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Story Publication logo February 22, 2016

The Philippines: Curbing HIV with Empathy, Not Bigotry

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While most countries around the world have managed to control the rate of HIV infections, the...

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Brother Paul Bongcaras tends to Lilibeth, a 28-year-old woman suffering from opportunistic infections due to HIV. She was in that state when she went to see doctor who sent her home saying that it was “nothing serious.” She begged friends to find Brother Paul, knowing he was the only one who could help her. Image by Veejay Villafranca. Philippines, 2015.

For a long time, the Philippines did not have an HIV problem. In the 1980s, when HIV was an unfolding health emergency in Africa and the Americas, the Philippines reported less than a hundred new infections each year.

But since 2010, more than 20,000 new HIV infections have been recorded in the Southeast Asian country. While HIV rates have decreased dramatically around the world, the Philippines is one of nine countries where new infections are rising by more than 25%.

Infection rates are particularly concentrated among a few "high-risk" groups, like men who have sex with men (MSM), transgender women, injecting drug users, and sex workers. But last year, in some cities HIV prevalence breached a 5% threshold among these groups — which means that the virus could start spreading at an exponentially faster rate. In fact, the Philippines' Health Department forecasts that total infections could quadruple by 2022.

The government is scrambling to halt the spread of new infections, but is bogged down by outdated laws that reflect the deeply conservative values of the island nation's Catholic majority. For instance, minors are prohibited from accessing HIV testing and free condoms without parental consent. Drug laws criminalize the possession and distribution of needles, hampering needle exchange programs.

In response, some communities in the Philippines are coming together to break down stigma through acceptance, empathy, and simple acts of kindness.

In the city of Cebu, the country's second largest economic hub, a Catholic monk, an American midwife, and an HIV+ couple are extending services to those who are under the radar. Meanwhile, in the heart of Manila, the Philippines' bustling capital city, a quirky doctor and dedicated counselors are reaching out the hidden group of "discreet MSM."

Together, they are quietly trying to heal the stigma of HIV.

***

Brother Paul Bongcaras: The Catholic monk who hands out condoms


Brother Paul gently patted the young woman's arm in a rhythmic wordless lullaby, soothing her as blood flowed from the drip bag to her veins. She wailed that the cross tattoo on her leg was painful and itchy.

He had last seen the 28-year-old woman, whom we'll call Lilibeth, during his nightly walks in Cebu City's shantytowns and "shooting galleries." Almost every night for more than 30 years, the 69-year-old monk has been meeting with those most condemned in the Philippines' Catholic society: the sex workers, the injecting drug users, the dealers and the pimps. He talks with them without judgment, giving them condoms and crackers. Outside the shantytown, he advocates on their behalf.

Lilibeth's friends think of her as beautiful and kind-hearted. She was the freelance sex worker who never ran out of clients because of her looks — and was never short of friends because of her generosity and easy smile. It was common for Lilibeth to share earnings with friends in need. In the hospital, it was hard to imagine the same woman had become a fragile figure with stick-like limbs and ashen pallor.

She was in that state when she went to see a doctor who sent her home saying that it was "nothing serious." She begged friends to find Brother Paul, knowing he was the only one who could help her.

Brother Paul found a doctor at the Vicente Sotto Hospital, an HIV treatment hub, and personally explained Lilibeth's situation. It was because of his efforts that she was back in the hospital, getting the attention she needed. But there was little left to do now besides alleviate her pain. Speaking was difficult, but Lilibeth removed her oxygen mask to tell Brother Paul how thankful she was that he was there, along with her boyfriend and her best friend.

Officially, nearly 500 Filipinos died of HIV-related causes in 2015. But the health department acknowledges that many deaths go unreported or are quietly passed off as meningitis or pneumonia.

Over the years, Brother Paul has realized the possible reason for the euphemism. He recalled the story of one deceased woman who was declined a funeral mass. They did not give a specific reason for the snub, but Brother Paul can't help but think that her death certificate which stated AIDS as the cause of death had something to do with it. Brother Paul found a way to have burial rites at the cemetery before she was laid to rest. For the woman's sister and the three children she left behind, it was a final tribute of love.

It saddens him that the Catholic Church has remained obstinate on programs like condom distribution and needle exchange programs. To Brother Paul and other HIV advocates, these policies have directly contributed to Cebu City's exponential increase in HIV infection rates; among injecting drug users, rates skyrocketed from less than 1% in 2009 to more than 50% the following year. On his walks, he sees opiates and sex being bought and sold for as little as 20 Philippine pesos ($0.50) and drug users sharing "service needles."

