baja ES, Sy TR, et al. Is the Philippines ready for HIV self-testing? BMC Public Health . 2020;20(1). doi: https://doi.org/10.1186/s12889-019-8063-8
• O’Connor C, Leyritana K, Calica K, et al. Risk factors affecting adherence to antiretroviral therapy among HIV patients in Manila, Philippines: a baseline cross-sectional analysis of the Philippines Connect for Life Study. Sexual Health . 2021;18(1):95. doi: https://doi.org/10.1071/sh20028
• Restar A, Surace A, Adia A, et al. Characterizing Awareness of Pre-Exposure Prophylaxis for HIV Prevention in Manila and Cebu, Philippines: Web-Based Survey of Filipino Cisgender Men Who Have Sex With Men. Journal of Medical Internet Research . 2022;24(1):e24126. doi: https://doi.org/10.2196/24126

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Introduction.

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A model HIV/AIDS risk reduction programme in the Philippines: a comprehensive community-based approach through participatory action research

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Donald E. Morisky, Alfonso Ang, Astou Coly, Teodora V. Tiglao, A model HIV/AIDS risk reduction programme in the Philippines: a comprehensive community-based approach through participatory action research, Health Promotion International , Volume 19, Issue 1, March 2004, Pages 69–76, https://doi.org/10.1093/heapro/dah109

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A 3-year, longitudinal, quasi-experimental study using participatory action research (PAR) was conducted to determine the feasibility and efficiency of an expanded sexually transmitted infection (STI) HIV/AIDS prevention program among diverse high-risk male heterosexual populations in the southern Philippines. A total of 3389 participants (∼200 males from each of 18 study groups) were recruited, and 221 were trained as peer counselors to develop educational materials and reinforce safe sexual practices among their peers. Condom usage (36.10% to 38.70% to 46.31%), attitudes towards condoms (21.67% to 24.55% to 25.15%) and knowledge about HIV/STI transmission (41.87% to 42.19% to 33.31%) increased significantly from baseline to post-test and 6-month follow up, respectively ( p < 0.01). Furthermore, the reported STI incidence decreased significantly (7.4% to 4.6% to 2.4%, respectively). Changes differed significantly between the intervention and control group at post-test and follow up ( p < 0.01). These findings illustrate the appropriateness of using PAR methodology in promoting and sustaining positive behavior change.

Of the estimated 40 million persons who are currently infected with HIV worldwide, 7.1 million live in South and South-East Asia. In 2001, the epidemic claimed the lives of 435 000 persons in this region ( UNAIDS/WHO, 2001 ). Low HIV prevalence in this area still results in high numbers of infections as this region includes highly populated countries such as China, India and Indonesia. It is therefore important to implement health promotion and disease prevention programs to avert epidemics in countries where HIV prevalence is still low. One such country is the Philippines.

In the Philippines, infection rates in general, even among the high-risk groups, have remained at low levels (<1%) ( UNAIDS/WHO, 2000 ). The National HIV Sentinel Surveillance System (NHSSS) was implemented in two major cities, beginning in 1993 and expanded to 10 cities by 1996 throughout the entire archipelago ( Department of Public Health, 2001 ). Behavioral sentinel surveillance was added to NHSSS in 1997 to monitor trends in knowledge and behaviors of vulnerable groups (injecting drug users, registered and freelance female sex workers, and men having sex with men).

A participatory research process

This paper reports the results of an innovative community-based participatory research program in the Philippines targeting the heterosexual male clients of commercial sex workers (CSW). Clients of CSW constitute a significant risk group that may benefit from educational and behavioral interventions to improve HIV knowledge, attitudes and practices concerning HIV and sexually transmitted infection (STI). Such efforts are crucial to avert an HIV epidemic in the Philippines. The present study sought to achieve those goals using a participatory action research (PAR) approach. PAR is defined as ‘systematic inquiry, with the collaboration of those affected by the issue, for the purposes of education or effecting social change’ ( George et al ., 1999 ). The PAR approach is characterized by six major criteria: (i) it is participatory; (ii) it is cooperative; (iii) it is a co-learning process; (iv) it involves systems development and local capacity building; (v) it is an empowering process for participants; and (vi) it achieves a balance between research and action ( Israel et al ., 1998 ). One of the main characteristics of PAR is that it eliminates the traditional distinction between the ‘researchers’ and the ‘researched’ ( Gaventa, 1981 ). Both HIV/AIDS researchers and community-based organizations are partners and responsible for the conceptualization, needs analysis, development, implementation and evaluation of the program. As a result of this process, community participants are empowered with the realization of their own capabilities to be researchers and to induce desired changes within their communities ( Hagey, 1997 ). This method seems particularly suitable when one is conducting research on controversial or sensitive issues such as HIV/AIDS.

Most educational efforts in the early phase of the HIV/AIDS pandemic have been concentrated on the high-risk groups, particularly CSW, men having sex with men, and intravenous drug users. In the same light, the first project launched jointly by the School of Public Health, University of California Los Angeles, and the College of Public Health, University of the Philippines, entitled ‘Behavioral Science in Support of HIV/AIDS Prevention’, also focused on CSW and managers/owners of the entertainment establishments utilizing an organizational change behavioral approach, including educational policy in the establishment ( Tiglao et al ., 1996 ; Morisky et al ., 1998 ). Results of this programmatic effort indicated significant improvements in condom use behaviors and reduction of STI among female bar workers ( Morisky et al ., 2002a ; Morisky et al ., 2002b ; Morisky et al ., 2002c ). However, in order to have a comprehensive program in the community, the customers of the CSW need to be included as well.

It is clear that men still dominate women's sexual behavior. It is recognized that men are generally more sexually active, have more sexual intercourse than the general female population, have more sexual partners, and generally take risks to maintain their machismo image to the extent that they refuse to practice safe sex. In short, they have a major role in the transmission of STI and HIV/AIDS. As a result of this, the second phase of the research was entitled ‘Comprehensive Community Based STI/HIV/AIDS Prevention Project’, which focused on the high-risk male client populations. Very few studies have assessed multiple intervention programs targeting a diverse male population using a variety of health education/promotion strategies and a PAR component.

Study population

The research was conducted in six study areas in the southern Philippines, namely: Lapu-Lapu and Mandaue City in Metropolitan Cebu; Legaspi and Daraga in the Bicol Region; and Cagayan de Oro City in Mindanao and Cavite City in the southern Tagalog Region. The six male population study groups were: (i) the military (air force); (ii) police and firemen; (iii) industrial workers; (iv) taxicab drivers; (v) pedicab drivers; and (vi) community ( barangay ) residents.

A comprehensive community-based approach using a crossover study design was employed in the study. Baseline assessments were obtained with respect to HIV/AIDS knowledge, attitudes toward condoms, and condom use behavior in a 3-year longitudinal study. The six study groups were compared with post-intervention surveys (conducted 12 months following the training session) and follow-up surveys to evaluate the effectiveness of the intervention.

Table 1 displays the longitudinal crossover research design, with phase I and phase II of the intervention. All study groups were assessed at baseline (months 1–3), phase 1 interventions in study groups 1 and 3 (months 4–15), post-test assessment for all study groups (months 16–18), phase 2 interventions for study groups 2 and 4 (months 19–30), and finally follow-up assessment for all study groups (months 31–33). This design enabled all six study groups to participate in the intervention/training program, as well as allowing for the assessment of both short- and long-term impact of outcome indicators.

Research design

O 1 , O 2 and O 3 represent the baseline, post-test and follow-up assessment, respectively.

X 1 and X 2 represent the peer education intervention.

Social preparation and the participatory process

Prior to the initiation of the intervention phase of the project, which in a way also served as a form of intervention, the collaboration of the City Health personnel, the Mayors and other city officials was sought in each of the six targeted sites. Executive officers, managers, military commanders and supervisors of each of the target populations were likewise oriented on the magnitude of the STI/HIV/AIDS problem and the importance of male involvement in the prevention of STI/HIV/AIDS. Each of these groups were invited to serve on local advisory committees

Sample size of target groups

The entire population of males in each targeted site was invited to participate in the study following informed consent procedures. Most of the time, this amounted to ∼200 individuals from each of the study populations. Study groups included one entire squadron of air force personnel, the packing and bottling division of industrial factory workers, the entire adult male population (18–45 years) from the community ( barangay ) located near the commercial sex establishment, and the total population of taxi and pedicab drivers from four sites. These study groups are representative of the entire population of males in each of the targeted sites. For the air force personnel, one squadron was randomly selected out of a total of four squadrons. Preliminary analysis revealed that this squadron is similar in demographic characteristics to the other remaining squadrons not selected in the study site, and presented no selection bias. Participation rate in each of the selected sites was high, ranging from 99% to 100%. A total of 3389 males participated in the 3-year longitudinal study.

