HIV in the Philippines: A Persisting Public Health Crisis Closely Tied To Social Stigma

Posted on by BUJPH

drawing of women with text bubbles

By Emily Mrakovcic

Illustration by Ella Olea

 

Introduction

Human immunodeficiency virus, also known as HIV, is present in several regions around the world. Although the virus has the same transmission mechanisms and symptoms regardless of its locality, HIV is experienced very differently across the globe.¹ This is due to several cultural and social factors impacting how HIV is viewed and treated. The Philippines is one country where the way individuals view HIV heavily impacts its transmission and treatment.2 Due to stigma and discrimination surrounding HIV, the Philippines is currently experiencing the fastest-growing HIV epidemic in the Western Pacific.3 Specifically, stigma and discrimination against men who have sex with men (MSM) and HIV-positive MSM have significantly boosted the proliferation of the virus.4 MSM with HIV in the Philippines face an intersection of stigma: on the one hand they experience stigma toward their sexual orientation, and on the other hand, they experience stigma toward their HIV status.4 Because of the stigma MSM encounter, they face several barriers to HIV prevention, testing and treatment.5 Approximately 70 percent of HIV cases in the Philippines are among MSM,3 yet over three-quarters of MSM in the Philippines have never obtained an HIV test.2 Not only do MSM feel discouraged from seeking care, but healthcare facilities are failing to provide adequate services for this at-risk population.4 Understanding the social determinants of HIV transmission in the Philippines is needed to provide insight as to why MSM are disproportionately infected with the virus. 

In a country where discrimination is still legal in some contexts, and only 73 percent of Filipinos say society should accept homosexuality,6 discrimination against MSM is not uncommon. Homosexuality is legal, but LGBTQ+ individuals cannot adopt children, conversion therapy is not banned, and gay marriage is not recognized.6 Overall, Philippine views of homosexuality reflect an attitude that is tolerant, but not accepting, of LGBTQ+ individuals. This view often results in discrimination within workplaces and social circles.3 Attitudes toward HIV-positive individuals are also stigmatized, as HIV infection is often equated to sin and immorality.5 Strong roots in Catholicism coupled with poor HIV education are some of the main drivers of both HIV and sexual orientation-related stigma.4 Together, this array of stigma and discrimination solidify as barriers to HIV testing and treatment within the health care system. 

Individuals with HIV have viral loads, which are measurements of the amount of virus present inside the body.7 A high viral load indicates a large amount of HIV in the blood. When an individual has a high viral load, they are very contagious. Conversely, when an individual has a low viral load, they have a low amount of HIV in their blood and are unlikely to transmit the virus.8 In the Philippines, where treatment services such as antiretroviral therapy (ART) are not sufficiently provided and made accessible, a failure to treat is also a failure to prevent. When treatment services do not successfully suppress the viral loads of affected populations, not only do infected individuals become sicker, but they also have the potential to spread the virus.7

The research question I will address in this paper is: How do stigma and discrimination toward MSM in the Philippines impact their access to prevention, testing, and treatment services for HIV? Through this question, two general ideas can be explored through peer-reviewed literature. Firstly, the question will explore how the desire of MSM to seek prevention, testing, and treatment is affected by experiences of stigma and discrimination in multiple capacities. The question will also explore how discrimination within healthcare facilities, in addition to the failure of healthcare facilities to accommodate for discrimination experienced outside of the healthcare setting, contributes to the lack of appropriate HIV care for MSM. 

 

Methods

When conducting a literature search, I used the PubMed and Embase search engines. Through these search engines, I accessed peer-reviewed articles from the Multidisciplinary Digital Publishing Institute, National Library of Medicine, Guilford Journals, BMC Public Health, and Taylor & Francis Online. Keywords I used to search for material were “HIV/AIDS,” “HIV,” “MSM” and “the Philippines.” Generally, I looked for articles published in the last five years to capture the most recent updates on the epidemic.

