Wednesday, March 14, 2012
The Philippines: an HIV mystery (or, Why the Philippines must control the spread of condoms)
Can the Philippines keep AIDS at bay if it embraces condom culture?
The advance of AIDS in the Philippines has been "low and slow", but birth control ideology could unleash a full-blown epidemic.
by Oliver M. Tuazon and Angelo S. Porciuncula
(March 5, 2012)
While the Philippine Senate is busy with the impeachment trial of the Chief Justice of the Philippine Judiciary, the House of Representatives has resumed its interpellations on the controversial Reproductive Health Bill (HB 4244). President Benigno Aquino III is a known supporter of the bill, which has caused worry in some quarters that he will ask his allies in the lower house to fast-track its passage as he did with the impeachment of the Chief Justice. The Speaker of the House is a member of the Philippine Legislative Council for Population and Development, one of the most active groups lobbying for its passage.
The RH bill is entitled “An Act Providing for a Comprehensive Policy on Responsible Parenthood, Reproductive Health and Population Development and for Other Purposes.” However, let’s be clear that the Philippines is not a desert when it comes to birth control devices and services. In recent months, as condom ads flooded the streets and consciousness of Philippine society, it has become clear to everyone that the marketing and use of contraceptives in the Philippines is already legal and that the RH debate is actually about the use of government funds to promote and supply condoms, pills, injections, IUDs, sterilization procedures and so on to all and sundry.
This would, above all, complete a cultural revolution that began in 1967 when former President Marcos signed up to an international agreement on population control, a concept that the West has successfully imposed on many other developing nations. In conjunction with other social changes such as urbanisation, indigenous sexual and family culture has been undermined in these countries and new health threats have arisen, which lends doubt as to its genuine concern for “(reproductive) health”.
This is nowhere more evident than in the HIV/AIDS epidemic that has swept sub-Saharan Africa and parts of Asia while condom has been king. It is on this phenomenon that we now wish to concentrate as it demonstrates a compelling practical reason for rejecting the cultural package that the RH bill represents. The following is part of a longer paper that includes a wider review of the scientific evidence about condoms and AIDS.
The Philippines: an HIV mystery
Once referred to as an “HIV mystery” (1), the Philippines has HIV levels that have remained extremely low since the first AIDS case was diagnosed in 1984 (2). With a prevalence of less than 0.1%, it is second only to Bangladesh in Asia (see Figure 1) (3), despite having risk factors that have long pointed to an AIDS epidemic waiting to happen (4).
The status of the AIDS epidemic in the Philippines has been described as “low and slow” (5). This has been attributed to the following factors: very low numbers (less than 1 percent of the population) in conventional high-risk groups (sex workers, men who have sex with men, STD clients); low numbers of sex worker clients per night (calculated to average about 4 per week); the low number of injecting drug users; the early multi-sectoral response to the epidemic; and the presence of social hygiene for sex workers (5). However, men having sex with men has accounted for more than 80% of the HIV cases recently. (http://www.doh.gov.ph/sites/default/files/NEC_HIV_Dec-AIDSreg2011.pdf).
The very low rate of condom use has also puzzled experts, as it seems to “go hand in hand” with the very low rate of HIV infection, according to a 2003 New York Times article (6). A survey involving over 10,000 young people conducted in 1995 reported that only 23 per cent of sexually active men had used a condom and a fewer than 4 per cent had used a condom in their most recent sexual act (7).
Figure 1. The Philippines, characterized by a “low and slow” AIDS epidemic, has one of the lowest HIV rates in Asia. Source: USAID, “HIV/AIDS Health Profile: Asia” (2011)
The Philippines and Thailand started with almost the same number of AIDS infections. What are the current data?
The classic comparison of trends in condom use and HIV prevalence are between Thailand and the Philippines, although not indicative of causation, presents data of considerable epidemiological impact.