In response, Brother Paul is working with several NGOs and the Cebu City Health Office to build an informal care chain where information is shared and resources are pooled to provide whatever is needed: shelter for those disowned by family, formula milk for babies of HIV+ mothers, or simply emotional support.

While that remains to be decided by the hierarchy, Brother Paul will continue to comb the streets. He will hand out condoms and free advice — but what he is really offering is acceptance.

***

Hilary Overton: Caring for the pregnant and the unborn
It's not even 8am, and the waiting area of Cebu's Glory Reborn Birthing Clinic is abuzz. Women carrying their newborns close to their chest — some with a toddler snoozing on their shoulder — chat with pregnant ladies caressing their rounded bellies.

Hilary Overton walks in and cheerfully greets them good morning, her perfect Cebuano accent belying her blond hair and blue eyes. She greets some of the women by name and casually asks about their kids and husband, like old friends picking up an earlier conversation.

Hilary set up Glory Reborn in 2003, after her midwifery training led her to the Philippines. While working with Brother Paul, Hilary was exposed to the needs of women from the shantytowns, garbage dumpsites and brothels — and their vulnerability to HIV.

In 2008, around the time Cebu's health department first noticed an uptick in HIV infections among male injecting drug users, Glory Reborn started offering STI screening and HIV testing to their predominantly female clients.

"We weren't sure, but we thought that these women might be vulnerable to getting infected," said Hilary. Of the patients who agreed to testing, all turned out negative — until 2011, when a woman who was pregnant and tested positive at the city health clinic came to Glory Reborn for help.

As a birthing clinic, Glory Reborn was not certified to perform the C-sections or antiretroviral drug treatment (ARV) recommended to prevent mother to child transmission of HIV. Hilary instead referred the woman to Cebu Plus, an NGO that offers counseling and treatment.

And then another woman followed. And another.

A pattern emerged among these women. They would come during the later stages of their pregnancy with very little knowledge about HIV. They were all scared and confused after learning their test results. Also, most of these women did not typically fit the HIV risk profile; they were not engaged in sex work or shooting drugs. But their partners were.

Glory Reborn holds their hand through the process. A social worker will offer to go with the patient to Cebu Plus, who will immediately begin the procedures to help prevent mother-to-child transmission: ARV treatment and counseling for the mother, prenatal checkups, and scheduling of the C-section.

Throughout all this, Hilary and her team remain in the background, ready to help at any time. "We want to be with them on this journey," she said. "Once they are our patient, they are our patient for life."

The journey has taken her on an entire life cycle with her clients. Glory Reborn has sponsored numerous C-section deliveries and everything mothers and babies might need–food, vitamins, and formula milk. Sadly, they've sometimes paid for burials, too.

Brother Paul calls Glory Reborn's assistance "unli" — a colloquial term for unlimited mobile phone data plans. Hearing this, Hilary smiles. "Well, we're all in this together," she said.

***

Gabby and Rina Cardines: A blended family

Ask Gabby and Rina Cardines how many children they have, and their answer will vary.

Rina has a daughter from a previous relationship. They have two kids of their own and two "bonus" children: one who was abandoned by his mother and one who was orphaned by HIV. This doesn't count the ones who temporarily stay with them when an HIV+ positive parent is getting treatment or too sick to take care of them.

Gabby likes to tell people that their blended family is an extension of their own love story. "She had a big crush on me," he declared, winking at Rina.

"Oh yes, that I did," Rina quipped, proud that she had bagged a catch.

They met in a hospital in the early 1990s, when they were both getting treatment for HIV. People with the virus were feared as infectious, shunned, and disowned. Gabby had lost two wives to HIV, and before he met Rina, he was just waiting for his turn. Rina nursed his opportunistic infections with the promise of a family and that he would never be alone. Together, they became active HIV advocates and counselors at an NGO offering care and support for people living with HIV.

Eight years ago, they decided to move from Manila back to Gabby's hometown of Cebu and continued their work with a local HIV care group. The couple, who are open about their status, were shocked to find they had to relive the derision that marked the early years of the virus.

"Neighbors avoided us. No one spoke to us," said Rina.

Currently, there is only one NGO in the Philippines equipped to handle the needs of HIV-positive children — and it is in Manila, some 350 miles from Cebu. Usually, orphaned children who are not infected are turned over to the local social welfare department.

To help out, Gabby and Rina have opened their home to the children who need it. "We don't have much in terms of material things, but Rina and I believe that we can give the kids a loving home — and that is what they need the most," said Gabby.

Rina agreed and the two pull together what they can with Gabby working as a contractual worker and Rina as an HIV counselor.

