Filipino MSM and the epidemic of HIV Infection

by Diana G. Mendoza

(unedited version of the Inquirer article published December 1, 2008, page 1)

JR, 28, a single male professional, is currently seeing a girl. He wants to be married to a girl and have children someday. He has had romantic and sexual affairs with eight other females, including around 20 males. He avoids categorizing himself into such labels as gay or MSM (men having sex with men), but says he is into gay pornography, chatting in the Internet chat rooms for men who want to contact other men, and “cruising” in parks, second-run cinemas, and subdivisions. He reads a lot of stuff about men like him, but never forgets to know how to stay healthy and clean. “I have been in all kinds of sexual exploits, and there were only a few times that I failed to use a condom,” he said. At home and in the workplace, he is just one of the guys.

Marco, 20, is into his first job as an office assistant. College was just a year ago, but he remembers that he had his first same-sex relationships during this time, and he considers it educational. “I continue to meet up with boys my age. We act like regular guys on a night out, but I have constant sex with one of the boys,” he told an interview. He also had sex with two girls already. Asked if he uses condoms for protection during sex, he chuckled, “Is that necessary? I’m just starting.” He said he knows how to use condoms, “but it’s just disturbing when you have to put it on in the middle of it.”

JR and Marco are part of what health experts call the “hidden population” of MSM that are difficult to reach in HIV prevention programs. Although the two men have different levels of knowledge and circumstances, it is the vast population of young and uninformed or older and uneducated MSM that challenge the public health system. JR said it helps that he has a friend who constantly informs him to be conscious of his health and to seek medical help when needed. But for Marco, the dangers are out there, as he is still in a prolonged experimental stage.

Dr. Eric Tayag, head of the Department of Health epidemiology center, said boys like Marco are the persons most in need of appropriate intervention programs because of the shift in the age group that is now becoming infected. Tayag sounded the alarm of an epidemic of HIV infection among MSM in October 2008 during the Philippine National AIDS Convention, a biannual event of the non-government organization AIDS Society of the Philippines. He said the huge problem for the Department of Health was to declare this unusual epidemic in the tradition of announcing an outbreak of dengue fever.

Citing the DOH HIV/AIDS Registry, a collection of reports from hospitals, clinics and treatment centers of laboratory-confirmed HIV tests, Tayag noted sudden, steep increases in HIV infection among MSM in the last three years compared with the yearly cumulative numbers. For instance, the registry recorded 210 new infections among MSM in 2005, 309 in 2006, and 342 in 2007. From January to September 2008 alone, there were already 395 cases. The numbers posted a 96% increase since 2005. He said the last three years surpassed and broke the 21-year pattern of slow trickles of increases, with the last 12 years from 1993 to 2004 averaging only 100 or more each year. Because the cases were tremendously in excess of what was usually expected, he concluded that “there is an ongoing HIV and AIDS epidemic among the MSM. Several factors may be responsible, but we believe MSM has become the new sexual norm (in HIV transmission).” Independent behavioral studies, he said, showed widespread unsafe sex happening in this group, such as the non-use of condoms during sexual contact, mainly anal sex.

As a result, the ongoing epidemic will escalate and will not be contained in the next five years unless fearless, aggressive interventions are done. “The die is cast,” he said. Tayag said the DOH is searching for ways to engage the MSM communities in information and education. But this will not be easy because the MSM are “invisible men” and many of them may be “closeted” or are not open about their sexual orientation and sexual activities. “We cannot predict the level of stigma and discrimination against MSM when we link the new findings to them,” he said. “The last thing the DOH wants is to label HIV and AIDS as a “gay disease.”

Through the years, males comprised 69 percent of the total number of infections through heterosexual, homosexual and bisexual contact, with MSM triggering the bulk. The MSM are grouped in the homosexual (having sex with the same sex) and bisexual (sex with both male and female) modes. He noted that for the first time in 2007, homosexual and bisexual mode of infection surpassed heterosexual transmission. The most affected age group among males has also moved younger -- from 45 to 49 years old to 20 to 29. Among the newly-infected, he said, “We are looking at a special population of 15 to 24 years old and we would like to see how HIV moves in this age group.” He said the 25 to 34 age group is also widely affected.

He said the newly-infected, 90 percent of whom are single, are mostly students and young professionals -- a sudden departure from the sectors that health experts call “most-at-risk populations” such as freelance sex workers or those plying their trade in the streets, establishment-based sex workers working inside nightclubs and bars, male clients of sex workers, and injecting drug users. Prostituted males who service other men are also in the newly-infected MSM group, and they are also very young. Because the HIV registry is a passive surveillance system as it receives reports only from hospitals, clinics and treatment centers nationwide doing HIV blood tests, he said the entire picture of HIV infection is not captured, but nevertheless provides a trend.

For now, Tayag said the predominance of MSM is highest for Metro Manila. One limitation of the registry is the accuracy of “place of residence” since services for treatment, care and support are more readily available in Manila, thus, those who seek these services may report Manila as their residence to increase their chances of obtaining these services or, had temporarily stayed in Manila while getting services. The capital’s HIV hotspots are Manila, Quezon City and Pasay. Elsewhere, increasing infection rates among MSM are also reported in Angeles, Cebu and Davao.