An interview schedule to measure knowledge, attitudes and practices related to STI/HIV/AIDS was used, including a 20-item, five-point scale which included questions on perceived level of knowledge, HIV/STI/AIDS transmission and risk of getting AIDS (α reliability = 0.81). Attitude towards condoms was measured by a seven-item, five-point scale (α reliability = 0.86). Participants were also asked a series of questions (yes/no) pertaining to condom use, STI incidence, discussion of AIDS with co-workers, attendance of AIDS prevention classes, and whether they received AIDS educational materials.

Gaining access to the community: presentation of baseline results

The coordinators of each of the six intervention sites arranged for presentation of baseline results to the entire group of participants. This included an overview of the problem of HIV/AIDS in Asia as well as the Philippines. Data were presented on cognitive indicators (knowledge, beliefs and attitudes) as well as behavioral determinants (condom use, multiple-sex partners and STI infection). Following this presentation of baseline information, speakers from the academe, the Department of Health and non-governmental organizations (NGOs) provided information on different types of STI with an emphasis on HIV/AIDS and its modes of transmission, and various methods of STI prevention, underscoring the importance of practicing safe sex (condom use), followed by demonstrations and role playing on the proper use of condoms. Slides and video presentations ensured lively discussion among participants.

Before the seminars ended, 10–20 peer counselors from each target group were recruited either by unanimous choice of the group, volunteering, or recommendation by their supervisors. Peer counselors attended a 1-day workshop, which included: a review of the technical aspects of STI/HIV/AIDS transmission and control; discussion of some of the myths about STI/HIV/AIDS and clarification of issues; skill-building teaching methods and strategies; counseling techniques; how to prepare Information, Education and Communication (IEC) materials; and how to use flip charts on HIV/AIDS. The flip chart was provided for each peer counselor during the training program. All peer counselors engaged in role plays simulating peer counseling activities. Resource speakers from the City Health Department Social Hygiene Clinic, NGOs, other government sectors (education and social welfare), and at times private clinician specialists on STIs were used as resource persons during the training.

Following this training session, peer counselors were expected: to educate at least 10 of their peers on STI/HIV/AIDS prevention; to meet with the site coordinator regularly to report the progress of their work; to conceptualize and develop IEC materials on STI/HIV/AIDS, including posters, stickers and photonovellas; and to distribute IEC materials on STI/HIV/AIDS to their co-workers. The photonovelas developed can be viewed online ( Morisky, 2002c ).

Peer counselors meet with the site coordinator every week for ∼1 h to go over the baseline data (at the aggregate level) specific to their own organization. Counselors review frequencies, request cross tabulations of different variables (such as how are attitudes towards condom use related to condom use behavior), and begin to construct a diagnostic assessment of the educational and counseling needs of their fellow co-workers. This process continued for ∼2 months, at which time educational responses to the identified needs were to be developed, including posters, fliers, brochures, stickers and photonovellas, or picture story presentations of common situations and events. One of the major activities of the peer educator was the conceptualization and development of the photonovella and posters and stickers. This proved a very productive process, evolving over several brain-storming sessions. Important diagnostic findings were conceptualized into story boards and scripts. As peer counselors clarified the facts and what went through the process, they unconsciously internalized the concept of STI/HIV/AIDS prevention. This was the most important component of the participatory research process in which the participants themselves developed and produced the educational responses to the diagnostic findings from the baseline needs assessment. Each study group produced their own photonovella, posed for pictures and translated the original English versions into the local dialect ( Morisky, 2002c ). The finished product was distributed to their peers. The posters were displayed in strategic places and the stickers placed in taxis and pedicabs.

Throughout the intervention, peer counselors and researchers identified and discussed specific problems arising at their sites. This strategy of identifying community needs and problems, highlighting the strategies used to engage in successfully influencing community development, has proven to be an effective modality in effecting change within the community ( Wadsworth, 1998 ).

Demographics

The socio-demographic characteristics of the participants and their peer counselors obtained at baseline were not significantly different. The mean age of the participants was 34.7 years. Sixty-seven percent were married, and had worked in their jobs for an average of 10 years. The mean educational level of the participants was 10.7 years of schooling.

Knowledge, attitudes and beliefs surrounding HIV/AIDS

Knowledge about HIV/STI transmission increased significantly from baseline to post-test and 6-month follow up in the intervention group (see Table 2 ). The control group's knowledge about HIV/STI was not significantly different from the intervention group at baseline and remained constant at post-test and follow up.

Comparison of knowledge and attitudes between the intervention and control group in the study

p < 0.01.

Similarly, there was no significant difference in attitude towards condoms at baseline between the intervention and control group; however, at post-test and follow up there were significant differences in condom use attitude between the intervention and the control group, with scores significantly increasing for the intervention group.

Reported STIs and condom use

The number of respondents who had ‘ever used condoms’ increased significantly among participants in the intervention group (38.7% to 46.3%) but not in the control group (33.79% to 38.72%) during the post-test and the follow-up period (see Table 3 ). Furthermore, there was a significant difference in the responses between peer counselors and regular participants at post-test ( t = 2.5, p < 0.01) and follow up ( t = 2.6, p < 0.009). Among respondents in the intervention group who had sex with CSW, the condom usage ‘during the last time’ they had sex also increased significantly from post-test to follow up for peer counselors (13.36% to 18.65%), but condom usage remained unchanged for the control group (11.08% to 11.81%). Peer counselors reported a significantly higher condom usage ‘during the last time’ they had sex compared with regular participants in the study in the post-test ( t = 2.2, p < 0.02) and follow-up period ( t = 2.60, p < 0.009).

Comparison of condom use practice and STI infections between the intervention ( n = 1819) and control groups ( n = 1570) in the study

p < 0.05.

After the intervention, there was a decrease in the number of participants who reported having an STI episode. Self-reported STI incidence decreased among participants from 4.6% to 2.4% versus 6.9% to 5.8% for the control group. There was a significant difference in the reported STI incidence between regular participants and peer counselors at post-test ( t = 2.59, p < 0.009) and follow up ( t = 2.71, p < 0.008).

A more detailed analysis of condom use behavior revealed that in the high-risk population (barangay residents), condom usage with CSW was not significant at post-test, but increased significantly at follow up (from 29% to 55%). Additionally, we found that among those who declared that they did not have sexual intercourse, condom use with CSW increased significantly for the industrial factory workers (18% to 30%) and for the taxi drivers (17% to 21%) from post-test to follow-up. Among tricycle drivers and military personnel, however, condom use increased at post-test, but the level of condom use at follow up was below that observed at baseline. And in the police/fireman group, condom usage decreased at both post-test and follow up ( Table 4 ).

Condom use behavior: sexual intercourse with CSWs

Monitoring community participation, peer influence and policy change

In order to monitor community participation, individuals were asked whether they had ever discussed HIV/STI prevention with their co-workers, and whether they had ever attended an AIDS prevention workshop or seminar. Participants were also asked whether they ever received educational materials on AIDS/STI prevention from their employers.

The number of respondents who had ‘ever discussed HIV/AIDS with their co-workers’ increased significantly in the intervention group (51.9% to 54.9%), but not in the control group during the post-test and the follow-up period ( Table 3 ). Furthermore, there was a significant difference in the responses between peer counselors and regular participants during the post-test ( t = 3.52, p < 0.001) and follow-up periods ( t = 4.81, p < 0.001). The participation in HIV/STI prevention workshops increased significantly from post-test to follow up among participants in the intervention group (22.0% to 32.0%), but not in the control group (6.2% to 5.8%). Peer counselors reported a significantly higher participation in HIV/STI prevention workshops compared with the other participants in the study during the post-test ( t = 2.8, p < 0.003) and the follow-up periods ( t = 2.7, p < 0.008).

The number of respondents who received educational materials on HIV/STI prevention from their employers increased significantly from post-test to follow up in the intervention group (88.0% to 90.4%), but not in the control group (70.2% to 72.4%). There was a significant difference between regular participants and peer counselors who received the educational materials during the post-test ( t = 2.6, p < 0.007) and the follow-up period ( t = 2.9, p < 0.001).

The theoretical benefits of using a participatory peer education approach are well discussed in the literature. However, little information on the application and efficacy of community-based participation research methods in actual projects has been reported ( Higgins and Metzler, 2001 ). This study reports the results of a PAR intervention program. It stresses the impact of the intervention on risk reduction and includes a comparison of the incremental difference the intervention had for peer counselors compared with the regular participants. The theoretical concept behind peer education is relative simple. People with the same cultural background, experience and lifestyles are more effective teachers within that group compared with outsiders. Since peer counselors are selected within the group, they share the same concerns and have similar values and norms to the rest of the community that they work within. Peer counselors also have more access to influence the group, provide a more credible and trusted source of information, and can constantly reinforce safe sexual practices in a culturally sensitive manner, thereby enhancing the educational learning process.

