PHILIPPINES Health Sector Response: The National AIDS and STI Prevention and Control Program (NASPCP)

Dr. Jonathan Neil Erasmo STI/HIV/AIDS Program Coordinator Department of Health-Region VII
Disclaimer: The views expressed in this paper/presentation do not necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Board of Governors, or the governments they represent. ADB does not guarantee the accuracy of the data included in this paper and accepts no responsibility for any consequence of their use. Terminology used may not necessarily be consistent with ADB official terms.

Outline of Presentation
I.
Epidemiologic Background

II. Policies and Guidelines

III. Elements of STI and HIV Program

Essential Health Interventions for Key Affected Populations

IV. Program Goals and Objectives and Current Initiatives V. Conclusion

I. Epidemiologic Background
14
12 10 MSTD 8 6 4 2 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2005 2007 2009 2011 MSM IDU FLSW

1.

Concentrated HIV Epidemic

2-6% HIV
Prevalence among MSM in selected cities 52% Prevalence among people who inject drugs in Cebu City

RFSW

2.

HIV prevalence among different risk groups noted in the past 5 years
(Source: Integrated HIV Behavioral and Serologic Surveillance, NEC)

Estimated HIV Prevalence (2013): 0.048% Half of new infections are in Metro Manila

3.

National Center for Disease Prevention and Control

Size of Key Affected Populations

(National Epidemiology Center, 2011) Cluster Metro Manila Key Population Numbers (Est.) MSM RFSW FFSW Cebu Province MSM IDU RFSW FFSW 95,909 15,008 7,504 30,149 6,000 3,480 1,989 Proportion to Population 0.211% 0.03% 0.17% 0.066% 0.013% 0.008% 0.004%

Rest of Country

MSM
IDU RFSW FFSW

563,471
9,355 35,996 25,198

1.241%
0.021% 0.079% 0.056%

Estimated Number of PLHIV in Selected Countries 2012

(Source: UNAIDS Website)

Country

Number of PLHIV

Prevalence Rate (15-49 yo)

Thailand Indonesia Vietnam Malaysia Cambodia Philippines

490,000 380,000 250,000 81,000 64,000 26,907*

1.20% 0.30% 0.50% 0.40% 0.60% 0.04%

* High estimate maybe lowest among the selected countries but increasing rate of cases per month

HIV Cascade Model, 2012

30,000
25,000 20,000 15,000 10,000 5,000 4969 3,121 351 11,125 23,918

*Projected No. of PLHIV

No. of Reported HIV Cases

PLHIV in **Enrolled in need of ART Tx Hubs

Deaths

*Due to lack of regional projections, the national projection of PLHIV from EPP/Spectrum was disaggregated based on the regional proportion in the HIV/AIDS registry. **Number of PLHIV on ART is based on the treatment hub in the region. No available data for regions with no treatment hubs.

Current Gaps in HIV Response for MSM

1 2
Significant Portion of the Population are not being covered
(HIV Prevention Activities, HIV Counseling and Testing, Enrollment on ART and Reported Low Adherence to Treatment and Lost to Follow up of those on ART)

Very Basic Package of Intervention offered at SHCs, which are primarily intended for FSWs

3. Lack of a Comprehensive/Holistic Services among MSMs

4. Current Strategies are not age-specific and innovative to
respond to the needs of the MSMs

5. Limited involvement of PLHIV CBOs in MSM Programs

II. Key Policies and Guidelines for HIV Response

Subject (Year Issued) HIV Counseling and Testing (2010) PMTCT (2009) Access of ARV (2009) TB-HIV (2008)
Objectives of the Policy Guidance on HIV counseling and testing (HCT) at community and health facility settings Guidance on prevention of mother to child transmission of HIV that shall be used by health care providers nationwide Standards for the use of ARVs among adults and adolescent living with HIV in the Philippines Provide guidelines for cross-referral of TB to HIV, and HIV to TB and TB/HIV comanagement

Internet Link
https://dl.dropbox.com/u/ 84112124/HCTao.pdf

https://dl.dropbox.com/u/ 84112124/PMTCTao.pdf https://dl.dropbox.com/u/ 84112124/ARTao.pdf https://www.dropbox.com /sh/19ts3d5yq5nt9j2/mHQ _FOgti1/TB_HIVao.pdf http://db.tt/XgNkcjN1

Philhealth Memo aimed to increase the proportion of population having access to effective on HIV Benefit HIV/AIDS treatment Package
(2010)

Technical Guidelines
POST EXPOSURE MANAGEMENT Hepa B & C, HIV

MANUAL OF PROCEDURES Social Hygiene Clinics

PEDIATRIC HIV GUIDELINE

HACT GUIDELINES

III. Elements of STI and HIV Program

HIV Prevention STI Diagnosis and Treatment Safer sex and condom promotion Post-Exposure Management for health workers Prevention of mother-to-child Transmission Harm reduction HIV Testing and Counseling Pretest education/counseling HIV testing Post-test counseling

