Philippines: Policy Failures Fuel HIV Epidemic

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The Philippines is facing one of the fastest-growing epidemics of human immunodeficiency virus (HIV) in the Asia-Pacific region. According to official statistics, HIV prevalence among men who have sex with men has increased tenfold in the last five years. In 2015, the Department of Health reported that at least 11 cities have recorded HIV prevalence rates of more than 5 percent among men who have sex with men, with Cebu City, the county’s second largest city, recording a 15 percent prevalence rate in 2015. Those statistics dwarf the 0.2 percent overall HIV prevalence rate for the Asia-Pacific region and 4.7 percent overall HIV prevalence rate in Sub-Saharan Africa, which has the most serious HIV epidemic in the world.

The country’s growing HIV epidemic has been fueled by a legal and policy environment hostile to evidence-based policies and interventions proven to help prevent HIV transmission. Such restrictions are found in national, provincial, and local government policies, and are compounded by the longstanding resistance of the Roman Catholic Church to sexual health education and condom use. Government policies create obstacles to condom access and HIV testing and limit educational efforts on HIV prevention. Children may be particularly vulnerable to HIV due to inadequate sex education in schools and misguided policies requiring parental consent for those under 18 to purchase condoms or access HIV testing.

Despite its claims that it is adopting policies to help prevent the spread of HIV, the Philippine government is failing to adequately target HIV prevention measures at men who have sex with men (MSM). HIV prevention education in Philippine schools is woefully inadequate and the commercial marketing of condoms to MSM populations is nonexistent. (MSM is an umbrella term originated by health professionals for men and male youth who have sexual relations with persons of the same sex, whether or not they identify as gay or bisexual or also have sexual relationships with women.)

The Philippine government has erected barriers to condom access and HIV testing for men who have sex with men and adolescent males who engage in same-sex practices, particularly those under 18, factors that all contribute to the worsening epidemic. Philippine rights activists for lesbian, gay, bisexual, and transgender (LGBT) people blame these policy failures on the government’s focus on HIV prevention policies that target heterosexual couples rather than members of the LGBT community.

As early as the 1990s, the Philippines earned international praise for its policies to prevent HIV transmission. HIV emerged in the Philippines in the 1990s primarily among commercial sex workers in the country’s urban centers. The government responded to that outbreak by aggressively promoting condom use among sex workers through strategies including the deployment of former sex workers as educational outreach volunteers and making the health secretary at the time, the jocular and grandfatherly Juan Flavier, the human face of an official condom promotion movement. Flavier marketed condom use as an activity that was as fun as it was potentially life-saving through media-friendly antics such as inflating condoms in front of journalists and photographers. The government pursued this strategy despite fierce opposition from the Catholic Church. The strategy was a success and contributed to low numbers of people living with HIV.

According to government statistics, which may not accurately reflect the real situation, the number of people living with HIV rose from 2 in 1984 (the year HIV was first reported in the Philippines) to 835 by 2009. From 2009 to 2010, the number of people living with HIV doubled to 1,591 as more men who have sex with men contracted HIV. Government statistics reflect the rise of rates of HIV transmission among MSM populations: health records indicate that 81 percent of the approximately 35,000 cases of HIV recorded between 1984 and June 2016 have been among men who have sex with men.

The government has not tailored HIV prevention policies to address the needs of populations most at risk of HIV infection, a failure that has facilitated HIV transmission among MSM populations. A 2013 report by the World Health Organization (WHO) on the Philippine government’s response to the HIV epidemic warned that “most [government anti-HIV] programme activities remained focused on FSWs [female sex workers], mostly through the vast and busy network of SHCs [social hygiene clinics], while HIV continues to spread, unabated, among other key populations that have little or no access to services suited to their needs.”

Some of the main factors fueling the HIV epidemic among MSM populations include government policies and social stigma that limit condom access. In the Philippines, condoms are readily available for retail sale at pharmacies and convenience stores. However, a legal restriction embodied in the Responsible Parenthood and Reproductive Health Act of 2012 (Republic Act No. 10354, known as the RH Law) prohibits condom purchases by individuals under the age of 18 without parental consent. As a result, retail store employees routinely refuse to sell condoms to youths or demand that they provide identification proving their age, which can be off-putting even for those over 18.

Further, government condom education and access programs fail to take into account the imposing public stigma that retail condom purchases can involve, particularly for teenagers. Human Rights Watch spoke to many people with HIV age 18 to 35 who described their unease when buying condoms. Although the government provides free condoms at public social hygiene clinics (SHCs), which provide no-cost contraceptive supplies and family planning services, many Filipinos will not visit SHCs because they carry a social stigma related to their outreach activities for commercial sex workers.

Local government policy and legal obstacles can further restrict condom access for men who have sex with men and the wider population. The RH Law’s prohibition on condom sales to children without parental consent notwithstanding, the law provides a wide array of reproductive health products and services, including reproductive health care, sexuality education, HIV prevention and treatment, and management of AIDS. However, governments in at least two cities have responded to the RH Law’s passage by passing local ordinances and executive orders banning the sale and distribution of family planning supplies, including condoms.