 

HIV Infection Incidence Among MSM

For the past two decades, the Philippines’ HIV epidemic has been driven by sexual transmission among MSM.9 However, the incidence of HIV infection among MSM was not extensively evaluated until a study titled “HIV incidence among men who have sex with men (MSM) in Metro Manila, the Philippines: A prospective cohort study 2014-2018” was conducted by Rossana Ditangco and Mary Lorraine Mationg. The purpose of this study was to determine the incidence of HIV infection and its associated risk factors among MSM in Metro Manila, the largest metropolitan area in the Philippines. By understanding the epidemiology of the outbreak, Ditangco and Mationg hoped to assist in the formulation of relevant biomedical and socio-behavioral interventions. Participants were 18 or older, Metro Manila residents, and confirmed HIV-negative. All participants had anal or oral sex in the past 12 months. The researchers administered in-person questionnaire interviews and HIV tests every 3 months to all 708 participants. Data was collected on participant knowledge, attitudes, and practices regarding HIV and AIDS. During the follow-up period, 56 new cases were recorded, resulting in an incidence rate of 2.7 cases per 100 patient years.9 The study found that having two or more sexual partners and having anal sex without a condom in the past 3 months were factors significantly associated with HIV infection.9 High incidence was also recorded among the 18-24 year age range;9 Ditangco and Mationg hypothesized that this may reflect the sexually active nature of young MSM. Overall, there was a high HIV incidence rate among Filipino MSM.9 The findings from this study highlight the need for effective HIV prevention, surveillance, and treatment strategies. Additionally, based on these findings, younger MSM aged 18-24 should be a focus of interventions. Although this study provides limited insight into the stigma and discrimination faced by MSM, baseline effects of certain risk factors, such as sexual activity and condom use, were established. Understanding HIV incidence among this key population provides a strong epidemiological foundation to build upon with social and cultural context.

 

Drivers and Experiences of Stigma and Discrimination

At a time of explosive HIV transmission in the Philippines, there was little understanding of MSM experiences with HIV-related stigma.10 In 2017, a study titled “‘An Evil Lurking Behind You’: Drivers, Experiences, and Consequences of HIV-Related Stigma Among Men Who Have Sex With Men With HIV in Manila, Philippines” was conducted by Alexander C. Adia et al. to understand MSM experiences with HIV-related stigma and how these experiences subsequently influence their behaviors and qualities of life. The study consisted of 21-hour-long interviews of both MSM living with HIV and community-based organization workers. Participants resided in Manila and were required to be able to communicate in English. The interviews were designed to capture specific patterns of stigma that MSM living with HIV experienced and internalized. Stigma resulting in mental health issues, delays in HIV testing, and avoidance of health services were the main points qualitatively measured during the interviews. The study found that a majority of MSM participants were affected by an intersection of HIV-related stigma and sexual orientation-related stigma.10 These stigmas were often rooted in ideas of morality, dirtiness, and sin.10 Participant #4 reported difficulty seeking treatment due to peers blaming them for their diagnosis and labeling them as promiscuous, and a sex addict, because of their serostatus and sexual orientation. Participant #16 mentioned that, due to being HIV-positive, they were ostracized from communities they were formerly a part of. Additionally, several participants expressed signs of internalized stigma, stating that they deserved to get HIV as a consequence of their wrongdoings, such as identifying as gay.10 Overall, the study identified three main ways that stigma serves as a barrier to HIV treatment: detering MSM from seeking treatment despite its availability, creating attitudes that reduce the urgency to take HIV medication, and impeding disclosure of HIV status, thus resulting in HIV-positive MSM not promptly receiving the treatment they need.10 The study concluded that public health strategies must be developed to address discrimination at both societal and individual levels to reduce stigma-related harms.

Law and policy are powerful tools capable of improving the lives of people facing discrimination due to a diagnosis. Attempting within the law to reform existing structural inequalities may have a positive impact on societal attitudes toward HIV-positive individuals.11 However, before this study, there was minimal research on the role legal protections in the Philippines play in improving the well-being of people living with HIV (PLHIV).11 In 2019, Alexander C. Adia et al. conducted a study titled “Sword and Shield: Perceptions of law in empowering and protecting HIV-positive men who have sex with men in Manila, Philippines” that aimed to examine how MSM living with HIV perceive HIV-related legal protections, and how these protections subsequently influence their lives. Currently, the Philippines has a law, Republic Act 11166, that contains several anti-discrimination provisions.11 The study conducted one hour-long semi-structured interviews with 21 participants to gauge how MSM living with HIV experience the impacts of Republic Act 11166. The participants were HIV-positive MSM living in Metro Manila, aged 18 years and above, and able to communicate in English. The study identified two overarching feelings experienced by participants as a result of the law: empowerment and protection.11 Participants reported that the law helped them feel normal in social settings they previously felt disconnected from.11 Additionally, participants derived empowerment from the law because it displayed government commitment to deterring discrimination.11 The law also allowed for more positive and beneficial discussions regarding HIV to occur among MSM living with HIV.11 However, the interviews also highlighted some participant concerns, such as the efficacy of the aforementioned legal protections. They worried that companies and local governments may only treat the law as a suggestion.11 Additionally, concerns were raised about the law lacking the authority to counter social discrimination in the workplace or social circles.11 Overall, however, the findings show that Republic Act 11166 has alleviated internalized stigma and feelings of powerlessness among MSM in the study. The necessity of legal justice and human rights advocacy in HIV treatment highlights the role stigma plays in shaping the HIV epidemic in the Philippines.