The reported condom usage increased significantly after the intervention, and along with this, the reported STI incidence also decreased significantly. The key factors for the success of the intervention included the fact that the peer counselors were able to understand important issues within the target group and develop educational materials that were culturally sensitive and easily understood by other participants in the study. The intervention overcame barriers of discussing sensitive issues like HIV, STI and condoms because the peer counselors were carefully selected, and were considered influential leaders among the different groups. The peer counselors were instrumental in developing culturally appropriate photonovellas that depict HIV/STI prevention in the form of a pictorial narrative illustrating different scenarios that can be easily understood, assimilated and accepted by the other participants in the group.

A more detailed analysis was also made of condom use behavior with CSW for the different types of client-centered populations (i.e. high-risk barangay residents, factory workers, taxi drivers, tricycle drivers, police/firemen and military). The results indicate that the intervention effect is not always apparent at post-test, but becomes meaningfully significant at follow up. For example, for the high-risk population ( barangay residents), condom usage with CSW was not significant at post-test, but increased significantly at follow up (from 29% to 55% condom usage, respectively). This result suggests a delay in the impact of the educational strategy that was not observed at post-test, but as other factors intervened over time (peer support, social influence, organizational policy) the behavior change became evident ( Green, 1977 ). However, since the findings also indicate that the intervention did not have the desired effect on condom use in some target groups, the results of the intervention may be considered somewhat mixed.

In order to be effective, peer education needs to be maintained over a long period of time. Other studies on peer education have reported that without continuing motivation and maintenance, momentum is diminished ( Hayman et al ., 1996 ). When support for the program decreased, knowledge and reported condom use declined but still remained at the pre-intervention levels. Follow-up evaluation for at least 6 months beyond the post-test has to be conducted to correctly assess the maintenance of the behavioral changes as a result of the intervention. In this study, if condom use had been assessed only at post-test, only minor changes would have been identified.

Monitoring participation and peer influence during the course of the intervention is important. In this research, discussion about HIV/AIDS among co-workers was assessed at baseline, post-test and follow up, and the effect was found to be significant from post-test to follow up, indicating maintenance of change. Participants also attended more HIV/AIDS-prevention workshops after the intervention, and received more educational materials on HIV/STI prevention from their employers. These measured effects, which reflect the degree of participation from the individuals (i.e. attendance, discussion, etc.) and the employers (distribution of education materials to employees), are important factors that help promote the success of this intervention.

PAR involves a process of cooperation and active participation among community members. In this research, the different communities were found to be cooperative and willing to participate in the program. The use of peer counselors was found to be an effective tool for increasing knowledge, improving attitudes towards more favorable condom use, and encouraging and sustaining appropriate behavior change.

We extend appreciation to the City Health Officers who provided access to the study sites, CEOs and managers of study sites, participants who enrolled in the program, peer counselors who provided educational counseling and site coordinators who provided ongoing training and management of the program. This research was supported by grant R01-AI33845 from the National Institutes of Allergy and Infectious Diseases to D. E. M.

Department of Public Health ( 2001 ) Annual Report 2001, Republic of the Philippines, Manila, Philippines . Department of Public Health, Manila.

Gaventa, J. ( 1981 ) Participatory action research in North America. Convergence , 14 , 30 –42.

George, M. A., Daniel, M. and Green, L. W. ( 1999 ) Appraising and funding participatory research in health promotion. International Quarterly Community Health Education , 18 , 181 –197.

Green, L. W. ( 1977 ) Evaluation and measurement: some dilemmas for health education. American Journal of Public Health , 67 , 155 –161.

Hagey, R. S. ( 1997 ) Guest editorial: The use and abuse of participatory action research. Chronic Disease Candada , 18 , 1 –4.

Hayman, J., Sonnichsen, C., Naamara, W. and Ochola, P. ( 1996 ) Comparative experience with worksite prevention programs in Africa: Zimbabwe, Tanzania, and Kenya. Eleventh International Conference on AIDS, Vancouver , 11 , 246 .

Higgins, D. L. and Metzler, M. ( 2001 ) Implementing community-based participatory research centers in diverse urban settings. Urban Health Bulletin of the New York Academy of Medicine , 78 , 488 –494.

Israel, B. A., Schultz, A. J., Parker, E. A. and Becker, A. B. ( 1998 ) Review of community-based research: assessing partnership approaches to improve public health. Annual Review of Public Health , 19 , 173 –202.

Morisky, D. E., Tiglao, T. V., Sneed, C. D., Tempongko, S. B., Baltazar, J. C., Detels, R. et al . ( 1998 ) The effects of establishment practices, knowledge and attitudes on condom use among Filipina sex workers. AIDS Care , 10 , 213 –220.

Morisky, D. E. ( 2002 ) A Community-Based STD/HIV/AIDS Research Project Photonovella Presentation . Available at http://www.ph.ucla.edu/morisky/ .

Morisky, D. E., Peña, M., Tiglao, T. V. and Liu, K. ( 2002 ) The impact of the work environment on condom use among female bar workers in the Philippines. Health Education and Behavior , 29 , 461 –472.

Morisky, D. E., Stein, J. A., Sneed, C. D., Tiglao, T. V., Temponko, S. B., Baltazar, J. C. et al . ( 2002 ) Modeling personal and situational influences on condom use among establishment-based commercial sex workers in the Philippines. AIDS and Behavior , 6 , 163 –172.

Morisky, D. E., Ang, A. and Sneed, C. ( 2002 ) Validating the effects of social desirability on self-reported condom use behavior among commercial sex workers. AIDS Education and Prevention , 14 , 351 –360.

Tiglao, T., Morisky, D. E., Tempongko, S., Baltazar, J. and Detels, R. ( 1996 ) A community participation action research approach to HIV/AIDS prevention among sex workers. Promotion and Education , 3 , 25 –28.

UNAIDS/WHO ( 2000 ) Epidemiologic Fact Sheets on HIV/AIDS and Sexually Transmitted Infections: Update [revised]. UNAIDS/WHO, Geneva.

UNAIDS/WHO ( 2001 ) Aids Epidemic Update . UNAIDS/WHO, Geneva.

Wadsworth, Y. ( 1998 ) What is Participatory Action Research? Action Research International, Paper 2 . Available at http://www.scu.edu.au/schools/sawd/ari/ari-wadsworth.html .

Author notes

1University of California, Los Angeles, CA, USA and 2University of the Philippines, Manila, the Philippines

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• Published: 21 February 2022

Outcomes of a community-led online-based HIV self-testing demonstration among cisgender men who have sex with men and transgender women in the Philippines during the COVID-19 pandemic: a retrospective cohort study

• Patrick C. Eustaquio 1   na1 ,
• Roberto Figuracion Jr 2   na1 ,
• Kiyohiko Izumi 3 ,
• Mary Joy Morin 4 ,
• Kenneth Samaco 3 ,
• Sarah May Flores 4 ,
• Anne Brink 5 &
• Mona Liza Diones 2  

BMC Public Health volume  22 , Article number:  366 ( 2022 ) Cite this article

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Introduction

The Philippines, which has the fastest rising HIV epidemic globally, has limited options for HIV testing and its uptake remains low among cisgender men who have sex with men (cis-MSM) and transgender women (TGW), especially amid the COVID-19 pandemic. As HIV self-testing (HIVST) and technology-based approaches could synergize to expand uptake of HIV testing, we aimed to evaluate the outcomes of a community-led online-based HIVST demonstration and to explore factors associated with HIVST-related behaviours and outcomes.

We did a secondary data analysis among cis-MSM and TGW who participated in the HIVST demonstration, who were recruited online and tested out-of-facility, in Western Visayas, Philippines, from March to November 2020. We reviewed data on demographics, sexuality-, and context-related variables. Using multivariable logistic regression, we tested for associations between the aforementioned covariates and two primary outcomes, opting for directly-assisted HIVST (DAH) and willingness to secondarily distribute kits.

HIVST kits were distributed to 647 individuals (590 cis-MSM, 57 TGW), 54.6% were first-time testers, 10.4% opted DAH, and 46.1% were willing to distribute to peers. Reporting rate was high (99.3%) with 7.6% reactivity rate. While linkage to prevention (100%) and care (85.7%) were high, pre-exposure prophylaxis (PrEP) (0.3%) and antiretroviral therapy (ART) (51.0%) initiation were limited. There were no reports of adverse events. Those who were employed, had recent anal intercourse, opted for DAH, not willing to secondarily distribute, and accessed HIVST during minimal to no quarantine restriction had significantly higher reactivity rates. Likelihood of opting for DAH was higher among those who had three or more partners in the past year (aOR = 2.01 [CI = 1.01–4.35]) and those who accessed during maximal quarantine restrictions (aOR = 4.25 [CI = 2.46–7.43]). Odds of willingness to share were higher among those in urban areas (aOR = 1.64 [CI = 1.15–2.36]) but lower among first-time testers (aOR = 0.45 [CI = 0.32–0.62]).