"There are more and more pregnant positive women," she said. "What happens to the children if they die? Who will make sure they take their meds?"

Gabby and Rina know firsthand what it is like to be discriminated against. They will not let it happen to the children.

***

Kate Leyritana: The doctor who doesn't allow stigma in her clinic

Kate Leyritana doesn't wear a doctor's coat. In a big hospital, the white garment is a sign of authority. But in the small intimate confines of the HIV testing clinic where she works, it can signal intimidation and add to the anxiety of getting of an HIV test.

"Sometimes they think I'm the nurse or the receptionist and ask for the doctor," said Kate, while laughing. "I tell them, 'Well, I'm the doctor'." She loses no time in spinning a potentially awkward situation into a warm welcome at Sustained Health Initiatives in the Philippines (SHIP).

The dress code — or the lack thereof — is part of the clinic's strategy to shed off the impersonal and antiseptic vibe of a clinic. It distances itself from the testing clinics of the earlier years that were adorned with giant images of genitalia afflicted with STIs. Instead, cartoon drawings of farm animals hang in SHIP's three rooms.

(Certainly, that goal would have been difficult to achieve with a poster of gonorrhea hanging above your head.)

SHIP was established in 2013 as a memorial to a friend now simply referred to as "W", who died from HIV-related complications. His memory is inscribed in the clinic's logo of a ship with a W-shaped wave keeping it afloat. "We, his friends, did not know he had HIV and had refused treatment," recalled Kate. "We wanted to create an environment where no one would feel afraid of getting tested or talking to the doctor."

So far, the effort has paid off. If the clinic is a place where you can bring your mother, clients see Kate as a strict and well-meaning older sister. Since they started SHIP, they have seen and counseled more than 600 clients.

"Some of the check-ups extend to covering love and relationship advice — it's a good opening to talk about condom use and safe sex," she said with her characteristic hearty laugh that has put many clients at ease.

Check-ups have also expanded to include nervous parents whose questions need to be answered, siblings who affectionately jibe the patient, and concerned significant others. "I look at family members and boyfriends as my allies in healthcare," said Kate. "We're making sure the person we all care about stays healthy."

Some clients have, on their own, found a way to pay it forward.

Clients who are established professionals will see a student walk in and anonymously settle their bill. Regulars often donate a little something after each check-up to help defray the cost of transportation cost for others, one of the real but overlooked barriers to accessing treatment.

***

Klinika Bernardo: Treating patients after the sun goes down
Every Thursday, work starts before the crack of dawn for nurse Albert Milton and HIV counselors Jhun Oliveros and Anton Villanueva. Text messages are sent out to clients as early as 3am, serving as a wake-up call and reminder to meet at the train station at 6am for their weekly trip to the Research Institute for Tropical Medicine (RITM), the country's largest HIV treatment facility.

"The largest group that we had was 17 people," said Jhun. "We were like a tour group."

Of the estimated more than 12,000 HIV+ Filipinos enrolled in ARV treatment, about half go to RITM for free lab work and ARVs. More than a hundred clients weave their way through the treatment hub every day. But with only 18 employees, RITM decided to have a cut off at 10am. As early as 7am, patients start queuing to make sure they get a number.

When they're not on the train, Jhun, Anton, and Albert work at Klinika Bernardo (KB), the country's first "sundown clinic" open from 3pm-11pm. The local government opened it after officials realized that the bustling commercial district of Quezon City had one of the highest HIV infection rates in the country.

"It is the most convenient time for our clients who are mostly working professionals," said Nurse Albert. "Regular clinic hours would coincide with office hours."

Being open late into the night also offers the much needed anonymity for the discreet population of men who have sex with men (MSM); more than half of the country's HIV rates pool around young MSM between the ages of 25–34.

To attract this demographic, KB launched with a "Sexy and You Know It" campaign when they first opened. Chiseled male models trained in the basics of HIV, called "Bernardo Bodies," invited newcomers to check out KB.

But availability is not synonymous to availment. KB still needed a proactive effort to fish out the hidden MSM population. Anton and Jhun set up profiles on online dating sites advertising free condoms to initiate questions about STIs/HIV and later, an invitation to the clinic.

The group field trips, the Q&A hotline on dating sites, and in Jhun's case, offering his home to clients for a halfway stay from Wednesday night to Thursday morning is not expected of the staff. They are not paid extra for it, but they do it because they know it is a crucial step in closing the gap between testing and treatment.

Tomorrow night, Friday, will be the scheduled mobile testing at bars and cruising sites. On some days, it seems that KB is actually open 24 hours a day.

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