Although HIV is mainly transmitted through MSM, HIV testing uptake among this demographic remains low.12 This is mainly due to poor coordination of care within the Philippines’ health care system.12 A study conducted by Jan W. de Lind van Wijngaarden et al., titled “‘I am not promiscuous enough!’: Exploring the low uptake of HIV testing by gay men and other men who have sex with men in Metro Manila, Philippines,” aims to explain why a significant proportion of Metro Manila-based MSM lacked access to HIV testing and treatment services. The goal of collecting this data was to reform health services to be more accessible, effective, efficient, equitable, and MSM-friendly.12 48 MSM from Metro Manila were recruited by their level of engagement with the HIV care cascade. The HIV care cascade consists of four levels: diagnosis, linkage to care, receipt of care, and retention of care.12 Case series interviews were designed to explore barriers to the uptake of HIV services. The study found that the main reasons to postpone treatment were higher socioeconomic class, feelings of moral superiority to other gay-identifying men, lack of proximity to the testing facility, fear of what will happen once infected, fear of stigma pertaining to serostatus or sexual orientation, fear of ART side effects, and fear of high health care expenses.12 Misconceptions regarding HIV and ART were also observed. Some participants believed that feeling physically fit meant that they could not be sick.12 Additionally, if a potential sexual partner appeared healthy, participants reported feeling less inclined to use a condom. Social stigma excludes HIV from health education conversations, thus contributing to the aforementioned misconceptions. However, other concerns expressed by participants were not misconceptions, but striking realities. Participants feared loss of support from friends or family upon receiving an HIV diagnosis.12 Additionally, fear of discrimination often translated into concerns regarding testing confidentiality,12 which was of the utmost importance to most participants. The data overall shows that most participants did not see a need to get tested, despite significant risk. Even participants who acknowledged their high-risk status did not feel compelled to get tested.12 A major determining factor in this choice was fear of what would happen upon testing positive.12 Potential solutions outlined by the researchers were increasing testing locations, hiring non-medical outreach workers to enhance service delivery, and providing cost-free knowledge of HIV to help tackle commonly held misconceptions. All of these solutions aim to bridge existing gaps within the current healthcare system, thus enhancing the transition from one level of the HIV care cascade to the next.  

 

The HIV Health Care System

Healthcare providers are essential to curbing any epidemic, and the way providers structure their delivery of care can have lasting effects on the healthcare system as a whole. The purpose of Arjee J. Restar’s study, “Prioritizing HIV Services for Transgender Women and Men Who Have Sex With Men in Manila, Philippines: An Opportunity for HIV Provider Interactions,” was to examine healthcare provider attitudes, perceived competencies, and abilities to prioritize the provision of HIV-related services to MSM. One-on-one qualitative interviews examined factors that may have impacted HIV prevention and treatment services for MSM. 15 HIV providers residing in Manila were interviewed. All providers were over the age of 18 and had a history of serving MSM. Restar et al. found that a majority of providers had overall positive attitudes toward all patients in their practices. Most providers valued equality for all of their patients but reported that despite their willingness to provide care to MSM, their actual competencies to provide context-specific care were not up to par.13 This lack of competency was often due to one of three main reasons: not knowing the health needs of MSM, having little training with HIV, or having difficulty being sensitive to patient gender and sexual orientation.13 Some providers expressed interest in learning more about LGTBQ+ individuals in their practices but lacked knowledge of the lived experiences of these patients.13 Additionally, some providers reported that their facilities did not offer training specifically tailored to providing HIV services to MSM.13 The study conveys an overall lack of preparedness among many providers regarding delivering MSM and HIV-specific care. The findings of this study also indicate the importance of not just patient-focused interventions, but provider-focused interventions as well. Healthcare providers require cultural competence to deliver HIV-sensitive services. This study indicates the need for a shift to more specific interventions tailored to meet the needs of key populations. 