In the late 1980s, Thailand and the Philippines had roughly the same number of HIV/ AIDS cases at 112 and 135 cases, respectively. In the early 1990s, the government of Thailand enforced the 100% Condom Use program in its booming commercial sex industry while the Philippines was characterized by its very low rate of condom use and the firm opposition of church and government to condoms, among other forms of contraception. In 2003, almost fifteen years later, the number of HIV/ AIDS cases in Thailand had risen to 750,000 while the number in the Philippines remained low at 1,935 cases as the latter’s population grew to more than 30 per cent that of Thailand (8). Thailand now ranks as the country with the highest HIV prevalence in Asia.
As a side note, however, Thailand has also experienced declines in HIV levels. Although the decline has almost always been credited, hands down, to the mandatory condom policy, fundamental changes in behavioral patterns have also contributed to the effect, suggesting that “it was at least as important as increase in condom use” (9) such as the decrease in visits to sex workers from 22 per cent to 10 per cent and the decline in non-regular partners from 28 per cent to 15 per cent (9).
What is the best way to avoid contracting STDs?
Data point to a potential risk involved with inconsistent condom use that, according to studies, appears to reflect how it is indeed used in real-life situations. The same evidence also shows that the only type of condom use that is really effective in reducing the risk of HIV infection is consistent, perfect condom use (10). This raises the question whether “consistent, perfect condom use” is ever attainable given the often-imperfect circumstances of the human condition. Nevertheless, even perfect condom use cannot take away the risk altogether.
It is important to clarify that condoms may reduce the risk but cannot prevent it. We then question the role of condoms in AIDS prevention schemes, not to mention its inability to prevent the spread of skin-to-skin pathogens such as HPV and HSV, the top two most widespread STDs in the world.
Cumulative risk and risk compensation are possible explanations for the failure of condoms as frontline prophylactics in the world’s fight against AIDS, especially in some parts of Sub-Saharan Africa where massive condom promotion proved rather detrimental. Cumulative risk or “the likelihood of an outcome occurring at least once, given a repeated number of risk exposures” (11) explains why single-episode effectiveness may decrease as the number of exposures to an infected person increases. On the other hand, risk compensation refers to the phenomenon in which people may engage in riskier behavior because they feel safer than is actually justified when using a particular preventive technology (e.g., condoms). In effect, this offsets the benefits of risk reduction ascribed to that technology (12).
Extensive research on best practices in Africa, leading to a decline in HIV levels, unanimously highlight the essential role of the delay of sexual debut (abstinence) and, more importantly, partner reduction (fidelity) in AIDS prevention (13-14).
How do these apply to the Philippine scenario?
Now, applying these lessons to the Philippines, a country with a “low and slow” HIV epidemic, we recommend the optimal course of action: prevention and risk avoidance, never complacency. Regardless of whether one comes from Africa or from the Philippines, abstinence and fidelity are always an option. Abstinence and fidelity are concepts that are rooted in the character and values of the person (the values of temperance and chastity, for example). These goals can be sustainably achieved with character and values-centered education, not by mere information dissemination and slogans. This alternative to risky behavioral patterns should always be proposed “for reasons of health, ethics, and well-being“. (13).
What could be done by our legislators to help maintain the “low and slow” HIV/AIDS prevalence in the Philippines and to reduce further infections?
Although correlation does not necessarily mean causation, the data presented above shows that in countries where condoms were promoted, the prevalence of HIV/AIDS increased. The latest book of Harvard University AIDS research expert Dr. Edward Green, Broken Promises: How the AIDS Establishment has Betrayed the Developing World, boldly takes up this topic and suggests that a “sex-positive” approach and condoms promotion in Africa have contributed to the continent being the home of the greatest number of AIDS victims in the world. Even way back in his 2003 book, Rethinking AIDS Prevention, Dr. Green had already pointed out that behavioral change was more effective than condom promotion.
While HIV/AIDS prevalence in the Philippines is still “low and slow”, and before condom promotion undermines its sexual culture any further, legislators need to craft a law that will regulate, if not totally ban, the promotion of condoms -- just as they have done with tobacco.
What could be the provisions of a “Condoms Regulation Act”?
