Wednesday, September 28, 2016

HIVisions - We’ll Need More than Apples: Medical professionals on the continuum of HIV services in the Philippines

By Jan Gabriel Castañeda

The HIV crisis has gone on for four decades, and for four decades the world has struggled against it. Doctors, scientists, educators, policy makers, writers, artists -- people of all walks and all colors have, in their own ways, sought to make sense of this crisis and its relationship with society. From citizens to states, from medicine to prayer, from cures to cries for reform, people’s visions of how to respond to the crisis are as diverse as the people who bear its scars. The goal of this series is to give you a glimpse of these visions: the roles people of different passions and disciplines have played in this crisis that, as of March 2016 as recorded by the Department of Health’s Epidemiology Bureau, is infecting 25 Filipinos daily.

The phrase "An apple a day keeps the doctor away" is a troublesome one. Besides being an adage to a complicated colonial heritage, it's not even that good (native fruits like langka and durian are far more nutritious and patriotic alternatives). And when it comes to HIV services, spanning the whole gamut from testing to treatment, apples aren’t much of a solution either. The powerlessness of the colonial fruit is especially pronounced in the Philippines where, despite our successes, the reality is still mostly bad news -- a far-cry from when, just a little over a  decade ago, health experts puzzled over why HIV infections were so uncommon here.

Apples aside, there’s something else we need to puzzle over: what will keep the doctor away? If the country's HIV services were to come in for a full check-up, what would be the prescription? Despite their busy schedules, two doctors spoke with us about their work and to give us their diagnoses and prescriptions.

Doctor Jon Fontilla, a full-time consultant for the National HIV Monitoring and Evaluation Team, explained that his work was motivated by a personal tragedy. "During the course of my career in the HIV program, I had friends who died from AIDS related causes," Doc Jon shared, his experience a motive many of us in the community know all too well. "This pushed me to stay with the program."

Doctor Winlove Mojica, who recounts a similar shock in another interview, currently works as a Clinical Associate Professor at the Philippine General Hospital's Section of Dermatology. In 2014, he was granted a scholarship by the National Skin Centre Singapore, during which he saw an average of 30 to 50 patients daily in his one-month stay at their Department of Sexually Transmitted Illnesses (STI) Control.

Dr. John Fontilla

Dr. Winlove Mojia

The diagnosis

While they work under different circumstances – Doc Jon in program management and Doc Winlove in dermatology – both doctors converge on the fact that people have cultivated a whole constellation of fears around HIV, what we generally refer to as “stigma”. And stigma, as we now know, drastically impacts our ability to deliver HIV services effectively.

"The most pervasive issue that I encountered is stigma. Many people shy away from talking about HIV because of its mode of transmission," Doc Jon explained. "People generally don’t want to talk about very personal things such as sex and drug use."

Doc Winlove on his end, talked about how people were scared "away" – sometimes by the doctors themselves. "People with HIV also have other STIs and they do not know where to go to avail of quality services," Doc Winlove shared. "Most of my patients tell me that they are either ashamed to disclose their other conditions to their primary doctor or their doctor does not know or refuse to provide them treatment especially for conditions manifesting on the skin."

Asked what the contexts of these refusals were, he clarified that doctors want HIV testing to be done before performing an invasive procedure. “In a lot of provinces, doctors refuse to do life-saving operations because of fear of getting infected with HIV for those suspected to have the virus,” Doc Winlove lamented. “The lack of understanding of how the virus is transmitted among health professionals is saddening and sickening at the same time.”

But even when one zooms out from the individual case study, the bigger picture does not offer much comfort either.

"There are so many gaps in the national HIV program: lack of facilities, lack of trained professionals, hesitance of people getting services," Doc Jon laments, citing curious instances of dishonesty. "And it's not just a matter of whether they have it or not: it’s functionality. There are sites with equipment, but they’re not functional. It's declared by the social hygiene clinic, but they have no counselors or testing kits. There’s a Local AIDS Council on paper, but they do nothing.”