The HIV care cascade, designed to examine the engagement of PLHIV with medical care, previously lacked sufficient data on non-heterosexual populations, despite MSM being disproportionately affected by the epidemic.14 A study conducted by Marisse Nepomuceno et al., titled “A descriptive retrospective study on HIV care cascade in a tertiary hospital in the Philippines,” sought to describe the HIV care cascade at the tertiary level in a hospital-affiliated HIV clinic after the adoption of the test-and-treat strategy. The test-and-treat strategy screens patients for HIV infection and provides treatment soon after a positive test result, thus bridging the gap between testing and treatment.14 A descriptive, retrospective cohort study was conducted. Researchers reviewed the medical records of patients enrolled at the University of the Philippines’ Philippine General Hospital in Manila. Demographic and clinical data relevant to each stage of the HIV care cascade were collected in order to understand the linkage to care, ART initiation, retention in care, and virologic suppression. 584 participants were included; all were receiving treatment from the Philippine General Hospital and were aged 18 or older. Ninety one percent were male, and 55.6 percent contracted HIV from male-male sex.14 Ninety-nine point five percent of patients were linked to care following diagnosis, 95 percent of patients initiated ART, 78.8 percent of patients were retained in care and maintained ART, 47.9 percent of patients had their HIV viral load tested in follow-up, and 45.5 percent of patients achieved viral suppression.14 Additionally, of the 99.5 percent of patients who were linked to care, 10 percent of these patients were linked to care more than 12 months following their diagnosis.14 This is especially concerning with HIV, as failure to achieve viral suppression allows for further transmission. Overall, this study captured the substantial loss of patients throughout the HIV care cascade. The study concluded that many gaps are remaining in the cascade. Nepomuceno et al. suggested the use of outreach programs and telemedicine to enhance adherence to ART and viral load testing. Traditional medical facilities may lack the capacity to fulfill all medical needs of MSM living with HIV, but these needs can still be met if some responsibility for care is shifted to informal care settings, such as community-based programs.

 

The Intersection of Health Care and Stigma

Structural, social, and behavioral factors all impact HIV service uptake among MSM.15 Understanding these factors is critical when developing culturally competent care models. A study conducted by Arjee J. Restar et al., “Differences in HIV risk and healthcare engagement factors in Filipinx transgender women and cisgender men who have sex with men who reported being HIV negative, HIV positive or HIV unknown,” aimed to understand HIV risk and health care engagement among at-risk individuals. An online cross-sectional survey examined the structural, social, and behavioral factors impacting HIV service uptake among cisgender MSM. The survey assessed factors typically associated with HIV status, such as demographics, social marginalization, HIV risk, healthcare engagement, and substance abuse.15 The study found that the most prominent barriers to healthcare engagement were discrimination by healthcare workers, clinic wait time, inconvenient location, and concerns about disclosing HIV status.15 Roughly a third of participants reported sexual orientation, gender identity, or a lack of anti-LGBT discrimination policies as reasons for avoidance of HIV services.15 The study also found that only 16 percent of cis-MSM participants had ever received an HIV test and knew of their HIV status.15Concurrently, MSM are more likely to engage in HIV-risk behaviors including drug and alcohol use, condomless sex, and sex work.15 Restar et al. suggest harm reduction services, testing outreach, and community partner involvement to increase MSM engagement with HIV services. These solutions, both inside and outside the healthcare setting, acknowledge the social determinants responsible for MSM behaviors that increase their risk of HIV and decrease their odds of healthcare engagement. 