Conclusions

HIVST could effectively reach hard-to-reach populations. While there was demand in accessing online-based unassisted approaches, DAH should still be offered. Uptake of PrEP and same-day ART should be upscaled by decentralizing these services to community-based organizations. Differentiated service delivery is key to respond to preferences and values of key populations amid the dynamic geographical and sociocultural contexts they are in.

Peer Review reports

The limited demand for HIV testing among the key populations (KP) has challenged the Philippines to reverse its HIV epidemic, where annual incidence of new infections and AIDS-related death increased by 237 and 315%, respectively, over the past decade [ 1 ]. Although estimated national prevalence is at 0.2%, the epidemic is concentrated among KP with prevalence disproportionately higher among people who inject drugs (PWID) (29.0%), cisgender men who have sex with men (cis-MSM) (5.0%), transgender women (TGW) (4.9%), and female sex workers (0.6%) [ 2 ]. Improvements in the first 95% of the UNAIDS 95–95-95 targets were noted in the recent years until the COVID-19 pandemic has decreased HIV tests done by 61% in 2020, ultimately leading to 68% of estimated people living with HIV (PLHIV) knowing their status in 2021 [a], similar to the proportion estimated 5 years ago [ 2 ].

The diagnosis gap is a known driver of the HIV epidemic [ 3 ]. The low uptake of HIV testing among cis-MSM and TGW has been attributed to meager options for testing in the Philippines [ 4 , 5 ], limited currently to facility-based and community-based testing. The former is the more prevalent model [ 6 ] and involves using rapid diagnostic test (RDT) kits, available only in Department of Health (DOH)-accredited stand-alone laboratories, hospitals, and clinics, and is only facilitated by medical technologists specifically trained for HIV [ 7 ]. Whereas community-based testing is carried out by trained lay providers during community visits and outreach programs using RDT kits. To address the low uptake amid the limited choices, expanding options may be key to upscaling access and uptake of HIV testing. The World Health Organization (WHO) has recommended HIV self-testing (HIVST), which involves the use of RDT kits for individuals to perform and interpret on their own [ 8 ]. This may remove barriers in the current HIV testing in the Philippines, including geographical distance, lack of confidentiality or privacy, conflicting schedules, and stigma [ 4 , 5 , 9 , 10 , 11 , 12 ]. HIVST has been shown to be safe and effective at increasing uptake and frequency of HIV testing without compromising condom use, social safety, and enrollment to treatment [ 13 ]. In the Philippines, limited evidence shows acceptability and preference of blood-based over fluid-based tests among cis-MSM and TGW [ 14 , 15 ].

An equally important approach is the use of technology-based interventions—this is the concurrent use of technology to expand reach, accelerate scale-up, and facilitate cost-efficient and instantaneous service delivery, responding to the inherent restrictions in face-to-face services [ 16 ]. Examples of these are online-based interventions, which if used with HIVST seem to synergistically remove barriers to HIV testing among cis-MSM especially among first-time testers [ 17 , 18 ]. Even though the proportion of Filipinos accessing the internet (67.0%) and using social media (80.7%) are higher than the global average [ 19 ], this approach has not been maximized, yet has been increasingly used during the COVID-19 pandemic [ 20 ].

We aimed to describe the outcomes of a community-led online-based HIVST demonstration project done in Western Visayas, Philippines, particularly, in terms of reach, reporting and reactivity rates, and successful linkage to services. Furthermore, we aimed to explore the demographic, sexuality-, and context-related factors associated with HIVST-related behavior and preferences, particularly opting for DAH and willingness to share HIVST kits to their partners and peers.

Study design, setting, and participants

We did a multiple-center, retrospective cohort analysis of participants recruited in a community-led online-based HIVST demonstration in Western Visayas, Philippines, implemented from March to November 2020. The STROBE statement checklist of items was used to guide the development of this research [ 21 ].

Western Visayas is in the center of the Philippines and is composed of six provinces separated in three different islands. Its two highly urbanized cities (Bacolod City and Iloilo City) are HIV high burden areas [ 1 ]. HIVST was demonstrated in the region in 2020 by the DOH Western Visayas because, firstly, two thirds of new HIV cases in the Philippines are detected outside Metro Manila and the Western Visayas is among the areas with highest HIV incidence, contributing 6.2% of newly diagnosed cases in 2019 nationally [ 22 ], and secondly, almost one fourth of PLHIV in the region has not been diagnosed in 2019 [ 22 ].

The demonstration project was implemented by different CBOs led by the main study site, Family Planning Organization of the Philippines-Iloilo (FPOP-Iloilo)-Rajah Community Center. Both online and offline recruitment campaigns were conducted, using social media platforms and face-to-face invites in social and sexual networks, respectively. As the HIVST demonstration was only limited among individuals within the Western Visayas region, the campaigns were targeted among cis-MSM and TGW in the said region. These campaigns led interested individuals to an online sign-up sheet. All adults residing in the six provinces in Western Visayas who signed-up were eligible to receive the HIVST services from implementing CBOs which started to distribute INSTI® HIV Self-Test kits (BioLytical Laboratories, Richmond, British Columbia, Canada) in March 2020. While extreme lockdowns were implemented due to the unprecedented COVID-19 pandemic, the online-based nature of the program allowed continuity of provision of HIVST.

Using convenience sampling, we performed a secondary data analysis among people who opted and consented for the HIVST demonstration who fit the following inclusion criteria as follows: (1) self-identified as cis-MSM or TGW, (2) 18 years old and above, and (3) opted for online-based services. The following were excluded: (1) assigned female at birth, (2) assigned male at birth and identified as heterosexual, (3) opted for offline services, and (4) those who eventually disclosed that they were known PLHIV.

When signing up online, the participants were provided with pre-test and programmatic information. Upon providing their electronically recorded consent, data on demographics, sexual risk and behavior, and HIV testing related behavior and preference were collected through self-reporting. Thereafter, the participants were reached by the implementers through phone calls to verify the intent and data they provided. Participants accessed the HIVST package, either through pick-up or courier, containing the HIVST kit itself, instructional materials (containing information on HIV, on how to use, interpret, and dispose of the kit, on accessing the support hotline, and linkage to appropriate HIV-related services), and condoms and lubricants. Participants were followed-up through phone calls within two days upon access to determine the outcomes, to provide post-test counseling and support on linking them to appropriate services. For validation purposes, the participants were asked to show the outcome of the HIVST kit by sending a photo or through a video call. In rare cases when the result was invalid ( n  = 4), they were offered retesting using their preferred strategy (DAH or unassisted) but with a different HIVST kit.

Those who tested reactive were referred directly to HIV treatment facilities and follow-up calls were conducted at two weeks, four weeks, and then every four weeks until ART initiation or twelve weeks, whichever came first, to determine self-reported linkage to the cascade of HIV care services. Those who neither responded to follow-ups nor reported their cascade outcomes within twelve weeks were tagged as lost to follow-up. Verification of the self-reported cascade outcomes were legislatively possible only if they were eventually enrolled in the main study site, FPOP-Iloilo. Meanwhile, those who tested non-reactive were routinely provided with risk reduction counseling and were offered to be enrolled in the HIV preexposure prophylaxis (PrEP) program of FPOP-Iloilo (the only provider in the region during the span of the study) as part of the post-test counseling. The project officers in each CBO were designated to collect all the data using a standardized data collection sheet.

We created a research dataset for the purposes of the secondary analysis from the deidentified dataset from the implementers, which included participants who fit the study inclusion and exclusion criteria. We cleaned the dataset and ensured that recoding would preserve the original data as much as possible. The following outcomes were included: (1) HIVST result (reactive or non-reactive), (2) whether they opted for directly assisted (DAH) (i.e., in-person demonstration and / or supervision by a provider) or unassisted HIVST [ 8 ], (3) whether they were willing to distribute the kits to their partners or peers (i.e., secondary distribution of HIVST kits) or not [ 8 ], (4) linkage to appropriate HIV services, i.e., enrollment to care (confirmatory testing and treatment) among those reactive and prevention services (risk reduction counseling, condoms and lubricants, and/or PrEP) among those non-reactive, and (5) reports of adverse events such as suicidal attempts, coercion, and social harm [ 8 , 23 , 24 ]. Included covariates were (1) demographics (age, gender identity, and employment), (2) sexuality-related variables including (a) anal sex within the past 3 months, (b) number of male partners for the past 12 months, (c) history of HIV testing, i.e., first-time tester or not [ 25 ], and (d) source of information regarding the HIVST program, and (3) context-related variables such as (a) time, measured in the date of access of the HIVST service, and (b) place of residence. These variables were determined a priori [ 25 , 26 ]. Some quantitative variables were transformed into categories, particularly, (1) age, grouped into less than or equal to 24 or 25 and over, signifying the young KP group [ 8 ], (2) number of male sexual partners in the past 12 months, grouped based on the median number based on national biobehavioral surveillance [ 4 ]. Some qualitative variables were recoded: (1) the extent of quarantine restrictions into “None to minimal” or “Maximal”, based on the date and location of the individual participation, and (2) the place of residence classified into either urban or rural.