The mayors of Balanga City in Bataan province and Sorsogon City in the Bicol region have both issued directives to government clinics—which low-income people rely on for health care—forbidding them from procuring and distributing contraceptive products, including condoms. The mayor of Sorsogon, Sally Lee, has threatened to punish government employees who refuse to comply with the order. Mayor Lee has called for the removal of condoms from government clinics due to what municipal health personnel have described as “morality issues” related to the use of condoms. Representatives of the official Commission on Human Rights have criticized the anti-condom policies of Sorsogon and Balanga as threats to public health, and have warned that similar policies might be adopted by other cities in the Philippines.

In January 2015, the Philippine Senate cut one billion pesos (about US$21 million) from the Department of Health’s budget intended for family planning commodities, including condoms. Senators who lobbied for the cut justified it on the basis of fiscal savings. But critics contend that the cut reflected the influence of conservative elements in the Senate. The impact of this cut on condom supplies in 2016 has so far been minimal due to adequate back-supply of condoms at clinics and SHCs. But doctors warn that unless the Senate reinstates the needed funding for contraceptive products, SHCs and other government clinics are likely to exhaust their condom supplies in early 2017.

The government’s failure to provide adequate public access to HIV testing is also fueling the epidemic. Philippine law prohibits HIV testing of children below age 18 without the consent of parents or guardians. This seriously limits HIV testing of men who have sex with men in the 15 to 25 age bracket. Although some clinics skirt the law by assigning clinic personnel to act as “guardians,” public health officials describe the age restriction as a serious obstacle to testing, counseling, and treatment for adolescents and young men, and a barrier to accurately measuring the epidemic’s growth.

These restrictions in part reflect the influence of the Catholic Church on government health and education policy. An estimated 80 percent of Filipinos are Roman Catholics, and the Catholic Bishops Conference of the Philippines (CBCP) has long had an obstructive influence on government anti-HIV policies. Since the early 1990s, the CBCP has issued official statements vilifying condoms, campaigned against legislation that would expand condom access, and levied personal attacks against government officials who favor inclusion of condoms in HIV prevention programs. The Church, backed by conservative lawmakers, has obstructed efforts to expand public education and awareness of the value of condoms in HIV prevention on the basis that condom use promotes promiscuity.

The administration of President Fidel Ramos, who was in office from 1992 to 1998, overrode such objections in favor of evidence-based HIV prevention measures that included condom use. However, the governments of both President Gloria Macapagal-Arroyo from 2001 to 2010 and President Benigno Aquino III from 2010 to 2016 failed to give priority to condom use as an HIV prevention method in apparent deference to Catholic Church sensitivities.

The administration of President Rodrigo Duterte, who assumed office on June 30, 2016, has yet to announce any specific policies to address the country’s HIV epidemic. However, during the campaign Duterte spoke in favor of improving the rights of LGBT people, which LGBT rights activists hope will extend to needed policies for addressing the HIV epidemic among men who have sex with men. Duterte has also committed his government to full implementation of the RH Law. At the same time, Duterte has engaged in vitriolic anti-gay rhetoric, which may indicate a different path than the one suggested by his more positive public pronouncements.

Currently, the Philippine government fails to provide adequate school education programs on safe sex practices, particularly condom use. Both the RH Law and the Philippine AIDS Prevention and Control Act of 1998 (Republic Act No. 8504, known as the AIDS Law) mandate compulsory “age- and development-appropriate” sexuality education for adolescent children. The RH Law specifically provides for “comprehensive sexuality education,” which includes sexual health, children’s rights, and values formation. However, in practice the majority of public and private schools provide no sex education classes or instruction on methods to prevent sexually transmitted infections.

Most of the people living with HIV interviewed for this report said that their schools provided no sex education lessons, let alone specific lessons on HIV prevention and condom use. Those who told us that their schools did offer sex education courses described the curriculum as focused strictly on dry explanations of human reproductive functions, rather than on condom use to prevent sexually transmitted infections.

The Department of Education (DepEd) tried in 2006 to implement a pilot sexuality education program in its curriculum. However, strong opposition from conservative lawmakers backed by the Catholic Church scuttled the plan. Private schools, many of them established by Catholic orders including the Jesuits and De La Salle Brothers, have also refused to implement mandatory sex education classes on the grounds that such teachings “promote sin.” At one private Catholic school in Manila in 2009, the school administration rejected a sex education module because it did not explicitly condemn masturbation as a sin. As a result, implementation of Comprehensive Sexuality Education (CSE) effectively remains in limbo. The DepEd only issued its draft of official standards needed to teach CSE in early 2016, and it had not yet officially adopted them at time of writing.

The absence of effective promotion and retail marketing of condoms also limits their use, particularly among MSM populations. Commercial mass media advertising for retail branded condoms including Trust and Frenzy is relatively rare in the Philippines. A Philippines-based manufacturer of Trust blames the lack of advertising on obstacles created by the Ad Standards Council (ASC), a private group tasked by the government to regulate outdoor advertising. The ASC discourages the use of even the word “condom” in billboard ads, let alone an actual photo of a condom or any overt display of same-sex affection.

The Philippine government, with the assistance of international agencies and donors that support health in the Philippines, should demonstrate leadership in taking the necessary measures to address the country’s worsening HIV epidemic. That leadership hinges on the political will to recognize both the severity of the epidemic and the decisive role that the government can play in addressing it. By removing legal and policy obstacles to condom access and remedying the dangerous deficit in public awareness of safer sex and HIV prevention methods, the Philippine government would have the opportunity to stop a growing health crisis in its tracks.

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