Testing rates among MSM, especially young MSM, remain low despite high rates of transmission.16 The main model of HIV testing, facility-based testing, has proven to be unsuccessful in providing sufficient means of testing to MSM.16 HIV self-testing (HIVST) is an alternative strategy to address this gap in testing. HIVST allows individuals to conduct their own rapid diagnostic tests and maintain result confidentiality.16 So far, HIVST has successfully increased testing in other Asian countries, including China, Hong Kong, and Vietnam.16 Jesal Gohil et al. conducted a study titled “Is the Philippines ready for HIV self-testing?” to measure perceived acceptability, feasibility, and challenges of HIVST among key informants and target users. Semi-structured interviews qualitatively assessed potential barriers, opportunities, and challenges regarding HIVST policy and regulation. Focus group discussions took place with 42 target users and 15 individuals involved with the provision of HIV testing programs. All participants resided in Metro Manila. The study found that MSM were receptive to HIVST due to its elements of convenience and privacy.16 Linkage to HIV care following a positive test result was a point of concern for participants, but they also worried about stigma-related barriers they would face within the health care system upon initiation of care.16 The study also found that pharmacies and community-based facilities, not traditional medical facilities, were popular choices for picking up tests.16 Based on these findings, the study concluded that one of the largest problems associated with HIVST is not MSM willingness, but HIV-related stigma within the health care system. While HIVST allows individuals to take responsibility for their testing, they still lack control over what they will experience within the healthcare system following a positive diagnosis.

A key principle to treating HIV, U=U, asserts that if HIV is undetected, it is also untransmittable.17 If an HIV-positive individual adheres to their ART regimen, then their viral load will remain low enough to prevent transmission.17 This idea highlights the importance of viewing treatment as prevention. Thus, supporting adherence to ART is crucial to managing HIV. Cara O’Connor et al. conducted a study titled “Risk factors affecting adherence to antiretroviral therapy among HIV patients in Manila, Philippines: a baseline cross-sectional analysis of the Philippines Connect for Life Study” to measure treatment adherence and to identify whether ART adherence requires additional interventions to increase its effectiveness. Such an analysis would provide the groundwork for adherence interventions specifically tailored to MSM. A cross-sectional analysis was conducted using a framework that gathered information on HIV-related risk behaviors and adherence to ART. To guide data collection, questions were framed around demographics, clinical characteristics, HIV knowledge, risk behaviors, and adherence or lack thereof.17 All 426 participants were HIV-positive and attending a clinic in Metro Manila that was a part of the Connect for Life Cohort Study. All participants were required to speak English and have a mobile phone. The study found that 100 percent adherence in the last 30 days was only achieved by 52.1 percent of participants.17 Longer time on treatment, inconsistent condom use, and injection drug use were all associated with reduced adherence.17 The most common reasons for missing medication were being too busy, forgetting, falling asleep, being away from home, or having a change in their daily routine.17 Additionally, 44 percent of patients who skipped a pill at some point did so because they did not want to be seen taking their medication.17 On the other hand, being in a relationship with an HIV-negative partner was associated with increased adherence.17 These findings indicate a similarity between HIV-risk behaviors and nonadherence behaviors. The data also indicates a positive association between HIV knowledge and ART adherence. The data collected from this study underscores the need for interventions addressing treatment fatigue and social stigma. Interventions may accomplish this through the implementation of social support and harm reduction programs centered specifically around the struggles of MSM. 

Pre-exposure prophylaxis (PrEP) is the primary prevention mechanism for HIV.18 To be effective, the pill must be taken once a day. Although PrEP has proven to be extremely successful in preventing HIV transmission, the uptake of HIV prevention services among MSM in the Philippines remains low.18 Awareness and interest in PrEP are key determinants of successful uptake, but current levels of these feelings among MSM were unknown18 until a study was conducted by Arjee Restar et al., titled “Characterizing Awareness of Pre-Exposure Prophylaxis for HIV Prevention in Manila and Cebu, Philippines: Web-Based Survey of Filipino Cisgender Men Who Have Sex With Men.” The purpose of this study was to examine levels of PrEP awareness and interest among cisgender MSM in the Philippines. The results of this study have the potential to guide the future rollout of PrEP programs. A quantitative web-based survey was designed to examine the relationship between PrEP awareness/interest and factors such as socioeconomic status, healthcare experiences, and access to HIV services. The study found overall high levels of awareness and interest in taking PrEP. While only 56.4 percent of participants had high HIV knowledge, 74.9 percent of participants were aware of PrEP, and 88.8 percent of participants were interested in taking the medication.18 PrEP knowledge was more common than a high level of HIV knowledge.18 The most frequently recorded reasons for lack of interest in PrEP were needing to know more information first and not liking medication in the form of pills.18 Factors associated with greater odds of PrEP awareness were a college education or higher, having had an HIV test in the past, high HIV knowledge, and having discussed PrEP among friends.18 Factors associated with lower odds of PrEP awareness were being straight-identified, experiencing health care discrimination due to sexual identity, and avoiding HIV services due to cost, sexual identity, or a lack of LGBT anti-discrimination policies.18 Restar et al. concluded that there is a growing demand for PrEP in the Philippines. However, those who were less aware of PrEP either came from poorer, less educated backgrounds or encountered barriers in the HIV health care system.18 To increase the likelihood of successful PrEP interventions, future actions must be taken to provide HIV education and reduce discrimination within the healthcare system.