Statistical analysis

Descriptive statistics were done to summarize the predictors. We performed Chi-square and Fisher exact tests to compare baseline characteristics, stratified by reported HIV test result. To describe the outcomes of the HIVST demonstration, we determined the prevalence at each component of the testing cascade. Moreover, we performed multivariate logistic regression using complete case analyses and backward elimination to determine predictors associated with our outcomes of interest: (1) opting for DAH and (2) willingness to distribute. Predictors found to be statistically associated in the initial bivariate analyses using p  < 0.25 were included in the final multivariate analyses. Chi-square tests were used to assess collinearity of potential predictors. We used c statistics and Hosmer-Lemeshow statistics to assess predictive power and model fit. We used p  < 0.05 to determine significant outputs in Chi-square and Fisher exact tests and crude (cOR) and adjusted odds ratio (aOR). All analyses were performed using R version 4.0.3.

Ethical approval

The study adhered to the principles of the Declaration of Helsinki and the ethical approval (NEC Code: 2021–004) was provided by the National Ethics Commission of the Philippine Council on Health Research and Development, Department of Science and Technology, Republic of the Philippines.

From March to November 2020, 768 HIVST kits were distributed (Fig.  1 ). Due to missing documentation, 33 participants were not assessed for eligibility. Among those assessed, 88 were excluded based on the inclusion and exclusion criteria. Eventually, 647 participants were included in the analysis.

Flow diagram of the retrospective cohort study. HIVST – HIV self-testing, PLHIV – people living with HIV

Median age of the participants was 26 (interquartile range 23–30) years. Majority self-identified as cis-MSM (91.2%), and most were employed (77.6%) and residing in an urban area (69.1%) (Table  1 ). Many (70.2%) had three or more sexual partners in the past 12 months and 51.8% had anal sexual intercourse in the past 3 months.

Among those distributed with HIVST kits, more than half (54.6%) had never tested previously for HIV, most (89.6%) preferred unassisted HIVST, and almost half (46.1%) were willing to distribute kits to their sexual partners and peers. Furthermore, reporting rate of HIVST result was high at 99.3%.

Of the 643 who reported their HIVST outcomes, 49 (7.6%) tested reactive. The proportions of testing reactive were significantly higher among those employed ( p  = 0.023), who had anal intercourse in the past 3 months ( p  = 0.021), who opted for DAH ( p  = 0.018), not willing to distribute the HIVST kits ( p  < 0.000), and who accessed HIVST during none to minimal quarantine restrictions ( p  = 0.017) compared to their corresponding counterparts. There was no significant difference in the proportion of those tested reactive between first-time testers and those with a history of HIV testing ( p  = 0.743). Moreover, among those who tested reactive, 42 (85.7%) were eventually linked to care and 25 (51.0%) were initiated on ART during the study period (Table  2 ). Among those non-reactive, all 594 participants (100%) were provided prevention services through routine provision of risk reduction counseling and condoms and lubricants. Only 2 (0.3%) were successfully linked to PrEP services. Lastly, there were no reports of adverse events in the program.

Only a few (10.4%) opted for DAH (Table 3 ). The likelihood of opting for DAH was higher among those who had three or more partners in the past year (aOR = 2.01 [CI = 1.01–4.35], p  = 0.049) and among those who accessed HIVST during maximal quarantine restrictions (aOR = 4.25 [CI = 2.46–7.43], p  < 0.00).

Almost half (46.1%) were willing to distribute the HIVST kits to their partners and peers (Table 4 ). The likelihood of willingness to share was higher among those residing in urban (aOR = 1.64 [CI = 1.15–2.36], p  = 0.007), whereas it was lower among first-time testers (aOR = 0.45 [CI = 0.32–0.62], p < 0.00).

We found that online-based HIVST reached many first-time testers among cis-MSM and TGW, similar with previous studies [ 27 , 28 , 29 , 30 , 31 ]. Reporting and linkage to care and prevention rates were high but ART and PrEP initiation were sub-optimal. Reactivity rate and HIVST preferences were associated with participants’ vulnerabilities and context.

It is striking that there seemed to be no difference in reactivity rate between first-time and ever testers, especially considering that in the Philippines all of those who come for HIV testing are routinely provided with risk reduction counselling [ 7 , 32 ] which would be expected to decrease their risk for HIV. Our finding suggests that the aforementioned may have had marginal impact, as noted in other studies [ 33 ]. Nonetheless, HIV testing is a good avenue to educate KP regarding HIV and their risks. Hence, the DOH should not only consider reviewing its risk reduction counseling strategy but also advocate for and upscale all aspects of combination prevention [ 34 ], particularly pre- and post-exposure prophylaxis, condom use, and addressing stigma and discrimination, which have been determined as national priority interventions for HIV prevention [ 35 ].

Although only a minority in our cohort (10.4%) opted for DAH, the following findings have important implications for policy. Firstly, reactivity among those who opted for DAH was significantly higher compared to unassisted, similar with another study [ 36 ]. Moreover, we found that those with three or more sexual partners in the past year had twice higher odds of opting for DAH. There is evidence on the presence of anxiety related to the HIVST process, particularly linkage to care, and this translates to a desire for assistance among cis-MSM [ 14 ], TGW [ 14 , 31 ], and other KP [ 37 , 38 ]. Secondly, while it may be intuitive that testing for the first-time is associated with higher odds of DAH as seen in previous studies [ 14 , 25 , 39 ], it was the opposite in our bivariate model. Participants may have been enticed by the privacy, convenience, and independence that HIVST offers. Lastly, we found that stricter COVID-19-related quarantine restrictions were associated with higher likelihood of DAH. We could only speculate that the perceived limited access to healthcare services amid a time of public health crisis and uncertainty may have reinforced dependence on health providers and peers especially given that PLHIV and KP are at increased risk of vulnerability to both HIV and COVID and its physical, mental, and social comorbidities [ 40 , 41 ]. Therefore, as DAH was associated with better retention [ 42 ] and higher ART initiation [ 43 ], even during the COVID-19 pandemic [ 44 ], implementation of HIVST in the Philippines should provide and expand options for direct assistance that go beyond in-person demonstration and also include emotional support [ 45 ]. This could involve capacitating community-based testing providers and “seeds” to provide demonstrations and peer support to their communities and networks [ 46 , 47 ], respectively, and kits being delivered by trained providers themselves. Moreover, ensuring DAH may be crucial if the Philippines introduces oral fluid-based test, to address lack familiarity as Filipino KPs are more accustomed to blood-based tests.

Secondary distribution has been shown to increase the reach, positivity yield, and cost-efficiency of HIV testing among cis-MSM [ 26 , 46 , 48 ]. Like other studies which showed increased distribution [ 26 , 49 ], we found that willingness to distribute was higher among those with prior HIV testing. This is reassuring as we also found that online-based HIVST can effectively reach to first-time testers, consistent with other studies [ 17 , 18 ]. Hence, in the Philippines, where less than half (43%) of cis-MSM and TGW were ever tested for HIV [ 4 ], technology-based HIVST has the potential to increase the proportion of ever tested for HIV [ 17 , 18 ] and, consequently, facilitate initial and repeat testing among their networks though secondary distribution [ 30 , 50 ]. We also found that residing in urban areas was associated with increased odds of willingness to distribute. This may be due to the dense clustering of KP [ 51 ], higher access to queer culture [ 52 ] and HIV education [ 53 ], and higher acceptability of HIV interventions [ 51 ]. This is opportune as urban areas are priority sites for sustainable and effective HIV response [ 54 ]; as willingness was high, secondary distribution of HIVST kits could augment current HIV testing practices through approaches like index testing and sexual and social network testing [ 46 , 47 ]. There is plenty of evidence that secondary distribution [ 55 ] and technology-assisted models [ 18 , 55 ] play a role in increasing testing uptake among cis-MSM and TGW, whereas community-based models were found to be more effective among young people and male partners of females in antenatal clinics [ 55 ]. The knowledge gap on effective distribution models among other KPs, like PWID, people in prisons, and female sex workers, may be attributed to the disproportionately limited studies among these vulnerable groups. Hence, further studies are required to fully respond to their values and preferences on HIV testing.