Mobilization and coordination of key players including people living with HIV/AIDS and Key Population Key players - health centers and clinical services (incl. TB, antenatal clinics, Social Hygiene Clinics), PLHIV, Local AIDS Council, private sector, CBO, FBO and NGO Referral system to ensure access to and continuity of care Promotion of peer support mechanisms for Key Population, PLHIV
Clinical care Management of OIs including TB, PCP ART including adherence support Palliative care including symptoms and pain Psychological and socioeconomic support HIV counseling and spiritual support End of life care Social welfare Nutritional and daily living support Stigma and discrimination reduction

Prolonged quality of life through optimal ART adherence Accelerated HIV prevention

STI and HIV Prevention

STI Diagnosis and Treatment

Safer sex and condom promotion

Infection Control in the hospital setting
Post-Exposure Management for health workers

Syphilis Management during Pregnancy Harm reduction for People Who Inject Drugs

SelfAssessment of Risk

Promotion of HIV Testing

HIV Counseling and Testing

SHC based HCT for walk in clients Mobile VCT

Provider Initiated Counseling and Testing (PICT)

all patients with STI partners of high risk individuals TB and pregnant women in Category A sites patients with AIDS-defining conditions in hospitals

Clinical Care
Management of common opportunistic infections (OI)
including TB, PCP

Antiretroviral therapy (ART) Care for chronic conditions for those under long term
ART

Palliative care including symptoms and pain

Psychological and socioeconomic support for PLHIV

Counseling and spiritual support

Linkage to social support

Nutritional and daily living support Stigma and discrimination reduction End of life care

Males Having Sex with Males

Education and interpersonal
communication thru peers and outreach HIV Counseling and Testing linked to MSM organised events Repeat HIV testing every 6 months for regular clients Condom and water-based lubricants distribution Mobile VCT for cruising, bar/establishment based Syndromic STI diagnosis and treatment

People Who Inject Drugs (PWID)

Communitybased Peer Education Motivational Counseling and offer of
drug counseling and rehabilitation Education on use of clean needles and syringe Condom promotion and distribution Mobile VCT STI Diagnosis and Treatment Hepatitis B and C testing

People Living with HIV

Baseline CD4 testing (requested by facilities doing the
testing) Adherence counselling prior to ARV initiation and during ARV treatment HIV Outpatient Benefit Package of Philhealth Management for common opportunistic infections (eg., TB, co-trimoxazole for PCP, fluconazole) ARV for pregnant mothers and children Early infant diagnosis thru PCR testing (as early as 6 weeks of life)

Service Delivery Network for HIV

Blood Service Facilities Satellite Treatment Hubs

TB-DOTS, Ante-natal and OFW Clinics Hospitals

Social Hygiene Clinics And HACT of Hospitals

HIV Treatment Hubs

Community Based Organizations

Support Groups, Networks,

IV. Program Goals, Objectives and Current Initiatives

HEALTH SECTOR GOALS by 2016

GOAL#1: Reduce New HIV Infections

Lower the cumulative new HIV infections by 50% (between 2013-2016) Lower the cumulative new pediatric HIV infections by 90% (between
2013-2016)

60% of people living with HIV (PLHIV) know that they are infected
GOAL#2: Improve the quality of life of People Living with HIV (PLHIV)

90% of PLHIV in need of treatment are on Antiretroviral (ARV) drugs 90% of 2-year cohort patients are still on the first-line ARV regimen 90% of PLHIV with TB are provided TB treatment

Key Accomplishments
% of patients eligible for treatment are started on
Antiretrovirals: 76% (2012), 67% (as of June 2013) % of PLHIV on ARV enrolled to Philhealth HIV Benefit Package: 47% 18 HIV Treatment Hubs established nationwide 4,500,000 male condoms distributed to MSM and Sex Workers Organised outreach activities linked to HIV testing in high risk communities Mobilised individuals to volunteer as peer educators esp in high risk cities Supported CHD-NCR for establishment of 7 Satellite Treatment Hubs

Reflections on the Results of the Getting to Zero Assessment Tool for NCR
HIV/AIDS perceived as vertical health program can be good
opportunity or hindrance depending on the priority of health authorities (national/local) Danger of staff burn-out Health services are available but not widely promoted, hence less popular; Stigma and discrimination felt/perceived (lack of understanding on MSM/TG concerns) Ineffective IEC and communication Opportunities - enthusiasm by CSO, individual volunteers, current projects, CHO support SHC customers and stakeholders generally satisfied with the services

V. Conclusion
Limited program coverage only 15% of MSM underwent HCT and only 5% know their
status less than half of PLHIV know that they are infected Services not friendly to MSM/Transgender; and Young People HIV testing not accompanied by adequate quality counseling services Referral systems from diagnosis to HIV treatment Effective IEC and health promotion campaigns Prisons, young people (males who like other males), partners of KP (for PMTCT) No established system to notify partners of PLHIV