 

Discussion 

Limitations: Assessment of the studies reveals some flaws among study designs and collected data. All of the studies were based in urban areas, primarily Manila. The lack of regard for rural areas may result in conclusions not entirely representative of all MSM in the Philippines. HIV knowledge and risk behaviors may vary among urban and rural areas depending on what resources and funding are available. Additionally, legal protections of Republic Act 11166 may be weaker in regions with less government oversight. Another weakness of some studies was that participation requirements potentially favored the participation of individuals from a higher socioeconomic class. Having to speak English or possess a phone may deter some individuals from partaking in the study, thus failing to assess the entirety of the target population. Bias could have also occurred in the studies that used self-reporting surveys and questionnaires, as participants may have misremembered information or been untruthful to avoid judgment. A final critique of many of these studies is a lack of specific, thorough solutions. After conducting extensive analyses of the HIV epidemic in the Philippines, many of the studies provided only brief and general descriptions of potential interventions.

 

Strengths: A significant strength of the research in this field is the high volume of qualitative studies conducted. When examining stigma and discrimination, no statistic can accurately capture the unique experiences of MSM pertaining to their serostatus and sexual orientation. The use of interviews and informal questioning provides a space for participants to openly share their experiences without being confined to black-and-white, yes-or-no questions. Additionally, the interviewing of healthcare providers by Restar et al. provided an alternative perspective that was beneficial to comprehensively understanding the HIV healthcare system.

 

Conclusion

The HIV epidemic among MSM in the Philippines continues to be a pressing public health issue, despite the growing body of research working to understand HIV in this specific context and provide potential solutions. Overall, the studies addressed in this synthesis had similar findings, thus reinforcing the idea that MSM in the Philippines receive inadequate HIV health care due to stigma and discrimination surrounding serostatus and sexual identity. I believe the studies in this synthesis provide sufficient, relevant data and evidence that adequately answer my research question. Stigma and discrimination are encountered by MSM among family, friends, peers, coworkers, and health providers alike.11 All of these experiences of discrimination summate into trends of hesitancy to seek HIV health care, including but not limited to PrEP,18 facility-based HIV testing, HIVST, ART, and follow-up viral load testing.14 Additionally, just as MSM experience discrimination that deters them from seeking treatment, there are also factors within the health care system limiting MSM engagement with HIV services. Inadequate skills and knowledge of providers,13 insufficient anti-discrimination policies,18 and gaps of continuity within the HIV care cascade14 are all shortcomings of the HIV health care system that serve as barriers to care for MSM. Stigma and discrimination may result in avoidance of testing, avoidance of treatment, nonadherence to treatment, or a lack of knowledge of available preventative and treatment services.10 Additionally, several misconceptions resulting from HIV stigma further contribute to the aforementioned behaviors.12 

Context-specific and community-based interventions that put patient-centeredness, convenience, and confidentiality at the forefront of their work have the potential to successfully reach a larger scale of MSM who are in need of preventative, testing, and treatment services. Future directions should incorporate these elements of care into both traditional medical facilities and outpatient clinics, community-based organizations, and educational programs. Stigma and discrimination toward these individuals are deeply rooted within Filipino culture, thus requiring solutions that are dispersed among a variety of support outlets accessible to MSM. Restructuring views toward MSM and PLHIV within both society and the health care system are critical for enacting meaningful change. Future research efforts may benefit from using already collected data to propel implementation-focused studies that aim to craft interventions specifically centered around both at-risk MSM and HIV-positive MSM.