Despite high rates of uptake, reporting, and referral to services, we found suboptimal initiation of antiretroviral interventions. Apart from the limitations brought by COVID-19, suboptimal initiation may be explained by the fact that only one in eleven CBOs in the demonstration was capable of prescribing ART or PrEP, similar to the experience in Thailand [ 43 ]. However, when treatment was also CBO-led, as in the HIVST demonstration in Vietnam, higher initiation rates was noted [ 56 ]. Furthermore, despite that rapid ART initiation has been recommended by the WHO since 2017, the current HIV treatment guidelines in the Philippines in 2018 did not mention this [b] and may explain the low ART initiation rate. Meanwhile, poor PrEP initiation may be explained by cost [ 57 ], especially that, unlike ART, PrEP is neither state-sponsored nor covered by health insurance in the Philippines. Overall, the benefits of online-based HIVST could not be maximized without concurrent innovations in treatment and prevention. Although a few treatment and PrEP facilities are CBOs or have partner CBOs in the Philippines, continuing the endeavor by the DOH to further decentralize HIV-related services to CBOs should be prioritized. Likewise, technology-supported interventions or seamless online-to-offline transition during ART or PrEP prescribing, linkage to care, and retention, should be considered and further studied. Lastly, local treatment guidelines should be revised to allow rapid ART initiation.

The primary strength of this study was the technology-based delivery of the demonstration project; this allowed numerous and precise data points to be used to explore associations. Furthermore, to our knowledge, this is the first association study to consider the potential influence of quarantine restrictions on HIV service delivery in the Philippines. Meanwhile, it is important to acknowledge some study limitations. Firstly, as this study is a secondary data analysis, we were bound to the limitations of the primary data collection such as high potential for information bias, as much of the data was collected through self-reporting which is particularly vulnerable to social desirability bias. However, verification was done whenever possible. Moreover, likewise with a previous study [ 58 ], the willingness to distribute HIVST kits were collected at baseline and, hence, may be influenced by the uncertainty of their HIV status. Secondly, the online-based convenience sampling may have led to self-selection bias. Generalizing the findings of our study must be done with caution. Lastly, there are limitations of in the use of stepwise backward elimination. Although it prevents overfitting and allow different combinations of variables [ 59 , 60 , 61 , 62 ], there is considerable variance when different samples are used [ 62 ] and there is potential for inappropriate variables to be included in the model [ 59 , 60 , 62 ]. We did, however, ensure that there were sufficient events per variable [ 60 , 63 ] and that we explored a priori predictors, respectively. Thus, we are confident that the models predict the outcomes within the context of the study.

We have shown that a community-based online-based HIVST intervention is safe and has the potential to increase uptake of HIV testing and linkage to appropriate service among cis-MSM and TGW, yet initiation of ART and PrEP were low. The study emphasized the importance of providing different options for HIVST which suite their values and preferences of KP. Geographical, temporal, and sociocultural contexts are important considerations in ensuring differentiated services are provided.

Availability of data and materials

Due to ethical reasons, the dataset created and analyzed is not publicly available as it contains potentially sensitive information. For further inquiries, email may be sent to the corresponding author, Dr. Patrick C. Eustaquio via [email protected] .

Abbreviations

Acquired immune deficiency syndrome

Adjusted odds ratio

Antiretroviral therapy

Community-based organization

Confidence interval

• Cisgender men who have sex with men

Crude odds ratio

Coronavirus disease in 2019

Directly-assisted HIV self-testing

Department of Health

Family Planning Organization of the Philippines

Human immunodeficiency virus

• HIV self-testing

Key population

People living with human immunodeficiency virus.

Pre-exposure prophylaxis

Strengthening the reporting of observational studies

• Transgender women

Joint United Nations Programme on HIV/AIDS

World Health Organization

Department of Health Epidemiology Bureau. A briefer on the Philippine HIV estimates 2020. Manila: Department of Health; 2021.

Google Scholar  

Joint United Nations Programme on HIV/AIDS. UNAIDS Data 2020. Geneva: UNAIDS; 2020.

Fisher M, Pao D, Brown AE, Sudarshi D, Gill ON, Cane P, et al. Determinants of HIV-1 transmission in men who have sex with men: a combined clinical, epidemiological and phylogenetic approach. AIDS. 2010;24(11):1739–47.

Article   PubMed   Google Scholar  

Department of Health Epidemiology Bureau. 2018 integrated HIV Behavioral and serologic surveillance (IHBSS). Manila: Department of Health; 2020.

United Nations Development Programme. Missing in action - loss of clients from HIV testing, treat- ment, care and support services: case studies of gay men and other men who have sex with men in Manila missing in action. Bangkok: United Nations Development Programme; 2017.

Ross AG, Ditangco RA, Belimac JG, Olveda RM, Mercado ES, Chau TN, et al. The dire sexual health crisis among MSM in the Philippines: an exploding HIV epidemic in the absence of essential health services. Int J Infect Dis. 2015;37:6–8.

Department of Health. Administrative order 2017–0019 policies and guidelines in the conduct of HIV testing Services in Health Facilities. Philippines: DOH; 2017.

World Health Organization. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach. Geneva: World Health Organization; 2021.

Golub SA, Gamarel KE. The impact of anticipated HIV stigma on delays in HIV testing behaviors: findings from a community-based sample of men who have sex with men and transgender women in new York City. AIDS Patient Care STDS. 2013;27(11):621–7.

Article   PubMed   PubMed Central   Google Scholar  

Rutstein SE, Ananworanich J, Fidler S, Johnson C, Sanders EJ, Sued O, et al. Clinical and public health implications of acute and early HIV detection and treatment: a scoping review. J Int AIDS Soc. 2017;20(1):21579.

Hatzold K, Gudukeya S, Mutseta MN, Chilongosi R, Nalubamba M, Nkhoma C, et al. HIV self-testing: breaking the barriers to uptake of testing among men and adolescents in sub-Saharan Africa, experiences from STAR demonstration projects in Malawi, Zambia and Zimbabwe. J Int AIDS Soc. 2019;22(Suppl 1):e25244.

Piamonte S. Behavioral, Normative, and Control Beliefs of Filipino Men Who Have Sex with Men on Repeat HIV Testing and Counseling. Acta Med Philipp. 2021.

Witzel TC, Eshun-Wilson I, Jamil MS, Tilouche N, Figueroa C, Johnson CC, et al. Comparing the effects of HIV self-testing to standard HIV testing for key populations: a systematic review and meta-analysis. BMC Med. 2020;18(1):381.

Gohil J, Baja ES, Sy TR, Guevara EG, Hemingway C, Medina PMB, et al. Is the Philippines ready for HIV self-testing? BMC Public Health. 2020;20(1):34.

Pagtakhan R, Rosadiño J, Briñes M, Baja E. Community-led conversations on awareness and acceptability of HIV self-screening among men who have sex with men and transgender women in metropolitan Manila, Philippines. International AIDS Society Conference on HIV Science; 2019; Mexico City: International AIDS Society; 2019.

Simoni JM, Kutner BA, Horvath KJ. Opportunities and challenges of digital technology for HIV treatment and prevention. Curr HIV/AIDS Rep. 2015;12(4):437–40.

LeGrand S, Muessig KE, Horvath KJ, Rosengren AL, Hightow-Weidman LB. Using technology to support HIV self-testing among MSM. Curr Opin HIV AIDS. 2017;12(5):425–31.

McGuire M, de Waal A, Karellis A, Janssen R, Engel N, Sampath R, et al. HIV self-testing with digital supports as the new paradigm: A systematic review of global evidence (2010-2021). EClinicalMedicine. 2021;39:101059.

DataReportal. Digital 2021 The Philippines 2021 [Available from: https://datareportal.com/reports/digital-2021-philippines .

Quilantang MIN, Bermudez ANC, Operario D. Reimagining the future of HIV service implementation in the Philippines based on lessons from COVID-19. AIDS Behav. 2020;24(11):3003–5.

von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, et al. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335(7624):806–8.

Article   Google Scholar  

Department of Health Epidemiology Bureau. HIV/AIDS and ART registry of the Philippines - December 2019. Manila: Department of Health; 2019.

Mulubwa C, Hensen B, Phiri MM, Shanaube K, Schaap AJ, Floyd S, et al. Community based distribution of oral HIV self-testing kits in Zambia: a cluster-randomised trial nested in four HPTN 071 (PopART) intervention communities. Lancet HIV. 2019;6(2):e81–92.

Brown AN, Djimeu EW, Cameron DB. A review of the evidence of harm from self-tests. AIDS Behav. 2014;18(Suppl 4):S445–9.