And while the past five years have seen improvement, the reality remains a work in progress at best. Doc Jon offers a blunt reflection: "If there is not enough investment in HIV prevention programs, expect much higher incidence rates in the future. This means the cost of medicines for people living with HIV will also escalate. I don't know if the government will still afford to provide free medicines in the future." Although the government has worked to make sure medication remains available, Doc Jon’s worry coincides with broader issues pertaining to the economic impact of HIV/AIDS medication. Recall, for example, the scandal that broke out in 2014 regarding a supposed nationwide shortage of vital HIV medication.

Doc Winlove offered his own timeline: "With a biased focus on testing and treatment of HIV and the neglect of the prevention of other STIs, the epidemic could continue for at least the next ten years."

The doctors' prescriptions

But to say that a situation is bleak is not to say it is impossible. As the past five years have showed, creating better HIV services is actually doable. The doctors offer a few suggestions for how we can do it better.

Doc Winlove tells us that collaboration, in HIV/AIDS as in any field of interest, is a key component in addressing the issue. "It is hard to encourage different medical specialties to work together to fight these infections. But the good news is a younger generation of doctors are starting to collaborate to provide comprehensive and efficient STI-HIV services."

And since STIs and HIV often go together, Doc Winlove asks us (which is the practice elsewhere) to provide these services together. "Because of the focus on HIV, preventive aspects for other STIs are not given equal emphasis. I have learned that these services must be colocated. A one-stop-shop facility that provides management for STIs and HIV not only improves infection control but also reduces stigma."

And for his fellow doctors, Doc Winlove offers this advice: "As a doctor you have to have a high index of suspicion for possible HIV infection. You must not be afraid to ask sensitive questions. But you must do so in a non-stigmatizing manner." This might sound like novel advice, but to any doctor who takes their code of ethics seriously (and to all of us who understand the heavy price of stigma), this ought to be obvious.

Another key component to any kind of medical practice is clarity and consistency. On this point, Doc Winlove turns to HIV counselors: “Not all HIV Counselors have a medical background. Even if they do, it is not standardized. There is no regular monitoring and evaluation if the key messages are delivered during counseling services. Several times  when I went for HIV testing  and the counselor knew I was a doctor, the counselor stopped and told me, ‘Alam mo na 'yan doc’. No, it shouldn't be that way.”

“Each encounter must be effective and consistent,” Doc Winlove tells us. “To use an analogy: if you teach a group of students about a topic, it should not be assumed that they understand it. That's why we evaluate through oral and written exams. Counselors should have regular skills evaluation.”

Doc Jon, turning to the efforts of other countries and the overwhelming evidence supporting them, emphasized the need to take comprehensive sex education seriously: "Start young. Habits are formed at a young age, including sexual practices. People in DepEd, for example, still think that it’s wrong to talk about sex for fear of enticing kids to start having sex. Hello: they will have sex whether they talk about it or not." Places like the United States, for example, have learned this the hard way.

That is not to say that everyone in our schools are against it. For those who know better, their hands are often tied by institutional politics. "We had some teachers in our peer education trainings. They did change their perspective but the problem with schools is systemic. Some want to start a school-based program but school officials prevent them from doing so." But this dilemma is nothing new. Organizations like Human Rights Watch have observed this before, and even back in 2004 reported that “attempts by AIDS educators to teach comprehensive HIV prevention in schools were met with stiff resistance from teachers and principals opposed to birth control.” 2016 is the same old story.

But Doc Jon, focused as he is on programs, is deeply concerned with the budget. "The only way to improve the program is to increase the investment. We are so far from the four billion peso annual cost of a comprehensive HIV program." This number comes from the Department of Health's own calculations in their AIDS Epidemic Model, published two years earlier.

So the doctor's orders are clear so far: institutionalize prevention through comprehensive education, strengthen existing services, encourage collaboration among medical professionals, address the culture of fear, and get a bigger budget. Apples are optional.