In Metro Manila, the catch basin seems to be the Manila social hygiene clinic in Sta. Cruz, Manila that receives a mostly male clientele. In October 2008, clinic physician Dr. Diana Mendoza (not related to the author) said out of 30 who tested positive, 29 were men aged 20 to 34, most of them students and professionals.

Mendoza stares at the HIV epidemic up close. She said it is only part of the rising increase of sexually transmitted infections. Some of her male patients have multiple infections, which could be syphilis or gonorrhea, and then HIV. Her small staff struggles to do confidential counseling, which is given before and after blood testing, because risky sexual behavior is widespread. “Many men know they have risks but they still have sex, if not with one partner that was unprotected, it’s with more than two partners, either male or female, often under the influence of drugs and alcohol,” she lamented.

For male adolescents and teenagers, the liking for a partner of the same sex, just for kicks, is common, and so are parties and orgies. Smoking, drinking and drugs are fixtures. In some cases, older men initiate the risky practices to the young. “I often tell my patients, “you should be scared, not other people.” The clinic staff handles the double burden of a patient’s disclosure of his medical status to the family, more so because they engage in sex with the same sex, which is still a taboo in the conventional Filipino family.

Tayag said the shift in the mode of transmission is reflective of the evolving sexual norm. “It is possible that same sex experience is enjoyed as an alternative behavior to opposite sex relationships either influenced by peers or by society’s permissiveness,” he said. He said more studies are needed to reveal veritable factors that influence this sexual norm, but he said since most of the HIV-infected cases were reported in young than most MSM, same sex experience occurred at a much younger age.

One such study in 2004, “Sexually Transmitted and Blood-borne Infection Prevalence Assessment in a High Risk Population: Males who have sex with Males (MSM) in the Philippines” provided an explanation to the sexual norm --males are traditionally privileged in Filipino society and they have more sexual choices and freedom than women. Men can have multiple identities, from highly masculine men whose primary sexual partners are women, through gay and bisexual men, to transgenders. The study said prevention programs have often been limited by lack of understanding of the behaviors of different MSM subgroups and of the impact of those behaviors on the dynamics of HIV infection.

The settings are reflected in the 2002 Young Adult Fertility and Sexuality (YAFS) Survey of 20,000 15-27 year olds that found out that twice as many males had had premarital sex compared to females (31 percent as against 16 percent.). It also revealed that 15.1 percent of sexually active males had male partners. Likewise, a DOH and Family Health International study showed that 11 percent of 1,204 men in the general population had multiple sexual partners in the previous six months.

Other heath experts who acknowledge the HIV epidemic among MSM and who said the facts confirmed what they have been seeing more than five years ago -- that MSM will trigger infections, only that there were no sufficient data at that time – said the work will be tremendous for both government and the non-government organizations.

Dr. Ofelia Monzon, who pioneered the first medical investigative studies of HIV and AIDS in the Philippines through the Research Institute for Tropical Medicine in Alabang, Muntinlupa, told an interview she foresaw this epidemic during the beginnings of HIV infection in the Philippines for many reasons. “Considering the dynamics involved in HIV spread, we should remember that HIV infection is not a static infection, nor will it stay confined to a specific group,” she explained. She said “some of the men labeled MSM do have sex with females, showing a possible route for spread to others outside the group and so on.”

She said the major mode of transmission of the virus is sexual, and modifying or controlling behavior is most difficult as seen in cigarette smoking where knowledge has not resulted in cessation of the smoking habit. “In sex, other factors play roles in behavior such as culture, religion, even wealth and societal standing influence the ability to alter sexual behavior.”

Tayag said risky behavior often outweighs knowledge and awareness, citing results of a survey in the Philippines by the UN General Assembly Special Session on HIV and AIDS indicating that MSM have basic knowledge of sexually transmitted infections such as HIV, but the actualization is poor. Only two out of five men used a condom with their most recent sex partner but the use varied with consensual sex and paid sex. It is also unbelievable, he said, that some think HIV can be contracted from a mosquito bite, and are not aware that it is transmitted only through sex, transfusion of infected blood, exchange of contaminated needles and syringes among injecting drug users and from an infected mother to her baby.

Providing information alone requires complementary efforts in reaching out to target populations such as MSM. In Davao City, the NGO Wo/Men’s Access to Vital Education and Services (WAVES) is implementing HIV and AIDS counseling through Internet live chat and it is able to touch base with MSM. John Roxas, executive director, said most of his organization’s MSM chatters struggle with their emotions and ideas about their sexuality, and for a few who have come to terms with it, they believe they are men who happen to like and prefer to have sex with other men. Some have issues about “letting the female in them but remain manly-looking.”

But whatever their struggles are, Roxas said “almost all are into risky sexual activities with multiple partners, non-condom users, into anal sex most of the time, have experience sex with both men and women, have heard about HIV and AIDS but have not given it a serious thought, interested to get tested for HIV but are afraid to be identified, and only few can link HIV to other sexually transmitted infections. “