Living with HIV in the Philippines
MANILA, Philippines — Thirty-five years ago, HIV was identified as the causative agent of the deadly disease known as acquired immune deficiency syndrome (AIDS). In the intervening time, the world came together to valiantly fight the scourge that has killed 35 million people. Scientists, activists and nations toiled hand in hand and developed an effective treatment, nearly restoring the life expectancy of people living with HIV (PLHIV) and eliminating transmission in those on proper medication. In the last few years, we have seen two instances of a true HIV cure. Two weeks ago, scientists reported eliminating HIV in mice with transplanted human immune systems, an important first step towards finding a practical cure.
It seemed like only yesterday when Magic Johnson announced that he had HIV in the 1990s. Everyone was shocked. Many did not think HIV affected anyone other than gay men. But just as Johnson surprised everyone with his public disclosure, we were also astounded that he didn’t die, and he thrived and stayed relevant in his field despite his HIV diagnosis.
While cases of HIV have gone down in most of the world — thanks to the wider availability of life-saving antiretrovirals — the Philippines turned out to be a late bloomer. The first local cases of HIV were diagnosed back in 1984. Mysteriously, the numbers stayed low, while neighboring countries such as Thailand and China experienced full-blown epidemics. Many wondered why this was so, to the point that some felt that Filipinos had some sort of natural immunity to HIV. This ended up being too good to be true, and we now have the fastest-growing HIV epidemic in the world.
What changed? And why did it take so long for our epidemic to come to fruition? Part of the reason is that many Filipinos are circumcised, which decreases a male’s susceptibility to HIV infection. One of the major drivers of the unprecedented increase was discovered by our laboratory at the National Institutes of Health. We were studying reports of increasing drug resistance in HIV, and we found that the strain or subtype of HIV in the Philippines had drastically shifted.
HIV is one of the fastest-mutating organisms on the planet, with a mutation rate 1,000,000 times than bacteria. It has a duplicate set of genes, unlike most viruses and more like humans and animals, which can sexually reproduce.
Unfortunately, 90 percent of research on HIV is only on one subtype — subtype B, which makes up 12 percent of all the HIV in the world. It is the most studied because it is the predominant subtype in the US and Western Europe, where most of the research on treatment occurs. While we like to think that what works on subtype B is good for the other subtypes, this is a dangerous assumption to make. The genetic differences are just too great, and with the lack of proper monitoring, drug resistance to the life-saving antiretrovirals can rapidly emerge.
The present epidemic is being fueled by a shift from HIV subtype B to a circulating recombinant form that first emerged in Thailand known as CRF01_AE.
Coupled with suboptimal monitoring, the treatment failure is detected late, and drug resistance to multiple antiretroviral agents accumulates. Terrifyingly, sexually active persons with a drug-resistant virus can pass their resistant virus to their uninfected sexual partners, compounding the problem by causing early treatment failure. We already see a greater than 10-percent drug resistance rate among newly diagnosed persons living with HIV.
But hope is not lost. We have been lobbying for newer, more potent antiretrovirals for our patients at affordable prices. The amendment to the Philippine AIDS Law passed in the previous Congress and will provide more resources to promote testing and treatment of HIV for our countrymen. Stigma is being addressed through education and protection of patient confidentiality. The new law prohibits Health Maintenance Organizations from denying health insurance coverage to PLHIV. Anti-discrimination provisions include the prohibition of HIV testing as a requirement for employment, and the age of consent for confidential HIV testing has been lowered to 15 years old to increase uptake.
The Department of Science and Technology has invested in our project that is developing rapid and affordable mobile drug resistance testing to detect resistance in those who are starting or failing treatment, a world-first with tremendous implication for fighting resistance in resource-limited settings. We have strongly communicated to the World Health Organization (WHO) that suboptimal monitoring of HIV— when we only check for treatment failure after one year, compared to much earlier in developed countries — will just drive increasing resistance and is absolutely not acceptable. The antiretroviral regimens that WHO previously recommended are no longer being used in developed countries due to increasing resistance and side effects, not to mention their poorer performance in our non-B subtype epidemic. The WHO guidelines need to reflect the best practices in the world, not what they think we can afford. Our Filipino PLHIV deserves the very best of care, and we should work with international partners — not to tell us what we can or cannot do — but to help us do what we should do and make these best-practice interventions accessible and affordable.
HIV has killed enough Filipinos. It is time to turn the tide. Antiretrovirals not only restore life. They also virtually eliminate transmission when taken properly. This means that PLHIV can have normal relationships; have children naturally without fear of transmitting HIV, and health-care workers with HIV can operate and take care of patients without any risk of infecting them. We have the tools to reverse this epidemic. It is up to us to use these effectively and to demand the best for our Filipino PLHIV brothers and sisters who can now continue to live full and productive lives. — Dr. Edsel Salvana
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Dr. Edsel Salvana is the director of the Institute of Molecular Biology and Biotechnology at the National Institutes of Health and an associate professor of Medicine at the Philippine General Hospital. He was bestowed The Outstanding Young Men Philippines award for his work in HIV.