Lyons CE, Coly K, Bowring AL, Liestman B, Diouf D, Wong VJ, et al. Use and acceptability of HIV self-testing among first-time testers at risk for HIV in Senegal. AIDS Behav. 2019;23(Suppl 2):130–41.

Xiao W, Yan L, Chen L, Fu G, Yang H, Yang C, et al. Sexual network distribution of HIV self-testing kits: findings from the process evaluation of an intervention for men who have sex with men in China. PLoS One. 2020;15(4):e0232094.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Wang Z, Lau JTF, Ip M, Ho SPY, Mo PKH, Latkin C, et al. A randomized controlled trial evaluating efficacy of promoting a home-based HIV self-testing with online counseling on increasing HIV testing among men who have sex with men. AIDS Behav. 2018;22(1):190–201.

Tang W, Wei C, Cao B, Wu D, Li KT, Lu H, et al. Crowdsourcing to expand HIV testing among men who have sex with men in China: A closed cohort stepped wedge cluster randomized controlled trial. PLoS Med. 2018;15(8):e1002645.

Jamil MS, Prestage G, Fairley CK, Grulich AE, Smith KS, Chen M, et al. Effect of availability of HIV self-testing on HIV testing frequency in gay and bisexual men at high risk of infection (FORTH): a waiting-list randomised controlled trial. Lancet HIV. 2017;4(6):e241–e50.

Zhang C, Li X, Brecht ML, Koniak-Griffin D. Can self-testing increase HIV testing among men who have sex with men: A systematic review and meta-analysis. PLoS One. 2017;12(11):e0188890.

Witzel CTWT, McCabe L, Gabriel M, WOlton A, Gafos M, Ward D, et al. Impact and acceptability of HIV self-testing for trans men and trans women: A mixed-methods subgroup analysis of the SELPHI randomised controlled trial and process evaluation in England and Wales. EClinicalMedicine. 2021;32(100700).

Department of Health. Department Memorandum No. 2020–0276: Interim Guidelines on Community-based HIV Screening. Philippines: DOH; 2020.

Zajac K, Kennedy CE, Fonner VA, Armstrong KS, O'Reilly KR, Sweat MD. A systematic review of the effects of Behavioral counseling on sexual risk behaviors and HIV/STI prevalence in low- and middle-income countries. AIDS Behav. 2015;19(7):1178–202.

Brody C, Sok S, Tuot S, Pantelic M, Restoy E, Yi S. Do combination HIV prevention programmes result in increased empowerment, inclusion and agency to demand equal rights for marginalised populations in low-income and middle-income countries? A systematic review. BMJ Glob Health. 2019;4(5):e001560.

Department of Health, editor. Philippine Health Sector HIV Strategic Plan. In: Department of Health, editor. Manila: Department of Health; 2020.

Girault P, Misa Wong C, Jittjang S, Fongkaew K, Cassell MM, Lertpiriyasuwat C, et al. Uptake of oral fluid-based HIV self-testing among men who have sex with men and transgender women in Thailand. PLoS One. 2021;16(8):e0256094.

Burke VM, Nakyanjo N, Ddaaki W, Payne C, Hutchinson N, Wawer MJ, et al. HIV self-testing values and preferences among sex workers, fishermen, and mainland community members in Rakai, Uganda: A qualitative study. PLoS One. 2017;12(8):e0183280.

Wulandari LPL, Kaldor J, Guy R. Uptake and acceptability of assisted and unassisted HIV self-testing among men who purchase sex in brothels in Indonesia: a pilot intervention study. BMC Public Health. 2020;20(1):730.

Phanuphak N, Anand T, Jantarapakde J, Nitpolprasert C, Himmad K, Sungsing T, et al. What would you choose: online or offline or mixed services? Feasibility of online HIV counselling and testing among Thai men who have sex with men and transgender women and factors associated with service uptake. J Int AIDS Soc. 2018;21(Suppl 5):e25118.

Waterfield KC, Shah GH, Etheredge GD, Ikhile O. Consequences of COVID-19 crisis for persons with HIV: the impact of social determinants of health. BMC Public Health. 2021;21(1):299.

Iversen J, Sabin K, Chang J, Morgan Thomas R, Prestage G, Strathdee SA, et al. COVID-19, HIV and key populations: cross-cutting issues and the need for population-specific responses. J Int AIDS Soc. 2020;23(10):e25632.

Tonen-Wolyec S, Kayembe Tshilumba C, Batina-Agasa S, Marini Djang'eing'a R, Hayette MP, Belec L. Comparison of practicability and effectiveness between unassisted HIV self-testing and directly assisted HIV self-testing in the Democratic Republic of the Congo: a randomized feasibility trial. BMC Infect Dis. 2020;20(1):830.

Phanuphak N, Jantarapakde J, Himmad L, Sungsing T, Meksena R, Phomthong S, et al. Linkages to HIV confirmatory testing and antiretroviral therapy after online, supervised, HIV self-testing among Thai men who have sex with men and transgender women. J Int AIDS Soc. 2020;23(1):e25448.

Maatouk I, Nakib ME, Assi M, Farah P, Makso B, Nakib CE, et al. Community-led HIV self-testing for men who have sex with men in Lebanon: lessons learned and impact of COVID-19. Health Res Policy Syst. 2021;19(Suppl 1):50.

Janssen R, Engel N, Esmail A, Oelofse S, Krumeich A, Dheda K, et al. Alone but supported: A qualitative study of an HIV self-testing app in an observational cohort study in South Africa. AIDS Behav. 2020;24(2):467–74.

Okoboi S, Lazarus O, Castelnuovo B, Nanfuka M, Kambugu A, Mujugira A, et al. Peer distribution of HIV self-test kits to men who have sex with men to identify undiagnosed HIV infection in Uganda: A pilot study. PLoS One. 2020;15(1):e0227741.

Lillie T, Boyee D, Kamariza G, Nkunzimana A, Gashobotse D, Persaud N. Increasing testing options for key populations in Burundi through peer-assisted HIV self-testing: descriptive analysis of routine programmatic data. JMIR Public Health Surveill. 2021;7(9):e24272.

Okoboi S, Castelnuovo B, Van Geertruyden JP, Lazarus O, Vu L, Kalibala S, et al. Cost-effectiveness of peer-delivered HIV self-tests for MSM in Uganda. Front Public Health. 2021;9:651325.

Sha YX, Y; Wang Y; Ong, J; Ni, Y; Lu, Y; Cheng, M. Comparing the effectiveness of secondary distribution of HIV self-testing to testing card referral in promoting HIV testing among men who have sex with men in China: A quasi-experimental study. medRxiv. 2021.

Li S, Zhang J, Mao X, Lu T, Gao Y, Zhang W, et al. Feasibility of indirect secondary distribution of HIV self-test kits via WeChat among men who have sex with men: National Cross-sectional Study in China. J Med Internet Res. 2021;23(10):e28508.

He L, Pan X, Yang J, Ma Q, Jiang J, Wang W, et al. HIV risk behavior and HIV testing among rural and urban men who have sex with men in Zhejiang Province, China: A respondent-driven sampling study. PLoS One. 2020;15(4):e0231026.

Preston DB, D'Augelli AR, Kassab CD, Cain RE, Schulze FW, Starks MT. The influence of stigma on the sexual risk behavior of rural men who have sex with men. AIDS Educ Prev. 2004;16(4):291–303.

Colby D, Minh TT, Toan TT. Down on the farm: homosexual behaviour, HIV risk and HIV prevalence in rural communities in Khanh Hoa province. Vietnam Sex Transm Infect. 2008;84(6):439–43.

Article   CAS   PubMed   Google Scholar  

Joint United Nations Programme on HIV/AIDS. Global AIDS Update 2021 - Confronting Inequalities: Lessons for Pandemic Responses from 40 Years of AIDS. 2021.

Eshun-Wilson I, Jamil MS, Witzel TC, Glidded DV, Johnson C, Le Trouneau N, et al. A systematic review and network Meta-analyses to assess the effectiveness of human immunodeficiency virus (HIV) self-testing distribution strategies. Clin Infect Dis. 2021;73(4):e1018–e28.

Green KE, Vu BN, Phan HT, Tran MH, Ngo HV, Vo SH, et al. From conventional to disruptive: upturning the HIV testing status quo among men who have sex with men in Vietnam. J Int AIDS Soc. 2018;21(Suppl 5):e25127.

PubMed   PubMed Central   Google Scholar  

van Dijk M, de Wit JBF, Guadamuz TE, Martinez JE, Jonas KJ. Slow uptake of PrEP: Behavioral predictors and the influence of Price on PrEP uptake among MSM with a high interest in PrEP. AIDS Behav. 2021;25(8):2382–90.