The Tobacco Regulation Act of 2003 noted, among other things, the “policy of the State to protect the populace from hazardous products and promote the right to health and instill health consciousness among them.” The Act stipulated that the “use, sale, and advertisements of tobacco products shall be regulated in order to promote a healthful environment and protect the citizens from the hazards of tobacco smoke…”
Certain provisions of the tobacco Act could be translated into a “Condoms Regulation Act” as follows:
* Inform the public of the health risks, both cumulative and compensatory, associated with condoms.
* Regulate and subsequently ban all condom advertisements and sponsorships, including celebrity endorsements.
* Regulate the labeling of condoms along these lines: condoms are not 100% effective against HIV/AIDS; condoms do not protect you from STDs such as HPV and HSV; being faithful to your spouse is more effective than condoms; condoms can predispose you to STDs; say no to premarital sex…
* Protect youth from being initiated to pre-marital sex, which is a major reason for the spread of HIV/AIDS and other STDs. A behavior change program can be implemented for those already initiated, and programs on character formation, fidelity to one’s spouse and family can be incorporated in the grade school and high school curricula.
Compared with the global situation, the Philippines is still in a privileged position regarding HIV/AIDS prevalence. This could be due to the low prevalence of condom use and the persistence of traditional values that regard sex as proper to marriage. The unabated proliferation of condom ads in the country may, however, change these values. Lawmakers are highly encouraged to pass a bill that will regulate, if not totally ban, the promotion of condoms in the Philippines. This would be in the interests of preventing an increase in the incidence of STDs, particularly HIV/AIDS, and protecting the Filipino’s high regard for sex within marriage, which has been noted as the best guarantee to prevent the spread of HIV/AIDS.
Angelo S. Porciuncula is a PhD candidate in Molecular Biology at the Center for Applied Medical Research (CIMA), University of Navarra in Pamplona, Spain. He finished his undergraduate degree in Molecular Biology and Biotechnology at the University of the Philippines, where he was a student of Oliver M. Tuazon, who used to teach Biology and Microbiology classes.
1. X. Bosch, “HIV mystery in the Philippines.” Lancet Infect Dis 3, 320 (2003).
2. "ADB Supporting Philippines in Combating Spread of HIV/AIDS", ADB, Ed. (Manila).
3. USAID, “HIV/AIDS Health Profile: Asia” (2011).
4. A. C. Farr, D. P. Wilson, “An HIV epidemic is ready to emerge in the Philippines.” J Int AIDS Soc 13, 16 (2010).
5. R. Mateo, Jr., J. N. Sarol, Jr., R. Poblete, HIV/AIDS in the Philippines. AIDS Educ Prev 16, 43 (2004).
6. S. Mydans, “Low Rate of AIDS Virus in Philippines is a Puzzle,” New York Times, April 20, 2003.
7. D. Balk, T. Brown, G. Cruz, L. Domingo, “Are young people in the Philippines taking chances with HIV / AIDS?” Asia Pac Pop Policy, 1 (1997).
8. R. Bullecer, “Telling the Truth: AIDS Rates for Thailand and the Philippines” (2004).
9. D. Low-Beer, R. Stoneburner, “Behaviour and communication change in reducing HIV: is Uganda unique?” African Journal of AIDS Research 2, 9 (2003).
10. K. R. Davis, S. C. Weller, “The effectiveness of condoms in reducing heterosexual transmission of HIV.” Fam Plann Perspect 31, 272 (1999).
11. J. T. Fitch et al., “Condom effectiveness: factors that influence risk reduction.” Sex Transm Dis 29, 811 (2002).
12. M. M. Cassell, D. T. Halperin, J. D. Shelton, D. Stanton, “Risk compensation: the Achilles' heel of innovations in HIV prevention?” BMJ 332, 605 (2006).
13. M. Hanley, J. de Irala, Affirming Love, Avoiding AIDS: What Africa Can Teach the West. (The National Catholic Bioethics Center, PA, 2010), pp. 202.
14. E. Green, D. Halperin, V. Nantulya, J. Hogle, “Uganda’s HIV Prevention Success: The Role of Sexual Behavior Change and the National Response.” AIDS and Behavior, 10, 335 (2006).