 

References

  1. Aids I of M (US) C on a NS for. International Aspects of AIDS and HIV Infection. National Academies Press (US); 1986. https://www.ncbi.nlm.nih.gov/books/NBK219140/
  2. Sison OT, Baja ES, Bermudez ANC, et al. Association of anticipated HIV testing stigma and provider mistrust on preference for HIV self-testing among cisgender men who have sex with men in the Philippines. BMC Public Health. 2022;22(1). doi:https://doi.org/10.1186/s12889-022-14834-x
  3. Gangcuangco LMA, Eustaquio PC. The State of the HIV Epidemic in the Philippines: Progress and Challenges in 2023. Tropical Medicine and Infectious Disease. 2023;8(5):258. doi:https://doi.org/10.3390/tropicalmed8050258
  4. Bustamante J, Plankey MW. Identifying Barriers to HIV Testing Among Men Who Have Sex with Men (MSM) in the Philippines. Georgetown Medical Review. Published online July 18, 2022. doi:https://doi.org/10.52504/001c.36967
  5. Alibudbud R. The Philippine HIV crisis and the COVID-19 pandemic: A worsening crisis. Public Health. Published online September 2021. doi:https://doi.org/10.1016/j.puhe.2021.09.008
  6. Equaldex. LGBT Rights in Philippines | Equaldex. Equaldex.com. Published June 19, 2018. https://www.equaldex.com/region/philippines
  7. What Does HIV Viral Load Tell You? WebMD. https://www.webmd.com/hiv-aids/hiv-viral-load-what-you-need-to-know
  8. Centers for Disease Control and Prevention. HIV Basics. CDC. Published 2019. https://www.cdc.gov/hiv/basics/index.html
  9. Ditangco R, Mationg ML. HIV incidence among men who have sex with men (MSM) in Metro Manila, the Philippines: A prospective cohort study 2014–2018. Medicine. 2022;101(35):e30057. doi:https://doi.org/10.1097/MD.0000000000030057
  10. Adia AC, Bermudez ANC, Callahan MW, Hernandez LI, Imperial RH, Operario D. “An Evil Lurking Behind You”: Drivers, Experiences, and Consequences of HIV–Related Stigma Among Men Who Have Sex With Men With HIV in Manila, Philippines. AIDS Education and Prevention. 2018;30(4):322-334. doi:https://doi.org/10.1521/aeap.2018.30.4.322
  11. Adia AC, Restar AJ, Lee CJ, et al. Sword and Shield: Perceptions of law in empowering and protecting HIV-positive men who have sex with men in Manila, Philippines. Global Public Health. 2019;15(1):52-63. doi:https://doi.org/10.1080/17441692.2019.1622762
  12. de Lind van Wijngaarden JW, Ching AD, Settle E, van Griensven F, Cruz RC, Newman PA. “I am not promiscuous enough!”: Exploring the low uptake of HIV testing by gay men and other men who have sex with men in Metro Manila, Philippines. Melendez-Torres GJ, ed. PLOS ONE. 2018;13(7):e0200256. doi:https://doi.org/10.1371/journal.pone.0200256
  13. Restar AJ, Chan RCH, Adia A, et al. Prioritizing HIV Services for Transgender Women and Men Who Have Sex With Men in Manila, Philippines. Journal of the Association of Nurses in AIDS Care. 2019;31(4):1. doi:https://doi.org/10.1097/jnc.0000000000000131
  14. Nepomuceno M, Abad CL, Salvaña EM. A descriptive retrospective study on HIV care cascade in a tertiary hospital in the Philippines. Santella AJ, ed. PLOS ONE. 2023;18(1):e0281104. doi:https://doi.org/10.1371/journal.pone.0281104
  15. Restar AJ, Jin H, Ogunbajo A, et al. Differences in HIV risk and healthcare engagement factors in Filipinx transgender women and cisgender men who have sex with men who reported being HIV negative, HIV positive or HIV unknown. Journal of the International AIDS Society. 2020;23(8). doi:https://doi.org/10.1002/jia2.25582
  16. Gohil J, Baja ES, Sy TR, et al. Is the Philippines ready for HIV self-testing? BMC Public Health. 2020;20(1). doi:https://doi.org/10.1186/s12889-019-8063-8
  17. O’Connor C, Leyritana K, Calica K, et al. Risk factors affecting adherence to antiretroviral therapy among HIV patients in Manila, Philippines: a baseline cross-sectional analysis of the Philippines Connect for Life Study. Sexual Health. 2021;18(1):95. doi:https://doi.org/10.1071/sh20028
  18. Restar A, Surace A, Adia A, et al. Characterizing Awareness of Pre-Exposure Prophylaxis for HIV Prevention in Manila and Cebu, Philippines: Web-Based Survey of Filipino Cisgender Men Who Have Sex With Men. Journal of Medical Internet Research. 2022;24(1):e24126. doi:https://doi.org/10.2196/24126
Ella Olea Emily Mrakovcic