Sharma A, Chavez PR, MacGowan RJ, McNaghten AD, Mustanski B, Gravens L, et al. Willingness to distribute free rapid home HIV test kits and to test with social or sexual network associates among men who have sex with men in the United States. AIDS Care. 2017;29(12):1499–503.

Ratner B. Variable selection methods in regression: ignorable problem, outing notable solution. J Target Meas Anal Mark. 2010;18:65–75.

Hosmer D, Lemeshow S, Sturdivant RX. Applied logistic regression. New York: John Wiley & Sons, Inc.; 2013.

Book   Google Scholar  

Steyerberg E. Clinical prediction models: a practical approach to development, validation, and updating: Springer Science & Business Media; 2008.

Chowdhury MZI, Turin TC. Variable selection strategies and its importance in clinical prediction modelling. Fam Med Community Health. 2020;8(1):e000262.

Austin PC, Steyerberg EW. Events per variable (EPV) and the relative performance of different strategies for estimating the out-of-sample validity of logistic regression models. Stat Methods Med Res. 2017;26(2):796–808.

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Acknowledgments

Data used were collected from participants in the HIVST demonstration project (iScreen) in Western Visayas, Philippines. We would like to acknowledge the vital role of different CBOs who made the HIVST demonstration project possible: Rajah Community Center, Montecarlo Clan, Cabatuan LGBT Association, La Villa Pride, GBT Janiuay, LGBTQ PAVIA Chapter, Red Seahorse, Bagani Community Center, Ogtonganon Mask Stewards, Kamini Community Center, and Red Lace Boracay. The investigating team would also like to acknowledge the following: Adrian Hort Ramos, DOH-CHD Region 6 HIV program coordinator, for providing his technical inputs in the demonstration project, Vincent Misterio, FPOP-Iloilo iScreen project coordinator, and other members of the iScreen implementation team for organizing the implementation of the HIVST demonstration project. We would also like to acknowledge Danvic Rosadiño for his technical review of the research protocol and to our peer reviewers for providing us crucial feedback on improving this manuscript.

The funding for ethics application and publication were provided by the Joint United Nations Programme on HIV/AIDS Unified Budget, Results and Accountability Framework 2020. The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

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Patrick C. Eustaquio and Roberto Figuracion Jr contributed equally to this work.

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LoveYourself, Inc, 715 Anglo Bldg., Shaw Blvd, 1550, Mandaluyong City, Philippines

Patrick C. Eustaquio

Family Planning Organization of the Philippines, Inc, Iloilo Chapter – Rajah Community Center, 2F Dulalia Building, Rizal St, 5000, Iloilo City, Iloilo City Proper, Philippines

Roberto Figuracion Jr & Mona Liza Diones

World Health Organization, Philippines, Ground Floor Building 3 San Lazaro Compound, C. S. Gatmaitan Ave, Santa Cruz, 1000, Manila, Metro Manila, Philippines

Kiyohiko Izumi & Kenneth Samaco

Department of Health, Philippines, Compound San Lazaro St, Santa Cruz, 1000, Manila, Metro Manila, Philippines

Mary Joy Morin & Sarah May Flores

Independent consultant, London, UK

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All authors conceived and designed the research question and analysis and provided technical inputs in the draft. RFJ and MD collected the data. PCE performed the statistical analysis while all other others contributed to the data analysis. PCE and RFJ wrote the first draft of the manuscript and all other authors provided technical inputs and contributed for the revisions. All authors have agreed on the final version of the manuscript.

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In accordance with the international standards and national guidelines, the study adhered to the principles of the Declaration of Helsinki and the research protocol received ethics approval from the National Ethics Commission of the Philippine Council on Health Research and Development, Department of Science and Technology, Republic of the Philippines (NEC Code: 2021–004). Data collection, processing, and management strictly adhered to the Republic Act 10173 Philippines Data Privacy Act of 2012 and the Republic Act 11166 HIV/AIDS Control Act. All participants voluntarily gave their electronically recorded informed consent to participate in the study.

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Eustaquio, P.C., Figuracion, R., Izumi, K. et al. Outcomes of a community-led online-based HIV self-testing demonstration among cisgender men who have sex with men and transgender women in the Philippines during the COVID-19 pandemic: a retrospective cohort study. BMC Public Health 22 , 366 (2022). https://doi.org/10.1186/s12889-022-12705-z

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DOH encourages Central Luzon residents to know HIV status

CABANATUAN CITY (PIA) — The Department of Health (DOH) is encouraging Central Luzon residents to know their human immunodeficiency virus (HIV) status.

HIV counseling and testing are available and free of charge at health centers, rural health units (RHUs), and HIV treatment facilities under the government.

DOH Central Luzon Center for Health Development HIV Program Manager Geliza Recede said early testing and detection is important to protect oneself from HIV and acquired immunodeficiency syndrome (AIDS).

“If an individual is a bit hesitant, they can go to HIV treatment facilities, health centers or contact them through online or social media pages,” Recede added.

There are about 34 designated HIV treatment hubs and primary HIV care facilities in Central Luzon including the Maria Aurora Community Hospital in the province of Aurora; and Bataan General Hospital and Medical Center, Jose C. Payumo Jr. Memorial Hospital, and Mariveles Mental Wellness and General Hospital in the province of Bataan.

Bulacan residents may visit City of San Jose del Monte Primary HIV Care Clinic, Guiguinto RHU II Primary HIV Care Clinic, Meycauayan City Primary HIV Care Clinic, R.E. De Jesus Multi-Specialty Clinic and Diagnostic Center, RHU 1 Marilao Bulacan, Usbong ng Bulakenyo Incorporated, Allied Care Experts Medical Center-Baliwag, Bulacan Medical Center, and Healthway QualiMed Hospital San Jose Del Monte.

These services are likewise available at Dr. Paulino J. Garcia Memorial Research and Medical Center, Guimba Community Hospital, Nueva Ecija Medical Center Inc., Premiere Medical Center, Talavera General Hospital, and Angel Cares Medical Health Services in the province of Nueva Ecija.

In the province of Pampanga, there is the Family Planning Organization of the Philippines-Pampanga Chapter, Mabalacat City RHU II Reproductive Health and Wellness Center and Primary HIV Care Clinic, Regional TB-HIV Support Network Incorporated, Apalit Doctors’ Hospital, Incorporated, Jose B. Lingad Memorial General Hospital, The Medical City Clark Hospital, and Angeles City Primary HIV Care Clinic.

In Tarlac, residents may visit Moncada RHU 1, Myrna’s Cafe Health Service Cooperative, Concepcion District Hospital, and Tarlac Provincial Hospital.

Lastly, anyone can get tests and treatment at the President Ramon Magsaysay Memorial Hospital, San Marcelino District Hospital, and James L. Gordon Memorial Hospital in the province of Zambales.

Recede said there are also self-test kits available at these treatment facilities, but it is still important to have counseling and guidance in the correct self-testing process.

In this regard, she emphasized the importance of regular checkups for early detection and treatment to improve the quality of life of Persons Living with HIV (PLHIV).

The effect of not immediately detecting HIV infection is lowering the body’s immune system, which can lead to AIDS and opportunistic infections or other diseases.

“Although there are cases of AIDS that they can still experience normal life,  we do not want PLHIVs to experience having AIDS, so as early as now if you know there is an exposure, find out your HIV status immediately,” Recede emphasized.

She said there should be no fear of knowing the status because regardless of the result, there are ways and activities to help oneself.

Having awareness is very important to the health of an individual, specifically knowing the ways to avoid getting HIV as well as taking steps to prevent infection.

HIV is transmitted through unprotected sex, using needles that have been used by others, transfusions of contaminated blood, and mother-to-child transmission.

Recede said being aware of the correct information about the disease will help to stop discrimination or stigma against PLHIV who are not contagious through their sweat, saliva, and cough.

Currently, there is no cure for HIV but there are treatments like antiretroviral treatment or therapy.

DOH always campaigns abstinence or avoiding sexual intercourse, being mutually faithful to your partner, correct and continuous use of condoms, and pre and post-exposure prophylaxis to prevent getting HIV.

Recede reported that throughout Central Luzon, the diagnosed cases of HIV reached 13,202 as of December last year.

The province of Bulacan has the highest number of cases, with 4,563 cases, followed by Pampanga with 3,782 cases, and Nueva Ecija with 1,671 cases. (CLJD/CCN, PIA Region 3-Nueva Ecija)

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New village halls to strengthen governance in Lanao del Sur

Northern Samar features tourism, and cultural heritage in 2024 Ibabao Festival

Bantayan’s multi-species marine hatchery to boost food security

LTFRB: 91% of transport units in CV already consolidated

EHAP brings hope to typhoon survivor in Cebu

Ordinance boosts blood donation campaign

Camarines Norte’s Dumagat tribe forms coop to support fisherfolk